ACUTE ACUTE RENAL RENAL
FAILTUREFAILTURELIJI VINCENT
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.
Reversible Pre-Renal Acute Reversible Pre-Renal Acute Renal FailureRenal Failure
Pathogenesis
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 (+)
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
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
Nephrotoxic ATNNephrotoxic ATNDirect toxicity of the causative agent Direct toxicity of the causative agent to the tubular cells.to the tubular cells.
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
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.
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.
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
•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
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
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
DRUGSDRUGS
HAEMODYNAMIC EFFECTS- NSAIDs , HAEMODYNAMIC EFFECTS- NSAIDs , ACE INHIBITORSACE INHIBITORS
DIRECT TOXICITY TO THE TUBULES- DIRECT TOXICITY TO THE TUBULES- AMINOGLYCOSIDESAMINOGLYCOSIDES
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
3.3. MicrobiologyMicrobiologyBlood cultureBlood cultureCRPCRPMid-stream urineMid-stream urineOther culturesOther cultures
4.4. Imaging Imaging Renal USGRenal USGChest X rayChest X rayECGECG
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
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
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
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.
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.
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
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.
Intermittent Intermittent haemodiafiltrationhaemodiafiltration
Peritoneal dialysisPeritoneal dialysis
Seldom achieves adequate Seldom achieves adequate biochemical controlbiochemical control
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
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
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