Clinical Presentation of Renal Disease

Chronic renal failure (CRF) Acute renal failure (ARF) Hypertension Asymptomatic proteinuria and persistent urinary abnormalities Nephrotic syndrome (NS) Urinary tract infection (UTI) Acute nephritis Obstructive nephropathy Renal stones Renal tubular defects

Acute Renal Failure

Acute renal failure (ARF) is a clinical characterized by an abrupt decline in glomerular filtration rate (GFR) and the accumulation of nitrogenous waste (urea nitrogen and creatinine)

Prerenal

Prerenal Hipovolemia Reduced effective extra cellular volume Renal Arterial Occlusion Intrarenal vascular Vasculitis Hemolytic uremic syndrome Trombotic thrombocytopenic purpura Accelerated hypertension Glomerulonephritis

Causes of acute renal failure

Renal

Renal parenchymal

Ischemic acute tubular necrosis (ATN) Toxic ATN Endogenous toxin Exogenous toxin Interstitial Acute allergic interstitial nephritis Bilateral acute pyelonephritis Intrarenal Obstruction Casts Crystal's Renal Vein occlusion

Postrenal

Urinary tract obstruction

Causes of prerenal failure

Prerenal failure

Reduced efective Extracellular fluid volume

Impaired renal autoregulation

Hypovolemia
Hemorrhage Fluid loss : gastrointestinal, renal, skin, respiratory, surgical Hypoalbuminemia Third spacing Cardiac failure

Systemic Vasodilatation
Sepsis Myocardial dysfunction Cirrhosis Valvular dysfunction Anaphylaxis

Preglomerular vasoconstriction Sepsis Hypercalcemia Hepatorenal syndrome Postglomerular vasoconstriction ACE inhibitors

Cardiac tamponade
Anesthesia Pulmonary hypertension Pharmacologic vasodilatation

Pharmacologic agents : NSAIDs, Cyclosporin A Amphotericin B Epinephrine norepinephrine

Angiotensin T1 receptor antagonists

Hypovolemia

Decreased effective Arterial blood volume

Baroreceptor activation

Neurohormonal responses

Renin angiotensin Aldosteron axis

Vasopressin

Sympathetic nervous system

Renal blood flow maintained Initially through : Local myenteric reflex prostaglandin synthesis actions of angiotensin II

Vasoconstriction Mesangial cell contraction Avid salt and water reabsorption Reduce sweating Thirst and salt appetite

Homeostatic goal : Restore intravascular volume And blood pressure to maintain Perfusion of essential organs

Prerenal acute renal failure Dramatic reduction in renal Blood flow, glomerular filtration, Urine flow

Dramatic reduction in Splanchnic, skin, and Musculoskeletal blood flow

Clinical evaluation of ARF is achieved by answering the following five question Is it ARF or acute on chronic renal failure ? Is there renal tract obstruction ? Is there reduction in effective ECF volume ? Has there been a major vascular occlusion ? Is there parenchymal renal disease other than ATN ?

Urine sediment in ARF

Condition
Prerenal azotemia
Valvular occlusion

Proteinuria
-

Hematuria Microscopy
-

Normal
Normal Dysmorphic red cells, red cell cast, granular casts White cell (pyuria) and occasionally white cell cast

Glomerulonephritis

+++

+++

Acute interstitial nephritis Hemolytic uremic Syndrome/Thrombotic thrombocytopenic purpura

++

+/-

Normal

Acute Tubular Necrosis (ATN)

Muddy brown granular ATN casts, tubular epithelial cell casts (fewer casts, sometimes none in nonoliguric ATN)

Renal ultrasound in acute renal failure

Observation
Pelvicalyceal dilatationa Shrunken kidneys

Indication
Obstructive nephropathy Chronic intrinsic renal disease

Normal size kidneys echogenic Acute glomerulonephritis, acute normal echo pattern tubular necrosis Prerenal azotemia, renal artery occlusion Enlarged kidneys Malignant infiltration, renal vein thrombosis, HIV-associated nephropathy, amyloid

aPC

dilatation is usual but not universal in the presence of obstruction

Clinical assessment of patients with acute renal failure

Search for reversible factors that may be exacerbating acute renal failure, e.g. hypovolemia, ongoing administration of nephrotoxins Examine for clinical evidence of uremic syndrome, e.g. asterixis, confusion, hiccups, nausea, vomiting, pericarditis Clinical assessment of intravascular volume Review most recent laboratory results for metabolic complications: hyperkalemia, acidosis, hype rphosphatemia Review drug prescription: discontinue all non-essential drugs and adjust dose or dose interval of drugs eliminated by kidney Review nutritional status: consider protein, salt, potassium, and phosphate restriction; consider need for enteral nutrition or hyperalimentation

Assessment of a Patient with Acute Renal Failure (1)

Procedure
Clinical history and examination

Information Sought
Clues to the cause of acute renal failure Indicators of severity of metabolis disturbance Estimate of volume status (hydration) Markers of glomerular or tubulointerstitial inflammation, urinary tract infection or crystal uropathy To assess extent of GFR reduction and metabolic consequences To differentiate prerenal from established renal failure To determine presence of anemia, leucocytosis, and platelet consumption

Urinalysis and urine microscopy

Plasma biochemistry Urine biochemistry Full blood count

Assessment of a Patient with Acute Renal Failure (2)

Procedure
Renal ultrasound Plus, where appropriate : Abdominal CT-Scan Radionuclide scan Cystoscopy +/- retragrade pyelograms Renal biopsy

Information Sought
To determine kidney size, presence of obstruction, abnormal renal parenchymal texture To define structural abnormalities of the kidneys or urinary tract To assess abnormal renal perfusion To evaluate / relieve urinary tract obstruction To define pathology of renal parenchymal disease

Changes in plasma biochemistry in acute renal failure

Hyperkalaemia
Decreased bicarbonate Elevated urea

Elevated creatinine
Elevated uric acid Hypocalcaemia

hyperphosphataemia

Management of ARF

Prerenal Classification of the major Causes of acute renal failure

Prerenal Hipovolemia Reduced effective extra cellular volume

Renal Arterial Occlusion Intrarenal vascular Vasculitis Hemolytic uremic syndrome Trombotic thrombocytopenic purpura Accelerated hypertension

Causes of renal failure

Hipovolemia

Management

Stop diuretic, administer blood, Glomerulonephritis crystalloid, colloid infusions

Ischemic acute tubular necrosis (ATN)

Reduced effective Renal Renalarterial blood volume parenchymal cardiac failure sepsis
Drug impaired autoregulation

Toxic ATN Endogenous toxin Exogenous toxin

Inotropes, diuretics, afterload reduction Pressor agents, crystalloid, antibiotics

Interstitial Acute allergic interstitial nephritis Bilateral acute pyelonephritis

Stop nonsteroidal anti-inflammatory agents, ACE inhibitors, cyclosporine Intrarenal Obstruction

Casts Crystal's Renal Vein occlusion

Postrenal

Urinary tract obstruction

Prerenal Classification of the major Causes of acute renal failure

Prerenal Hipovolemia Reduced effective extra cellular volume

Renal Arterial Occlusion Intrarenal vascular Vasculitis Hemolytic uremic syndrome Trombotic thrombocytopenic purpura Accelerated hypertension Glomerulonephritis Causes of renal failure

Management

Renal Renal parenchymal Renal Arterial Occlusion

Ischemic acute tubular necrosis (ATN)

Toxic ATN Endogenous toxin Exogenous toxin

Anticoagulation, thrombolysi Angioplasty/stent/surgery

Interstitial Acute allergic interstitial nephritis Bilateral acute pyelonephritis

Intrarenal Obstruction Casts Crystal's Renal Vein occlusion

Postrenal

Urinary tract obstruction

Prerenal Classification of the major Causes of acute renal failure

Prerenal Hipovolemia Reduced effective extra cellular volume

Renal Arterial Occlusion Intrarenal vascular Vasculitis Hemolytic uremic syndrome Trombotic thrombocytopenic purpura Accelerated hypertension

Causes of renal Glomerulonephritis failure

Management

Intrarenal vasculature Ischemic acute tubular necrosis (ATN) Renal RenalVasculitis Immunosuppressant parenchymal Toxic ATN Hemolytic uremic syndrome/ Plasma exchange/plasma infusion Endogenous toxin Exogenous toxin Trombotic thrombocytopenic Interstitial purpura Acute allergic interstitial nephritis Bilateral acute pyelonephritis Accelerated hypertension Lower blood pressure; sodium Intrarenal Obstruction nitroprusside, labetalol, etc
Casts Crystal's Renal Vein occlusion

Postrenal

Urinary tract obstruction

Prerenal Classification of the major Causes of acute renal failure

Prerenal Hipovolemia Reduced effective extra cellular volume

Renal Arterial Occlusion Intrarenal vascular Vasculitis Hemolytic uremic syndrome Trombotic thrombocytopenic purpura Accelerated hypertension

Causes of renal failure Glomerulonephritis

Renal Renal Glomerular disease parenchymal

Management

Consider Immunosuppressant Antibiotics of endocarditis Toxic ATN Endogenous toxin Supportive care if postinfectioous Exogenous toxin
Ischemic acute tubular necrosis (ATN)

Interstitial Acute allergic interstitial nephritis Bilateral acute pyelonephritis

Intrarenal Obstruction Casts Crystal's Renal Vein occlusion

Postrenal

Urinary tract obstruction

Prerenal Classification of the major Causes of acute renal failure

Prerenal Hipovolemia Reduced effective extra cellular volume

Renal Arterial Occlusion Intrarenal vascular Vasculitis Hemolytic uremic syndrome Trombotic thrombocytopenic purpura Accelerated hypertension Glomerulonephritis Causes of renal failure

Management

Renal Renal Ischemic parenchymal tubular acute

Ischemic acute tubular necrosis (ATN)

Toxic ATN Endogenous toxin Exogenous toxin

Supportive care Threat cause of circulatory failure

Interstitial Acute allergic interstitial nephritis Bilateral acute pyelonephritis

Intrarenal Obstruction Casts Crystal's Renal Vein occlusion

Postrenal

Urinary tract obstruction

Prerenal Classification of the major Causes of acute renal failure

Prerenal Hipovolemia Reduced effective extra cellular volume

Renal Arterial Occlusion Intrarenal vascular Vasculitis Hemolytic uremic syndrome Trombotic thrombocytopenic purpura Accelerated hypertension Glomerulonephritis Causes of renal failure

Management

Renal Renal Toxic ATNparenchymal

Ischemic acute tubular necrosis (ATN)

Toxic ATN Endogenous toxin Exogenous toxin

Supportive care Discontinue toxin

Interstitial Acute allergic interstitial nephritis Bilateral acute pyelonephritis

Intrarenal Obstruction Casts Crystal's Renal Vein occlusion

Postrenal

Urinary tract obstruction

Prerenal Classification of the major Causes of acute renal failure

Prerenal Hipovolemia Reduced effective extra cellular volume

Renal Arterial Occlusion Intrarenal vascular Vasculitis Hemolytic uremic syndrome Trombotic thrombocytopenic purpura Accelerated hypertension

Causes of renal failure

Management

Glomerulonephritis

Interstitial disease Ischemic acute tubular necrosis (ATN) Renal Renal Allergic interstitial nephritis Discontinue offending drugs ; consider corticosteroid parenchymal Toxic ATN Bilateral acute pyelonephritis Antibiotics Endogenous toxin Exogenous toxin Malignant infiltration Chemotherapy
Interstitial Acute allergic interstitial nephritis Bilateral acute pyelonephritis
Intrarenal Obstruction Casts Crystal's Renal Vein occlusion

Postrenal

Urinary tract obstruction

Prerenal Classification of the major Causes of acute renal failure

Prerenal Hipovolemia Reduced effective extra cellular volume

Renal Arterial Occlusion Intrarenal vascular Vasculitis Hemolytic uremic syndrome Trombotic thrombocytopenic purpura Accelerated hypertension

Causes of renal failure

Management

Glomerulonephritis

Ischemic acute tubular necrosis (ATN) Intrarenal obstruction Renal Renal Myeloma cast parenchymal Consider plasma exchange and chemotherapy Toxic ATN Endogenous toxin drugs Exogenous crystals Stop offending Exogenous toxin Endogenous crystals Alkaline diuresis for rhabdomyolysis or acute urate Interstitial nephropathy Acute allergic interstitial nephritis Bilateral acute pyelonephritis Intrarenal Obstruction Casts Crystal's Renal Vein occlusion

Postrenal

Urinary tract obstruction

Prerenal Classification of the major Causes of acute renal failure

Prerenal Hipovolemia Reduced effective extra cellular volume

Renal Arterial Occlusion Intrarenal vascular Vasculitis Hemolytic uremic syndrome Trombotic thrombocytopenic purpura Accelerated hypertension Glomerulonephritis Causes of renal failure

Management

Renal Renal parenchymal Renal Vein occlusion

Ischemic acute tubular necrosis (ATN)

Anticoagulation Toxic ATN Treat glomerular disease if Endogenous toxin Exogenous toxin nephrotic
Interstitial Acute allergic interstitial nephritis Bilateral acute pyelonephritis
Intrarenal Obstruction Casts Crystal's Renal Vein occlusion

Postrenal

Urinary tract obstruction

Prerenal Classification of the major Causes of acute renal failure

Prerenal Hipovolemia Reduced effective extra cellular volume

Renal Arterial Occlusion Intrarenal vascular Vasculitis Hemolytic uremic syndrome Trombotic thrombocytopenic purpura Accelerated hypertension

Causes of renalGlomerulonephritis failure

Management

Renal Renal parenchymal Toxic ATN Bladder catheter / nephrostomy toxin Urinary tract obstructionEndogenous Exogenous toxin Radiologic / surgical treatment of
Interstitial Acute allergic interstitial nephritis Bilateral acute pyelonephritis
Intrarenal Obstruction Casts Crystal's Renal Vein occlusion

Ischemic acute tubular necrosis (ATN)

obstructing lesion

Postrenal

Urinary tract obstruction

Non-dialytic management of acute tubular necrosis (1)

Complication
Intravascular Volume overload Hyponatremia

Treatment
Restrict salt (1-2g/day) and water (usually <1L/day) Diuretics (usually loop diuretics - thiazide) Restrict enteral water intake (<1Uday). Avoid hypotonic intravenous solutions (including dextrose solutions) Restrict dietary K' intake (usually <40mmol/day) Eliminate K` supplements and K'-sparing diuretics Potassiumbinding ion-exchange resins e.g. sodium polystyrene sulfonate (calcium resonium') Glucose (50mL of 50% dextrose) and insulin (10 units regular) Sodium bicarbonate (usually 50-100mmol) (32 Agonist (e.g. albuterol 10-20 mg inhaled or 0.5-1mg i.v.) Calcium gluconate (10mL of 10% solution over 2-5 minutes)

Hyperkalemia

Metabolic acidosis

Restrict dietary protein (usually 0.6g/kg per day of high biologic value) Sodium bicarbonate (maintain serum bicarbonate >15mmol/L and arterial pH >7.2)

Non-dialytic management of acute tubular necrosis (2)

Complication
Hyperphosphatemia

Treatment
Restrict dietary phosphate intake (usually <800mg/day) Phosphate-binding agents (calcium carbonate, calcium acetate, aluminum hydroxide) Calcium carbonate (if symptomatic or if sodium bicarbonate to be administered) Calcium gluconate (10-20mL of 10% solution)

Hypocalcemia

Hypermagnesemia
Hyperuricemia Nutrition

Discontinue Mg2+-containing antacids

Treatment usually not necessary [if urate <900pmol/L (<15mg/dL)] Restrict dietary protein (-0.6g/kg per day) if not catabolic Carbohydrate (-100g/day)Enteral or parenteral nutrition (if course prolonged or very catabolic)

Indications for dialysis in acute renal failure

Indications
Uremia

Characteristics
Obtundation, asterixis, seizures, nausea and vomiting. pericarditis

Hyperkalemia
Fluid overload Metabolic acidosis

K'>6.5mmol/L K` 5,5-6,5 mmol/L if ECG changes

Fluid overload resistant to diuretics, especially pulmonary edema pH <7.2 despite sodium bicarbonate therapy; sodium bicarbonate not tolerated because of fluid overload