ACUTE RENAL FAILURE

Hasyim kasim

Syndromes in Nephrology
Acute nephritis Nephrotic syndrome Asymptomatic urinary abnormalities Acute renal failure Chronic kidney disease Urinary tract infection Urinary tract obstruction Renal tubular defects Hypertension Nephrolithiasis

Syndromes in Nephrology
Acute nephritis Nephrotic syndrome Asymptomatic urinary abnormalities Acute renal failure Chronic kidney disease Urinary tract infection Urinary tract obstruction Nephrolithiasis Hypertension Renal tubular defects

Acute Renal Failure

An abrupt and sustained decrease (days to weeks) in renal function resulting in retention of nitrogenous (urea and creatinine) and non-nitrogenous waste products. Depending on severity and duration of the renal dysfunction, this accumulation is accompanied by metabolic dysturbance, such as metabolic acidosis and hyperkalaemia, changes in body fluid balance, and effects on many other organ systems.

Acute Renal Failure

An acute and sustained increase in serum creatinine concentration of 0.5 mg% if the baseline is < 2.5 mg%, or an increase in serum creatinine concentration of > 20% if the baseline is > 2.5 mg%.

Acute Renal Failure

Oligouric
Non-oligouric

EPIDEMIOLOGY
1% of hospitalized patients
20% of patients treated in ICU 4-15% of patients after cardiovascular surgery

Prerenal

35 %

CLASSIFICATION OF ACUTE RENAL FAILURE

Renal

50 %

Postrenal

10 %

ACUTE RENAL FAILURE

PRERENAL

Absolute decrease in effective blood volume Haemorrhage Volume depletion

Relative decrease in blood volume (ineffective arterial volume) Congestive heart failure Decompensated liver cirrhosis
Arterial occlusion or stenosis of renal artery

Haemodynamic form NSAIDs ACE-inhibitors or angiotensin-II receptor antagonists in renal-artery stenosis or congestive heart failure

Hypovolemia

Baroreceptor activation

Reduced affective circulation volume

Respons neurohormonal

Axis renin-angiotensin aldosterone

Vasopressin

Sympathetic nervous system

Vasoconstriction contraction of mesangial cells Reabsorpsi natrium and water

Reduced renal blood flow and glomerular filtration rate

Acute renal failure pre-renal

ACUTE RENAL FAILURE

INTRINSIC RENAL

Vascular Vasculitis, Malignant HT

Glomerulonephritis

Acute interstitial nephritis Drugs Allergy

Acute tubular necrosis

Ischaemic (50%)

Nephrotoxic (35%)

Exogenous Antibiotics (gentamicin) Radiocontrast agents Cisplatin

Endogenous Intratubular pigments (haemoglobinuria, myoglobinuria) Intratubular proteins (myeloma) Intratubular crystals (uric acid, oxalate)

ACUTE RENAL FAILURE

POSTRENAL

Obstruction of collecting system or extrarenal drainage

Bladder-outlet obstruction Bilateral ureteral obstruction or unilateral in one functioning kidney

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

Urinalysis and urine microscopy

Plasma biochemistry

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

Urine biochemistry

Full blood count

Findings that suggest prerenal causes Volume depletion Congestive heart failure Severe liver disease or other edematous state Findings that suggest postrenal causes Palpable bladder or hydronephrotic kidneys Enlarge prostat Abnormal pelvic examination Large residual bladder urine volume History of renal calculi (perform USG to screen obstruction) Findings that suggest intrinsic renal disease Hypotension, exposure to nephrotoxic drugs Recent radiographic procedure with contrast

Finding in the urine sediment

If no abnormalities: suspect prerenal or postrenal azotemia
If eosinophils: suspect acute interstitial nephritis If red blood cell casts: suspect glomerulonephritis or vasculitis If renal tubular ephitelial cells and muddy brown casts: suspect acute tubular necrosis

Assessment of a Patient with Acute Renal Failure (2)

Procedure
Renal ultrasound Plus, where appropriate : Abdominal CT-Scan To define structural abnormalities of the kidneys or urinary tract To assess abnormal renal perfusion To evaluate / relieve urinary tract obstruction

Information Sought
To determine kidney size, presence of obstruction, abnormal renal parenchymal texture

Radionuclide scan Cystoscopy +/- retragrade pyelograms Renal biopsy

To define pathology of renal parenchymal disease

Management priorities in patients with acute renal failure

Search for and correct prerenal and postrenal factors.

Review medications and stop administration of nephrotoxins.

Optimise cardiac output and renal blood flow. Monitor fluid intake and output; measure bodyweight daily. Search for and treat acute complications (hyperkalaemia, hyponatraemia, acidosis, hyperphospataemia, pulmonary oedema). Provide early nutritional support. Search for and aggressively treat infections.

Expert nursing care (management catheter care and skin in general; physicological support).
Initiate dialysis before uraemic complication emerge. Give drugs in doses appropriate for their clearance.

Indications for dialysis in acute renal failure

Indications Uremia Characteristics Asterixis, seizures, nausea & vomiting, pericarditis

Hyperkalemia

K+ >6.5 mmol/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

Fluid overload

Metabolic acidosis

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