Acute Kidney Failure

Dr. Syamsudin, M.Biomed

Fakultas Farmasi
Universitas Pancasila
 Anatomy
• 2 Kidneys
• 2 Ureters
• Bladder
• Urethra
 Kidney Function
• Detoxify blood
• Increase calcium absorption
– calcitriol
• Stimulate RBC production
– erythropoietin
• Regulate blood pressure and electrolyte
balance
– renin
 Acute Kidney Failure
• Suatu sindrom yang ditandai penurunan drastis
:-↓ GFR
- retensi limbah metabolisme Nitrogen
There is no “normal” serum Creatinine
Creatinine is a poor marker for true GFR
- Gangguan volume ekstraseluler
- Gangguan homeostasis asam-basa
GFR
 ARF definitions
• Anuria – no urine output or less than
100mls/24 hours

• Oliguria - <500mls urine output/24 hours or

<20mls/hour

• Polyuria - >2.5L/24 hours

 Presentasi GGA
• Penyakit yg menyebabkan hipoferpusi pada
ginjal tanpa kerusakan integritas dari
parenkim ginjal (GGA prerenal)……< 55%
• Penyakit yg secara langsung melibatkan
parenkim renal (GGA renal)…………<40%
• Penyakit yang berhubungan dg obstruksi
pada saluran kemih (GGA post
renal)…..<5%)
Gagal Ginjal Akut
ARF Pirouz Daeihagh, M.D.Internal medicine/Nephrology Wake Forest University School of Medicine. Downloaded 4.6.09
 Glomerular blood flow
Compensatory
Dilators:
Prostacyclin, NO

Blocker:
NSAID Glomerular
Afferent arteriole Capillaries & Efferent art
Mesangium
Blocker:
ACE-I

Compensatory
Constrictors: endothelin,
Constrictor:
catecholamines, thromboxane
Angiotensin II
 Causes of Prerenal Acute Kidney
Failure (↓ kidney blood flow)
• Decreased effective extracellular volume
– True volume loss
• Vomiting, diarrhea, hemorrhage, burns, diuretics
– Redistribution
• hepatopathy, nephrotic syndrome, pancreatitis, peritonitis
– Decreased cardiac output
• cardiogenic shock
– Peripheral vasodilation
• hypotension, shock, renal vasoconstriction or inflammation
Causes of Parenchymatous Acute
Kidney Failure
• Acute Tubular Necrosis
– Hemodynamic
• surgery, sepsis, severe dehydration
– Toxic
• antimicrobials, immunosuppressive, venoms, mannitol
– Intratubular deposists
• uric acid, myeloma
– Organic pigments
• Myoglobin (rhabdomyolisis), hemoglobinuria
 GGA renal
• Penyakit dari pembuluh darah besar ginjal
• Penyakit dari mikrosirkulasi ginjal dan
glomerolus
• GGA iskemik dan akibat nefrotoksik
• Redang tubulointerstisial
 GGA iskemik
• Tekanan ultrafiltrasi glomerolus dikurangi
sebagai konsekuensi dari rendahnya aliran
darah ginjal
• Aliran saringan glomerolus dalam tubulus
dihalangi oleh epitel dari berkas limbah
nekrotik yang berasal dari tubulus epitel
Acute Tubular Necrosis
 Parenchymal Acute Kidney Failure
• Acute Tubulointerstitial Nephritis
• Acute Glomerulonephritis
– Postinfectious: streptococcal or other
– Systemic lupus erythematosus
– Etc.
• Vascular Occlusion
– Renal artery thrombosis, bilateral renal vein thrombosis
 Most Frequent Causes of ATN
• Antimicrobials • Immunological
– Penicillin • Infections
– Ampicillin
• Analgesics • Neoplasia
– Fenoprofen/Ibuprofen • Idiopathic
– Naproxen – Associated with uveitis
• Other drugs and adolescent females
– Cimetidine
– Allopurinol
 Acute Kidney Failure
• Post-Kidney Obstruction
• BPH (older men)
• Stones
obstruction
• Posterior Urethral Valves (boys)
• Trauma
• Compression by tumor, hemorrhage
Urinalysis in ARF
Red Blood Cell Cast
 Red Blood Cells

Monomorphic Dysmorphic
Dysmorphic Red Blood Cells
White Blood Cells
White Blood Cell Cast
Pigmented Granular Casts
 Acute Kidney Failure
• Considerations
– Blood pressure status
– Potassium status
– Volume status
– Acid Base status
 Manifestasi klinik
• Akut atau Kronis? : nitrogen ureum darah
kreatinin

Kronis: -anemia
-neurofati
-radiologis osteodistrofi ginjal
Hydronephrosis
Complications: Hypertension
– Hypertensive Emergency
• Elevated blood pressure with evidence of end organ
damage
– Kidney failure
– Heart failure (pulmonary edema)
– Stroke
– Seizure
– Hypertensive Crisis
• Markedly elevated blood pressure without evidence
of end organ failure
 Hypertensive Emergencies
• Symptoms
– Headache
– Mental status change
– Blurry vision
– Seizures
– Respiratory failure
– Chest pain
 Antihypertensive Drug Doses

Drug Dose

Nicardipine 1-10 μg/kg/min IV drip

Labetolol 0.2-0.4 mg/kg IV push
Labetolol 0.25-1 mg/kg/min IV drip
Nitroglycerin 0.05-0.1 μg/kg/min IV
Nitroglycerin SL 0.4 mg Sublingual
Nitroprusside 0.3-8 μg/kg/min IV drip
Diazoxide 1-3 mg/kg/ IV push
Nifedipine SL 0.25-2 mg/kg/dose sublingual
Hydralizine 0.2-0.5 mg/kg/dose IV
 Complications: Hyperkalemia
• Mechanism: ↑ potassium release from cells
• Differential Diagnosis
• Metabolic acidosis (DKA, sepsis)
• Insulin deficiency
• Tissue catabolism
• Exercise
• Tissue Destruction (crush injury, electrical burns)
• Digitalis overdose
 Hyperkalemia
• Mechanism: Decreased Excretion
• Kidney Failure
• Hypoaldosteronism
• Hypovolemia
• Selective Impairment of excretion
 Hyperkalemia EKG Findings
• In order of occurrence
– Peaked T waves
– Reduced P wave voltage
– Widening of the QRS complex
– Sinusoidal EKG pattern
– Ventricular Fibrillation
 Hyperkalemia & EKG
• K > 5.5 -6
• Tall, peaked T’s
• Wide QRS
• Prolong PR
• Diminished P
• Prolonged QT
• QRS-T merge – sine
wave
 Pharmacologic Treatment

Drug Dose
Calcium Gluconate 0.5-1 mg/kg IV
Insulin and Glucose Glucose 0.5 g/kg Insulin 0.1unit/kg
Beta Agonists 10 mg nebulized/hour
Sodium Bicarbonate 1-2mEq/kg IV
Kayexalate 1 gm/kg PR for 1 hour, then repeat
Complications: Pulmonary Edema
• Definition
– Accumulation of fluid in the alveolar space either due
to hydrostatic forces or capillary leak

• Can occur with or without volume overload

• tachypnea, wheezing, pink frothy sputum

 Treatment of Pulm Edema

Drug Dose
Lasix 0.5-2 mg/kg/dose IV
Nitroglycerin SL, paste, or 1-10 μg/kg/min IV drip
Dobutamine 2.5-20 μg/kg/min IV drip
Morphine 0.2-0.4 mg/kg/dose IV
Complications: Metabolic Acidosis
• Definition
– Disturbance in the acid base homeostasis
– Causing a decrease serum bicarbonate concentration
• by the addition of exogenous acid to the serum
- or -
• the loss of endogenous bicarbonate
 Metabolic Acidosis
• Differential Diagnosis
– High anion Gap acidosis (MUDPILES)
• Methanol Inborn errors of metabolism
• Uremia (Kidney Failure) Lactic Acidosis
• Diabetic Ketoacidosis EtOH, Ethylene Glycol
• Paraldehyde Salicylates
– Normal anion gap
• Diarrheal losses
• Renal tubular acidosis
 Indications for Dialysis
• Severe pulmonary edema
• Hyperkalemia
• Severe electrolyte abnormalities
• Severe metabolic acidosis
• Specific intoxications
• Specific inborn errors of metabolism

• …which is unresponsive to medical therapy

 Hemodialysis
• 3-4 times a week
• Takes 2-4 hours
• Machine filters
blood and
returns it to
body
 Peritoneal Dialysis
• Abdominal lining filters blood
• 3 types
– Continuous ambulatory
– Continuous cyclical
– Intermittent
 Definitions- Solute Removal
• Dialysis- Osmosis
Permeable
Membrane Solute Equilibrium
Definitions- Solute Removal
Dialysis

Blood Dialysate Blood Dialysate Blood New

Dialysate

Dialysate
Flow
 Definitions- Dialysate
• Peritoneal dialysate can be used
• Or the following can be made in house
– NaCl 140 mEq/L
– KCl 3 mEq/L
– Dextrose 100 mg/dl
– MgSO4 1.5 mEq/L
– Lactate 35 mEq/L
– CaCl 3.5 mEq/L
• All values can be adjusted to conform to the
individual patient
Mortality Trends and Acute
Renal Failure