ACUTE RENAL FAILURE THERAPY

2014
 Stepwise Diagnostic Approach to Acute
Renal Failure
• Step 1
– History
– Record review
– Physical examination
• Volume status assessment
– Bladder evaluation
– Urinalysis

JASN 9(4):710-718, 1998

 Stepwise Diagnostic Approach to Acute
Renal Failure
• Step 2
– Urinary indices
– Renal/urinary imaging
– Additional volume status measures
– Renal vascular status
– Blood and urine lab tests
 Stepwise Diagnostic Approach to Acute
Renal Failure
• Step 3
– Consider therapeutic trials
• Volume challenge
• Foley placement
• Hemodynamic support
• Step 4
– Consider renal biopsy
– Consider empiric therapy
 Acute Kidney Injury

AKI

PRERENAL INTRINSIC POSTRENAL

 Acute Kidney Injury
• PRERENAL: 40-80%
– Volume loss/Sequestration

– Impaired Cardiac Output

– Hypotension (and potentially hypo-oncotic states)

• Net result: glomerular hypoperfusion

 Acute Kidney Injury
• RENAL/INTRINSIC: 10-30%
– Vascular disorders:
– small vessel
– large vessel
– Glomerulonephritis
– Interstitial disorders:
– Inflammation
– intercalative processes
– Tubular necrosis:
– Ischemia
– Toxin
– Pigmenturia
 Acute Kidney Injury
• POSTRENAL: 5-15%
– Intrarenal
– Crystals
– Proteins

– Extrarenal
– Pelvis/Ureter
– Bladder/Urethra
 Urinary Indices
• Prerenal • ATN

– Sp Gr >1.020 – Sp Gr ≈1.010
– Uosm >500 – Uosm >300
– FENa <1% – FENa >2%
– FEUrea ≤35% – FEUrea >50%
 AKI: Diagnostic studies-urine
• Urinalysis for sediment, casts
• Response to volume repletion with return to
baseline SCr 24-72 hr c/w prerenal event
• Urine Na; FENa
FENa (%) = UNa x SCr x 100
SNa x UCr

– FENa < 1%: Prerenal

– FENa 1-2%: Mixed
– FENa > 2%: ATN
• Hansel’s stain
 Urinalysis in Acute Kidney Injury

Normal/bland Abnormal sediment

Hematuria WBC Eosinophils RTE cells Crystalluria Non-

RBC casts WBC casts Pigmented albumin
proteinuria casts proteinuria

Prerenal Glomerulopathy Pyelonephritis AIN ATN Uric acid Plasma cell

Postrenal Vasculitis Interstitial Athero- Myoglobin Toxins dyscrasia
Oncotic Thrombotic MA nephritis embolic Hemoglobin Drugs
AKI AKI
 Acute Kidney Injury

LABORATORY DATA
• Creatinine; also BUN/Cr ratio
• CBC: anemia, thrombocytopenia
• HCO3ˉ: anion gap, lactic acid, ketones
• K
• CPK/LDH/Uric acid/liver panel
• Serologies:
– Complement
– ESR, RF, ANA, ANCA, AntiGBM
– Electrophoresis
• Toxicology studies
 Acute Kidney Injury: AIN causes

DRUGS INFECTION
• ACEI • Bacterial
• Allopurinol – Agents causing pyelonephritis
• Cephalosporins – Legionella
– Brucella
• Cimetidine
– Yersinia
• Fluoroquinolones
• Viral
• Loop diuetics
– Hantavirus
• NSAIDS – HIV
• PCN – CMV,EBV,HSV
• Phenytoin
• Rifampin
• Sulfonamides
• Tegretol
• Thiazides
 The Three Pivotal Bedside Tests

• Orthostatic Vital Signs

• Fluid Challenge
• Foley Placement
 Treatment of ARF
• Eliminate the toxic insult
• Hemodynamic support
• Respiratory support
• Fluid management
• Electrolyte management
• Medication dose adjustment
• Dialysis
 Prevention of ARF
• Diminish risk of nosocomial infection
– conservative use of IV catheters
– judicious use of antibiotics
– hand-washing
• Prevention of nephrotoxicity
– avoid/reduce nephrotoxins
– IV NS
– N-acetylcysteine, sodium bicarbonate
– correct hypokalemia, hypomagnesemia
– correct/treat other systemic diseases
• Pharmacology
– avoid overlapping nephrotoxins
– follow drug levels closely
• Attention to fluid status
– Regular weights, I & O
JASN 9(4):710-718, 1998
 Lab finding

• Rising creatinine and urea

• Rising potassium
• Decreasing Hb
• Acidosis
• Hyponatraemia
• Hypocalcaemia
 ARF TREATMENT
• Immediate treatment of pulmonary edema and
hyperkalaemia
• Remove offending cause or treat offending cause
• Dialysis as needed to control hyperkalaemia,
pulmonary edema, metabolic acidosis, and uremic
symptoms
• Adjustment of drug regimen
• Usually restriction of water, Na, and K intake, but
provision of adequate protein
• Possibly phosphate binders and Na polystyrene
sulfonate
 TREATMENT
• NON PHARMACOLOGY
– AGGRESSIVE FLUID MANAGEMENT
– MAINTAIN EUVOLEMIA
– TISSUE PERFUSSION
– ELECTROLYTE BALANCE
– AVOID NEPHROTOXIN
– REPLACEMENT THERAPY
• INTERMITTEN (IRRT)
• CONTINUOUS (CRRT)
 WHEN TO USE RT
• ACID –BASE ABNORMALITY
• ELCTROLYTE IMBALANCE
• INTOXICATION
• FLUID OVERLOAD
• UREMIA
 PHARMACOLOGY
• LOOP DIURETICS
• MANNITOL 20% AT 12.5 – 25 G IV OVER 3 – 5
MINUTES
• OPEN PAGE 778

• NUTRITIONAL THERAPY
 Recognise the at-risk patient
• Reduced renal reserve:
Pre-existing CRF, age > 60, hypertension,
diabetes
• Reduced intra-vascular volume:
Diuretics, sepsis, cirrhosis, nephrosis
• Reduced renal compensation:
ACE-I’s (ATII), NSAID’s (PG’s), CyA
 EVALUATION OF TOC
• PAGE 780
• CHECK BLOOD PARAMETER CONCENTRATION
• FOR RENAL FUNCTION
QUESTION??