Definition

Significant deterioration of renal function occurring over hours or day.

Clinically without symptoms or signs but with oligouria <400ml/day is
common

Hypercatabolic ARF: More severe rise in urea (>10-12mmol/day). Seen
in sepsis

Acute on chronic ARF: Sudden drop of renal function in stable CRF

Oliguric ARF: <400ml/day

Non-oliguric ARF: normal urine output. Seen in 50-60% of cases (burn,
aminoglycosides toxicity, head trauma)

Diagnosis Abrupt reduction of kidney function (<48Hr), manifested by any 1 of the
following:

An absolute increase in serum creatinine of 0.3 mg/dL or greater
(26.4 mol/L)
A percentage increase in serum creatinine of 50% or greater (1.5-
fold from baseline)
A reduction in urine output, defined as less than 0.5 mL/kg/h for
more than 6 hours

Classification

Causes 1. Prerenal
a. Generalised reduction in tissue perfusion
b. Volume depetion (blood loss/fluid loss, cardiac failure,
cardiac tamponade, etc)
c. Selective reduction in renal perfusion
d. Bilateral renal artery stenosis, ACE inhibitor and NSAIDS
2. Renal
 a. Acute tubular necrosis: nephrotoxic (drugs-
amphothericin B, aminoglycosides and radiocontrast
poisons-heavy metals and methanol), post ischaemia
b. Acute interstitial nephritis (drug related or systemic
infection-leptospirosis)
c. Glomerulonephritis
d. Vasoconstrictive disease (malignant hypertension and
HUS)
e. Intratubular obstruction (uric acid and oxalates crystal)
3. Post renal
a. Obstruction of renal pelvis, ureter and bladder neck
Investigation Functional diagnosis (urine output and renal profile)
Delineate the etiology (urinalysis, ultrasound, CTD screening, renal
biopsy)
Defining life threatening event (CXR, BUSE, ECG, ABD)
Monitor progress (repeat RP, ABG and CXR)

Pre-renal ATN
Urine Na <20 >40
Urine osmolality >500 <350
Urine/plasma urea >8 <3
Urine/plasma >40 <20
creatinine

Fractional excretion <1% >2%
Management Mainly supportive
1. Fluid management
2. Depending on clinical status, if oliguric: fluid restriction, while
for prerenal phase: fluid replacement and correction of
intravascular volume:
3. Judgement of intravascular volume: determine the body
weight, clinically by percentage of dehydration, vital signs
and central venous pressure

4. Volume deficit
a. In hypotensive: fluid challenge with 250mls of NS over 5
minutes. If BP still low, inotropic agent given; if urine
output is low, give furosemide.

5. In normotensive: fluid challenge +/- furosemide
a. Without volume deficit
b. Start IV furosemide +/- inotropic agent

6. Blood pressure (fluid challenge vs antihypertensive agent)
7. Hyperkalaemia: insulin + glucose
8. Metabolic acidosis: 1 ml of 9.4% NaHCOO3 per Kg BW over 30
minutes
9. Nutrition: oral feeding
 10. Drug dose: adjusted depending on renal function -> loading dose
similar to non-renal dose, reducing dose and increase drug
interval. Therapeutic drug monitoring is important
11. Others: antibiotic, ranitidine and treat anaemia

ATN
Restrict fluids to 500mls + previous day total output
Salt restriction 2-4 gm per day

Complication Fluid overload/pulmonary oedema
Electrolyte abnormalities (hyperkalaemia)
Malnutrition
Infection
Bleeding tendency
Anaemia
Uraemic symptoms (vomiting, confusion fits)
Dialysis Pulmonary oedema
indication Pericarditis
Severe acidosis
Uncontrolled hyperkalaemia
Uraemic syndrome
Deteriorating condition
Urea >30ml and rising