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Evaluation and Management of Acute Renal Failure

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Title: Evaluation and Management of Acute Renal Failure


1
Evaluation and Management of Acute Renal Failure
  • ????? 95/10/12

2
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erythropoietin, RAS
3
  • Anuria urine lt 100ml/day
  • Oliguria urine lt400-500 mL/d
  • Azotemia Increase Cr, BUN
  • May be prerenal, renal, postrenal
  • Does not require any clinical findings
  • Chronic Kidney Disease graduated loss of renal
    function, National kidney fundation stage 15
  • ESRD Loss of kidney function gt3 months

4
Blood Urea Nitrogen (BUN)
  • Catabolism of aminoacids generates NH3
  • NH2
  • 2 NH3 CO2 C 0 H2O
  • NH2
  • Urea Mol wt 60 BUN Mol wt. 28
  • Normal BUN 10-20 mg/dl
  • After filtration 50 is reabsorbed by the
    tubule
  • BUN level is related to Renal function, protein
    intake, liver function, GI bleeding, steroid,
    hyper catabolic states

5
Creatinine
  • Formed at a constant rate by dehydration of
    muscle creatine
  • Normally 12 of muscle creatine is broken into
    creatinine
  • Mol. Wt. 113
  • Creatinine is freely filtered by the glomerulii
    and is not reabsorbed 1015 is secreted into
    proximal tubule

6
GFR Estimation by Plasma Creatinine
  • Cockcroft and Gault Formula
  • Calculated creatinine clearance
  • (140age) x wt (kg)
  • 72 X serum creatinine(mg/dl)
  • For females, subtract 15 (or multiply by 0.85)
    for paraplegics multiply by 0.8, for
    quadriplegics, multiply by 0.6
  • Applicable only when patient is in a steady
    state, not edematous and not obese

7
Factors that affect serum creatinine
concentration
8
Acute Renal Failure
  • Definition
  • Rapid (hours to weeks) decline in glomerular
    filtration rate and retention of waste products
  • It is a clinical syndrome cause by many renal or
    extrarenal diseases
  • Lack a uniform definition
  • Cr gt 1.5x, urine output lt0.5ml/kg/hr
  • Cr increase 1.0 mg/dl/2d

9
The Second International Consensus Conference of
the Acute Dialysis Quality Initiative (ADQI) Group
10
The facts you need to know about ARF
  • Acute renal failure may reversible and should
    look for the causes to management
  • Incidence
  • - 2-5 of hospitalized patients(55
    iatrogenic)
  • - 7-23 of ICU patients
  • - 20-60 require dialysis of those who
    survive initial dialysis, lt25 require long-term
    dialysis

11
The facts you need to know about ARF
  • Motality
  • Liano(1996) reported mortality rate of 60 for
    patient with ATN, 35 for acute on chronic renal
    failure, 27 for obstructive ARF and 26 for
    renal disorder other than ATN.
  • Knaus(1986)50 for combination of acute renal and
    respiratory failure towards 100 with 5 system
    failure
  • In community-acquired ARF with mostly prerenal
    and postrenal causes and the prognosis is better.
  • Rates not significantly decreased over past 50
    years despite advances in dialysis and critical
    care (increased patient age and co morbid
    illnesses)

12
Symptoms and Signs of Renal Failure
  • Retention of nitrogenous waste products
  • Nausea, vomiting, diarrhea, hiccup, foul taste,
    dry crusted mouth, itching,
  • Drowsiness, clouding of consciousness,
    neuropathy, pericarditis, GI bleeding,
  • Coma
  • Retention of salt and water
  • Pulmonary edema, peripheral edema, ascites,
    pleural effusion

13
Symptoms and Signs of Renal Failure
  • Retention of potassium
  • Weakness, lassitude, paralysis, EKG changes with
    tenting T waves, widening of QRS complex,
    increased PR interval, sine wave pattern, cardiac
    arrest, VT
  • Retention of acid
  • Kussmaul respiration, hyperreflexia, hypotension

14
A Cr, BUN B H, P, K C NaCl
15
Classification of ARF
Acute Renal Failure
Pre-renal
Intrinsic
Post-renal
Glomerular
Interstitial
Vascular
Tubular
16
Pre-renal ARF
  • Accounts for 60-70 of cases of ARF
  • Represents physiologic response to mild-moderate
    renal hypoperfusion
  • Renal parenchymal tissue is not damaged therefore
    rapidly reversible upon restoration of RBF and
    glomerular filtration pressure
  • Elderly and those with pre-existing renal disease
    at increased risk

17
Pre-renal ARF
  • I. Hypovolemia
  • A. Hemorrhage, burns, dehydration
  • B. GI fluid loss vomiting, surgical drainage,
    diarrhea
  • C. Renal fluid loss diuretics, osmotic diuresis
    (e.g., diabetes mellitus), hypoadrenalism
  • D. Sequestration in extravascular space
    pancreatitis, peritonitis, trauma, burns, severe
    hypoalbuminemia
  • II. Low cardiac output
  • A. Diseases of myocardium, valves, and
    pericardium arrhythmias tamponade
  • B. Other pulmonary hypertension, massive
    pulmonary embolus, positive pressure mechanical
    ventilation

18
Pre-renal ARF
  • III. Altered renal systemic vascular resistance
    ratio
  • A. Systemic vasodilatation sepsis,
    antihypertensives, afterload reducers,
    anesthesia, anaphylaxis
  • B. Renal vasoconstriction hypercalcemia,
    norepinephrine, epinephrine, cyclosporine,
    tacrolimus, amphotericin B
  • C. Cirrhosis with ascites (hepatorenal syndrome)
  • IV. Renal hypoperfusion with impairment of renal
    autoregulatory responses
  • Cyclooxygenase inhibitors, ACEI
  • V. Hyperviscosity syndrome (rare)
  • Multiple myeloma, macroglobulinemia, polycythemia

19
Intrinsic Renal Causes
  • Accounts for 25-40 of cases of ARF
  • Types
  • Acute glomerulonephritis lt5
  • Interstitial nephritis 10
  • Intrarenal vascular disease lt5
  • ATN 85

20
Intrinsic Renal Causes
  • I. Renovascular obstruction (bilateral or
    unilateral in the setting of one functioning
    kidney)
  • A. Renal artery obstruction atherosclerotic
    plaque, thrombosis, embolism, dissecting
    aneurysm, vasculitis
  • B. Renal vein obstruction thrombosis,
    compression
  • II. Disease of glomeruli or renal
    microvasculature
  • A. Glomerulonephritis and vasculitis
  • B. Hemolytic uremic syndrome, thrombotic
    thrombocytopenic purpura, disseminated
    intravascular coagulation, toxemia of pregnancy,
    accelerated hypertension, radiation nephritis,
    systemic lupus erythematosus, scleroderma

21
Intrinsic Renal Causes
  • III. Acute tubular necrosis
  • A. Ischemia(60) as for prerenal ARF
    (hypovolemia, low cardiac output, renal
    vasoconstriction, systemic vasodilatation),
    obstetric complications (abruptio placentae,
    postpartum hemorrhage)
  • B. Toxins(40)
  • 1. Exogenous radiocontrast, cyclosporine,
    antibiotics (e.g., aminoglycosides), chemotherapy
    (e.g., cisplatin), organic solvents (e.g.,
    ethylene glycol), acetaminophen, illegal
    abortifacients
  • 2. Endogenous rhabdomyolysis, hemolysis,
    uric acid, oxalate, plasma cell dyscrasia (e.g.,
    myeloma)

22
Intrinsic Renal Causes
  • IV. Interstitial nephritis
  • A. Allergic antibiotics (e.g., -lactams,
    sulfonamides, trimethoprim, rifampicin),
    nonsteroidal anti-inflammatory agents, diuretics,
    captopril
  • B. Infection bacterial (e.g., acute
    pyelonephritis, leptospirosis), viral (e.g.,
    cytomegalovirus), fungal (e.g., candidiasis)
  • C. Infiltration lymphoma, leukemia, sarcoidosis
  • D. Idiopathic
  • V. Intratubular deposition and obstruction
  • Myeloma proteins, uric acid, oxalate, acyclovir,
    methotrexate, sulphonamides
  • VI. Renal allograft rejection

23
Post-renal Causes of ARF
  • Account for 5 of cases of ARF
  • ARF occurs when both urinary outflow tracts are
    obstructed or when one tract is obstructed in a
    patient with a single functional kidney

24
Post-renal Causes of ARF
  • I. Ureteric
  • Calculi, blood clot, sloughed papillae, cancer,
    external compression (e.g., retroperitoneal
    fibrosis)
  • II. Bladder neck
  • Neurogenic bladder, prostatic hypertrophy,
    calculi, cancer, blood clot
  • III. Urethra
  • Stricture, congenital valve, phimosis

25
Investigations
  • ARF Focused History
  • Nausea? Vomiting? Diarrhea?
  • Hx of heart disease, liver disease, previous
    renal disease, kidney stones, BPH?
  • Any recent illnesses?
  • Any edema, change in
  • urination?
  • Any new medications?
  • Any recent radiology studies?
  • Rashes?

26
Investigations
  • Physical Examination
  • Infection sign ? Blood pressure, vital sign
  • Volume Status
  • Mucus membranes, orthostatics, skin turgor, Edema
  • Cardiovascular
  • JVD, rubs
  • Pulmonary
  • Decreased breath sounds
  • Rales
  • Abd and back bladder distension, masses,
    ascites, CVA tenderness, large prostate
  • Rash (Allergic interstitial nephritis)

27
Investigations
  • Blood
  • CBC-DC
  • Electrolyte, Ca, Mg, P
  • Urea, Creatinine
  • Others LDH, Alb, CRP
  • Urine
  • Urine sodium, Cr
  • Urine osmolality
  • Urinalysis
  • Renal echo

28
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29
FeNa (urine Na x plasma Cr)
(plasma Na x urine Cr)
  • FeNa lt1
  • 1. PRERENAL
  • Urine Na lt 20. Functioning tubules reabsorb lots
    of filtered Na
  • 2. ATN (unusual)
  • Postischemic dz most of UOP comes from few
    normal nephrons, which handle Na appropriately
  • ATN chronic prerenal dz (cirrhosis, CHF)
  • 3. Glomerular or vascular injury
  • Despite glomerular or vascular injury, pt may
    still have well-preserved tubular function and be
    able to concentrate Na

30
More FeNa
  • FeNa 1-2
  • Prerenal-sometimes
  • ATN-sometimes
  • AIN-higher FeNa due to tubular damage
  • FeNa gt2
  • ATN Damaged tubules can't reabsorb Na
  • Calculating FeNa after pt has gotten Lasix.
  • 1. Fractional Excretion of Lithium (endogenous)
    (lt7 in prerenal )
  • 2. Fractional Excretion of Uric Acid (lt7 in
    prerenal )

31
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32
Is the renal failure really acute?
  • Factors suggesting chronicity
  • Duration of symptoms for months
  • Absence of acute illness in the face of very high
    urea and creatinine
  • Anaemia of chronic disorders
  • Bone disease (renal osteodystrophy)
  • Sexual dysfunction
  • Skin disorders, pruritus
  • Neurological complications
  • Small kidneys on renal imaging

33
Management
  •    Prevention
  •    Etiology treatment
  •    Prevention additional injury
  •    Treatment of complication
  •    Conservative measurement
  •    Renal replacement therapy

34
Prevention
  • Identification of high-risk patients for
    pharmacologic agents-induced nephrotoxicity
  • iodinated radiocontrast medium, NSAIDs
  • Aggressive surveillance for nephrotoxin-induced
    renal dysfunction
  • cisplatin, amphotericin B, aminoglycoside
  • Use of volume expansion in selected clinical
    settings
  • Hyperpigmenturia hemoglobinuria, myoglobinuria
  • Crystaluria uric acid, acyclovir, methotrexate,
    sulfonamides
  • Minimalization of catheters use to avoid
    nosocomial sepsis

35
Etiology Treatment
  • Correct postrenal factor
  • Correct prerenal factor
  • Treat underlying sepsis
  • Stop nephrotoxic drugs

36
Conservative Measurement
  • Fluid balance
  • Careful monitoring of I/O and body weight
  • Fluid restriction
  • (usually less than 1 L/day in oliguric ARF)
  • Total intake lt urine output extrarenal losses
  • Electrolytes and acid -base balance
  • hyperkalemia
  • hyponatremia
  • Keep serum bicarbonate gt15
  • hyperphosphatemia
  • Treat hypocalcemia only if symptomatic

37
Guide of Volume Expansion
  • CVP 8-14 cm H2O (5-2 rule)
  • PAWP 12-16 mmHg (7-3 rule)
  • Urine output 0.5-1.0ml/kg/hour
  • Weighing the patient daily
  • Insensible water loss from the skin and
    respiratory tract (500 ml/day)

38
Dietary modification
  • total caloric intake 35 50 kcal/kg/day
  • to avoid catabolism
  • Salt restriction 24 g/day
  • Potassium intake 40 meq/day
  • Phosphorus intake 800 mg/day

39
Conservative Measurement
  • Uremia-nutrition
  • Restriction protein is not necessary in ARF,
    maintain caloric intake
  • Carbohydrate 100gm/day to minimize ketosis and
    protein catabolism
  • Drug
  • Review all medication, Stop magnesium-containing
    medication
  • Adjusted dosage for renal failure, Readjust with
    improvement of GFR

40
Indication of Dialysis
  • Absolute indication
  • CCr ? 5 ml/min or serum Cr ? 10.0 mg/dl
  • Relative indication
  • CCr ? 10 ml/min or serum Cr ? 8.0 mg/dl
  • With accompanied symptoms or signs
  • CHF/Pulmonary edema Uremic pericarditis
    Bleeding tendency Neurologic symptoms
    Drug-resistant hyper-K Drug-resistant metabolic
    acidosis

    Drug-resistant nausea/vomiting Others

41
Take Home Points
  • Features of the history and physical examination
    in addition to relevant lab and radiologic
    investigations help to determine the most likely
    cause(s) of ARF in a given patient

42
Take Home Points
  • Management of a patient with ARF involves
  • Treating potentially life-threatening
    complications
  • Reversing pre-renal and post-renal causes
  • Minimizing further hemodynamic and toxic insults
    to the kidney
  • Admission and appropriate consultation
  • Lack of evidence for converting oliguric to
    non-oliguric ARF
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