Acute renal failure

Hendy Buana Vijaya

 Definition
• AKI is a condition in which the glomerular filtration rate is abruptly reduced,
causing a sudden retention of endogenous and exogenous metabolites (urea,
potassium, phosphate, sulfate, creatinine, administered drugs) that are
normally cleared by the kidneys. The urine volume is usually low (<400 mL/
day). If renal concentrating mechanisms are impaired, the daily urine volume
may be normal or even high (high-output or nonoliguric renal failure). In extreme
cases, anuria occurs (urine output completely shuts down) in acute kidney
injury
 Acute vs Chronic Renal Failure
• History
• Known Chronic
• Recent Toxic Exposure
• Recent Hypoxic Insult
• Recent Trauma
• Known Diseases Associated with ARF
• Prev. Abnormal Lab Results Suggesting Chronic
 Acute vs Chronic Renal Failure
• Rapidly Rising Creatinine = Acute
• Kidney Size
• Small = Chronic
• Renal Ultrasound
• Increased Echogenicity = Chronic
• Urine Flow Rate
• Oliguric or Anuric usually = Acute
 Acute renal failure
classification by urine volume

Oliguric: <400 cc/ 24 hrs

Non-oliguric: >500 cc/24 hrs
Anuric <50 cc/24 hrs
 ETIOLOGY OF ACUTE RENAL FAILURE

• PRE-RENAL 55-60%
• POST RENAL <5%
• RENAL 35-40%
 Pre-renal acute renal failure

• Most common cause of arf

• Results from decreased renal perfusion
• Treatment of the cause restores renal function
tubular function intact *
• Prolonged pre-renal failure may lead to atn
 CAUSES OF PRE-RENAL
AZOTEMIA
• Intravascular volume depletion
• Decreased cardiac output
• Systemic vasodilation
• Antihypertensives
• Sepsis
• Renal vasoconstriction
• Drugs impairing autoregulation
• Ace inhibitors
• NSAID
MECHANISMIS OF PRE RENAL ARF
 Post-renal acute renal failure

• Accounts for 2-15% of all arf

• Obstruction to urine flow
• Increased tubular pressure
• Vasoconstriction
• Decreased renal blood flow
• Must be bilateral to result in arf
• Unless : single kidney or prior chronic renal failure
 Post renal acute renal failure

• Suspect obstruction in anuria

• Etiology may be age dependent
• Young = congenital abnormality
• Older male = prostatic enlargement
• Arf most often associated with lesions in:
• Bladder, prostate or urethra
 Renal-acute renal failure

• Vascular disease
• Vasculitis (sle, polyarteritis etc.)
• Scleroderma
• Thromboembolic disease
• Malignant hypertension
 Renal--acute renal failure
• Glomerular disease
• Acute glomerulonephritis
• Post infectious gn
• Crescentic gn
• Anca positive diseases
• Goodpasture’s dis.
• Anti- glomerular basement antibody
 Acute interstitial nephritis
drug induced
• Penicillins • Nsaid (fenoprofen)
• Sulfonamides • Allopurinol
• Cephalosporin • Phenytoin

• Rifampin ( 2nd time) • Thiazides

• Furosemide
• Quinolones
• Cimetidine
Acute Interstitial Nephritis

• Fever
• Rash
• Eosinophilia
• Pyuria
• Eosinophiluria
• WBC Casts
 Renal --acute renal failure

• Acute tubular necrosis

• Ischemic injury
• Toxic injury
• Endogenous toxins
• Hemoglobinuria
• Myoblobinuria (rhabdomyolysis)

• Endotoxemia
 Renal-- acute renal failure

• Acute tubular necrosis

• Exogenous toxins
• Aminoglycosides
• Radiographic contrast
• Heavy metal compounds
• Ethylene glycol
• Methanol
• Carbon tetrachloride
• Cis platin
 HIGH RISK SETTINGS FOR ATN

CLINICAL SETTING FREQUENCY

• GEN.MED. --SURG. 3-5%
• INTENSIVE CARE 5-25%
• OPEN HEART SURG 5-20%
• AMINOGLYCOSIDE 10-30%
• BURNS 20-60%
• RHABDOMYOLYSIS 20-30%
• CIS-PLATIN 15-25%
 Diagnostic approach to arf

• History
• Physical examination
• Assment of urine volume
• Urine analysis
• Blood chemistry
• Blood and urine indices
• Radiologic studies
Treatment
of ARF
 Hyperkalemia
• Never occurs in the absence of renal excretory problem
• Pseudohyperkalemia
• Leukocytosis
• Thrombocytosis
• Prolonged Application of Tourniquet
 Hyperkalemia
• Significance of urine output
• Role of increased catabolism or tissue breakdown
• Factors affecting shift of Potassium out of cells
• Etiololgy of the renal failure
 Treatment of Hyperkalemia
• Urgency
• Role of the EKG in making the decision
• Clinical setting in which it occurs
• Acute renal failure
• Chronic renal failure
Table 5-3. Treatment of hyperkalemia

Medication Mechanism of action Dosage Peak effect

Calcium Antagonism of 10-30 ml of 10% solution IV -5 min

gluconate membrane over 2 min

Insulin and Increased K+entry Insulin, 10 U IV bolus 30-60 min

Glucose into the cells followed by 0.5 mU/kg of
body weight per minute in
50 ml of 20% glucose

Sodium Increased K+entry 44-50 mEq IV over 5 min; 30-60 min

bicarbonate into the cells can be repeated within 30
min
Albuterol Increased K+entry
into the cells 20 mg in the nebulized form 30-60 min

Kayexalate Removal of the 20 g of resin with 100 ml of 2-4 hr

excess K+ 20% sorbitol; can be
repeated every 4-6 hr

Hemodialysis Removal of the Dialysis bath K+ concentration 30-60 min

excess K+ variable
 Indications for dialysis in acute renal failure

• Uremic symptoms
• Severe fluid overload
• Refractory electrolyte
• Severe refractory acidosis
 Indications for dialysis in acute renal failure

• Pericarditis
• Neuropathy
• Mental status change
• Seizures
• Bleeding
• Toxins----ethylene glycol, methanol
• Prophylactic
~Recent studies fail to document benefit
 MORTALITY ASSOCIATED WITH SETTING
OF ATN
• OVERALL MORTALITY 40-60%
• POST TRAUMATIC 70-90%
• MEDICAL CAUSE 15-40%
• SURGICAL CAUSE 40-80%
• NON-OLIGURIC 26% *
• OLIGURIC 50% *
CAUSES OF DEATH IN ATN