Renal Failure

dr. H Tadjoedin Sp.Pd

William Osler

To study medicine without books is like to sail an uncharted sea

To study medicine without patient is not to sea at all -Medicine is an ever changing science-

Renal disease present into 2 ways:

1. 2. discover incidentally during routine medical exam renal dysfunction : - hypertension - edema - nausea - hematuri

Important: estimation of disease duration careful urinalysis GFR exam

Anatomic Distribution
Prerenal disease Post renal disease Intrinsic renal disease : : : poor renal perfusion obstractive urinary tract - Glomerular - Tubular - Interstitial - Vascular - Ischemic

Acute Tubular Necrosis (Olliguric/Polyuric) Acute Glomerulonephritis : poststreptococcal infection collagen-vascular disease Acute Interstitial Nephritis : allergic reaction, drug reaction

2 forms of renal failure :

1. Acute Renal Failure (ARF) 2. Chronic Renal Failure (CRF) ARF : within hours or days Retention nitrogen waste (urea nitrogen, creatinine) azotemia : a buildup of nitrogenous waste in blood. uremia : a constellation of symptoms and signs of multiple organ dysfunction caused by retention of uremic toxins in the setting of renal failure. CRF : lost of renal function over months / years DD between ARF and CRF is important for diagnoses and treatment

Diuresis :
Polyuri Oliguri Anuri : : : urine formation increase urine less than 400 cc/day urine less than 100 cc/day

Oliguri : crucial in CRF

Anaemi
Low in erythropoetin production rare in initial ARF Small kidneys in CRF Normal - large kidneys in CRF and ARF

Laboratory Examination :
I. II. Urinalysis : - must be examined within 1 hour - midstream Proteinuri : - greater than 150-160 mg / 24 hours - underlying diseases - usually glomerular in origin if greater than 1 gr / day 4 primary reasons : 1.Functional Proteinuri 2.Overload : Bence Jones

multiple myeloma myoglobulinuria (rhabdomyolysis) hemoglobinuria acute tubular necrosis toxic injury (Pb, aminoglycoside) drug induced hereditary metabolic diseases (Wilson diseases, Fanconi syndrome)

3. Glomerular Proteinuria 4. Tubular Proteinuria :

Laboratory Examination : (continue)

24 hours urine collection : Greater than 150 mg / 24 hours Greater than 3.5 gr / 24 hours

albuminuri nephrotic

In diabetic / non-diabetic reducing proteinuri by ACE or A2RB III. Haematuri

More than 3 RBC / high power field Glomerular / Non-glomerular False (+) : vitamin C, beets, bacteria, myoglobin

Examination
1. 2. 3. 4. 5. 6. USG IVP CT Scan MRI Scan Arteriography / Venography Renal Biopsy

Acute Tubular Necrosis

Tubular damage 85% of ARF 2 major causes :

1. Ischemic 2. Nephrotoxin

Ischemic :

- dehydration - hypotension - shock - hypoxemia - sepsis

- Tubular damage - Prerenal azotemia - Renal blood flow decrease - Major surgery : i. prolonged hypoperfusion ii. vasodelating effect of anesthetic agent

Acute Tubular Necrosis (continue)

Nephrotoxin : 1. Exogenous 25% aminoglycoside : gentamycin others : - tobramycin - streptomycin - amphotericin B. - vancomycin - acyclovir - cephalosporin - radiology contrast Basically : - renal damage - dehydration - old age

Acute Tubular Necrosis (continue)

2. Endogenous heme containing product uric acid paraprotein myoglobinuria due to rhabdomyolysis

Acute Tubular Necrosis (continue)

Symptoms : See renal failure Lab exam : urine brown renal tubular epithelial cells hyperkalemi hyperphosphatemi hypercalcemi

Acute Tubular Necrosis (continue)

Treatment : hastening recovery, avoid complication prevent overload, hyperkalemi loop diuretic thiaziade diuertic protein restiction : 0.6 mg / kg body weight hyperphosphatemi hypercalcemi aluminium hydroxcide

Indication HD :

- encephalopaty - pericarditis uremic complication - seizures - hyperkalemi - volume overload - worsening acidosis

Acute Tubular Necrosis (continue)

Course - Prognosis 3 stages : 1. initial injury 2. maintenance 3. recovery Mortality from ARF : 20% 50% due to medical illness 70% in surgical setting

Etiologies of Acute Renal Failure

Prerenal True volume depletion Extrarenal losses - Nausea / vomitting - Diarrhea, external fistulae Renal losses - Overdiuresis - Renal salt wasting - Diabetes inspidus Effective volume depletion - Sepsis - Cardiomyopathy - Cirrhosis / hepatic insufficiency - Nephrotic syndrome

Etiologies of Acute Renal Failure (continue)

Structural renal artery / arteriolar disease - Renal artery stenosis, arteriolonephrosclerosis Altered intrarenal hemodynamics - NSAIDs calcineurin inhibitors, ACE inhibitors, ARBs

Intrarenal Vascular disease - Arterial, arteriolar, venous Glomerular disease - Acute glomerulonephritis (immune complex, vasculitis, anti-GBM) - Thrombotic microangiopathy (TTP/HUS) - Monoclonal immunoglobulin deposition disease

Etiologies of Acute Renal Failure (continue)

Acute tubular necrosis - Nephrotoxic - Ischemic - Pigment-related - Crystal-associated nephropathy - Osmotic nephropathy Acute interstitial nephritis - Medication-induced - Infection (viral, fungal, bacterial) - Systemic diseases

Etiologies of Acute Renal Failure (continue)

Postrenal Pelvic / ureteral obstruction - Retroperitoneal disease - Nephrolithiasis - Fungus balls, blood clots Bladder obstruction - Structural (stones, benign prostatic hyperplasia, blood clots) - Functional (neuropathic, drugs) Urethral obstruction