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ACUTE ACUTE RENAL RENAL

FAILTUREFAILTURELIJI VINCENT

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Acute renal failure (ARF) refers to a sudden Acute renal failure (ARF) refers to a sudden

and usually reversible loss of renal function, and usually reversible loss of renal function,

which develops over a period of days or which develops over a period of days or

weeks and is usually accompanied by a weeks and is usually accompanied by a

reduction in urine volume.reduction in urine volume.

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Reversible Pre-Renal Acute Reversible Pre-Renal Acute Renal FailureRenal Failure

Pathogenesis

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Clinical FeaturesClinical Features Hypotension and signs of poor Hypotension and signs of poor

peripheral perfusionperipheral perfusion

Postural hypotension fall in SBP/DBP Postural hypotension fall in SBP/DBP >20/10 mmHg early sign of >20/10 mmHg early sign of hypovolaemia.hypovolaemia.

The cause of reduced renal perfusion The cause of reduced renal perfusion may be obvious or concealedmay be obvious or concealed

Metabolic acidosis and Metabolic acidosis and hyperkalaemia may be (+)hyperkalaemia may be (+)

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ManagementManagement Establish and correct the underlying cause of the Establish and correct the underlying cause of the

ARF.ARF.

If hypovolaemia (+) replace with blood, plasma or If hypovolaemia (+) replace with blood, plasma or isotonic salineisotonic saline

Optimise systemic haemodynamics. Monitor CPU Optimise systemic haemodynamics. Monitor CPU or pulmonary a wedge pressure.or pulmonary a wedge pressure.

Correct metabolic acidosisCorrect metabolic acidosis

- Restoration of blood volume will restore - Restoration of blood volume will restore

kidney functionkidney function

- Isotonic sodium bicarbonate- Isotonic sodium bicarbonate

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Established Acute Renal FailureEstablished Acute Renal Failure

Following severe or prolonged under Following severe or prolonged under perfusion of the kidney.perfusion of the kidney.

Histology: Acute tubular necrosis Histology: Acute tubular necrosis

Acute Tubular Necrosis:Acute Tubular Necrosis:

CauseCause (1)(1) IschaemiaIschaemia

(2)(2) NephrotoxicityNephrotoxicity

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Nephrotoxic ATNNephrotoxic ATNDirect toxicity of the causative agent Direct toxicity of the causative agent to the tubular cells.to the tubular cells.

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Recovery From ATNRecovery From ATN

o Tubular cells can regenerateTubular cells can regenerateo If the patient is supported during the If the patient is supported during the

regeneration phase.regeneration phase.o Kidney function restoresKidney function restoreso Recovery phase-Recovery phase-Diuretic phaseDiuretic phase

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3.3. Other featureOther feature Uraemic features- anorexia, nausea Uraemic features- anorexia, nausea

and vomiting and vomiting drowsiness, apathy, drowsiness, apathy, confusion, muscle twitchingconfusion, muscle twitching

Respiratory rate increased – Acidosis, Respiratory rate increased – Acidosis, pulmonary oedema, infection.pulmonary oedema, infection.

Anaemia – Blood loss, haemolysis Anaemia – Blood loss, haemolysis disordered platelet function and disordered platelet function and disturbances of the coagulation disturbances of the coagulation cascade.cascade.

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Clinical Features of Established Clinical Features of Established ARFARF

Reflect the causal condition – trauma, Reflect the causal condition – trauma, septicemia or systemic diseases +septicemia or systemic diseases +

1.1. Alterations in urine volumeAlterations in urine volume Oliguric (<500ml/daily)Oliguric (<500ml/daily)Anuria Anuria Non Oliguric - Normal or IncreasedNon Oliguric - Normal or Increased

2.2. Disturbances of water, electrolyte and Disturbances of water, electrolyte and acid – base balanceacid – base balance

Hyperkalaemia - massive tissue Hyperkalaemia - massive tissue breakdown, haemolysis breakdown, haemolysis

Dilutional Dilutional hyponatraemia.hyponatraemia.

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URINARY TRACTURINARY TRACTOBSTRUCTIONOBSTRUCTION

SUGGESTED BY LOIN PAIN, RENAL SUGGESTED BY LOIN PAIN, RENAL COLIC OR DIFFICULTY IN COLIC OR DIFFICULTY IN MICTURITIONMICTURITION

INVES- USGINVES- USG PROMPT RELIEF OF OBSTRUCTION PROMPT RELIEF OF OBSTRUCTION

RESTORES KIDNEY FUNCTIONRESTORES KIDNEY FUNCTION

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•VASCULARVASCULAR EVENTEVENT

MAJOR VASCULAR OCCLUTION OR MAJOR VASCULAR OCCLUTION OR SMALL VESSEL DISEASESMALL VESSEL DISEASE

URINE SHOW MINIMAL URINE SHOW MINIMAL ABNORMALITIESABNORMALITIES

MAY BE PRECIPITATED BY ACE MAY BE PRECIPITATED BY ACE INHIBITORSINHIBITORS

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RPGNRPGN

SIGNIFICANT DIP SIGNIFICANT DIP STICK HAEMATURIASTICK HAEMATURIA

ASSOSIATED WITH ASSOSIATED WITH SYSTEMIC SYSTEMIC FEATURES FEATURES

BLOOD TESTS-BLOOD TESTS-ANA, ANCA, ANTI-ANA, ANCA, ANTI-GBM ANTIBODIESGBM ANTIBODIES

DIAGNOSIS- RENAL DIAGNOSIS- RENAL BIOPSY BIOPSY

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ACUTEACUTE INTERSTITIALINTERSTITIAL NEPHRITISNEPHRITIS

CAUSED BY ADVERSE DRUG CAUSED BY ADVERSE DRUG REACTIONREACTION

SMALL AMOUNT OF BLOOD AND SMALL AMOUNT OF BLOOD AND PROTIEN IN URINEPROTIEN IN URINE

KIDNEYS NORMAL IN SIZEKIDNEYS NORMAL IN SIZE Tt-CESSATION OF DRUG AND Tt-CESSATION OF DRUG AND

PREDNISOLONE PREDNISOLONE

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DRUGSDRUGS

HAEMODYNAMIC EFFECTS- NSAIDs , HAEMODYNAMIC EFFECTS- NSAIDs , ACE INHIBITORSACE INHIBITORS

DIRECT TOXICITY TO THE TUBULES- DIRECT TOXICITY TO THE TUBULES- AMINOGLYCOSIDESAMINOGLYCOSIDES

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Screening TestsScreening Tests

1.1. HematologyHematologyFull blood countFull blood countBlood filmBlood filmClotting screen, Group and saveClotting screen, Group and save

2.2. BiochemistryBiochemistryUrea, electrolytes and creatinine calciumUrea, electrolytes and creatinine calciumUrinalysisUrinalysisUrine MicrocopyUrine MicrocopyQuantitative urinary protein measurement Quantitative urinary protein measurement

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3.3. MicrobiologyMicrobiologyBlood cultureBlood cultureCRPCRPMid-stream urineMid-stream urineOther culturesOther cultures

4.4. Imaging Imaging Renal USGRenal USGChest X rayChest X rayECGECG

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1.1. Immunoglobulin and protein Immunoglobulin and protein electrophoresiselectrophoresis

2.2. Urinary Bence Jones ProteinUrinary Bence Jones Protein

3.3. ComplementComplement

4.4. ANA and ds DNA ANA and ds DNA

5.5. Extractable nuclear Antigen (ENA)Extractable nuclear Antigen (ENA)

6.6. Rheumatoid factorRheumatoid factor

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ManagementManagement1.Emergency resuscitation1.Emergency resuscitation

Hyperkalaemia – treated immediatelyHyperkalaemia – treated immediately Circulating blood volume restorationCirculating blood volume restoration Acidosis-Isotonic sodium bicarbonateAcidosis-Isotonic sodium bicarbonate

2.Addressing the underlying cause2.Addressing the underlying cause USG showing urnary tract obstruction.USG showing urnary tract obstruction. ATN - restoring renal perfusion.ATN - restoring renal perfusion. Postrenal obstruction :Due to Pelvic or Postrenal obstruction :Due to Pelvic or

ureteric dilatation – Percutaneous ureteric dilatation – Percutaneous nephrostomynephrostomy

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3.3. Fluid and electrolyte balanceFluid and electrolyte balance Daily fluid intake should = prev. day urine Daily fluid intake should = prev. day urine

output + 500ml to cover unsensible loss.output + 500ml to cover unsensible loss. Abnormal loses like diarrhea – electrolyte Abnormal loses like diarrhea – electrolyte

replacement. replacement. Since NaSince Na++ and K and K+ + are retained their intake are retained their intake

should be restricted should be restricted

4.4. Protein and energy intakeProtein and energy intake In patients where dialysis is avoided – In patients where dialysis is avoided –

protein restriction to 40g/dayprotein restriction to 40g/day In patients with dialysis – more dietary In patients with dialysis – more dietary

proteinprotein

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5.5. Infection controlInfection control

Regular clinical examination and Regular clinical examination and microbiological investigation required.microbiological investigation required.

6.6. DrugsDrugs

Vasoactive drugs NSAIDs & ACE Vasoactive drugs NSAIDs & ACE inhibitors are to be avoided.inhibitors are to be avoided.

7.7. Renal Replacement therapyRenal Replacement therapy

This may be required as supportive This may be required as supportive management in ARF.management in ARF.

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Increased Plasma urea andcreatinineIncreased Plasma urea andcreatinine urea >30mmol/lurea >30mmol/lCreatinine >6.8mgdlCreatinine >6.8mgdlAt lower level – Progressive biochemical At lower level – Progressive biochemical deterioration.deterioration.

HyperkalaemiaHyperkalaemia – K+ >6mmol – K+ >6mmolMetabolic acidosisMetabolic acidosis raise the plasma raise the plasma

potassium further.potassium further.Fluid overload and pulmonary oedemaFluid overload and pulmonary oedema

Uraemic pericarditis/ uraemic Uraemic pericarditis/ uraemic encephalopathy.encephalopathy.

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Intermittent haemodialysisIntermittent haemodialysis

Best rate of small Best rate of small solute clearance.1 solute clearance.1 hour tt is prescribed. hour tt is prescribed. Subsequently when Subsequently when haemodyamically haemodyamically stable 3 – 4 hours 3 stable 3 – 4 hours 3 – 4 times a week.– 4 times a week.

Haemodialysis 2 – 3 Haemodialysis 2 – 3 hrs every day – hrs every day – severly catabolic severly catabolic

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HaemofiltrationHaemofiltrationIntermittentIntermittent 15 – 30 liters of plasma 15 – 30 liters of plasma ultra filtrate exchanged ultra filtrate exchanged for replacement fluid for replacement fluid over 3 – 5 hours.over 3 – 5 hours.ContinuousContinuous1 – 2 liters of filtrate 1 – 2 liters of filtrate replaced replaced higher rate of filtration higher rate of filtration MODS sepsis.MODS sepsis.

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Intermittent Intermittent haemodiafiltrationhaemodiafiltration

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Peritoneal dialysisPeritoneal dialysis

Seldom achieves adequate Seldom achieves adequate biochemical controlbiochemical control

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Difference BetweenHD&PDDifference BetweenHD&PDEfficientEfficient Less efficentLess efficent

4hours 3 times a week4hours 3 times a week 4 exchanges per day 4 exchanges per day each 30 60 min. – each 30 60 min. – CAPD or 8 -10 hrs CAPD or 8 -10 hrs Automated PDAutomated PD

2-3 day between2-3 day between Few hrs between ttFew hrs between tt

Requires visit to Requires visit to hospitalhospital

Performed at homePerformed at home

Requires adequate Requires adequate venous accesvenous acces

Requires an intact Requires an intact peritoneal cavityperitoneal cavity

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Careful compliance to Careful compliance to diet and fluid restrictiondiet and fluid restriction

Diet & fluid less Diet & fluid less restrictedrestricted

Fluid removal Fluid removal compressed during tt compressed during tt period - haemody period - haemody instabilityinstability

Slow continous fluid Slow continous fluid removal - asymptomaticremoval - asymptomatic

Infection reld to vascular Infection reld to vascular accessaccess

Infection – Infection – Peritonitis,catheter reld Peritonitis,catheter reld infectionsinfections

Patients are, to some Patients are, to some extent dependent on extent dependent on othersothers

Patients can take full Patients can take full reponsibility of their ttreponsibility of their tt