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Kidney Diseases - VOLUME ONE - Chapter 08

Kidney Diseases - VOLUME ONE - Chapter 08

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Published by Firoz Reza
Chapters are from VOL 1 of Atlas of Kidney Diseases. There are more 4 VOLUME. To get other VOLUME log on to http://www.kidneyatlas.org
Chapters are from VOL 1 of Atlas of Kidney Diseases. There are more 4 VOLUME. To get other VOLUME log on to http://www.kidneyatlas.org

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Published by: Firoz Reza on Feb 24, 2009
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01/29/2013

 
Acute Renal Failure:Causes and Prognosis
T
here are many causes—more than fifty are given within thispresent chapter—that can trigger pathophysiological mecha-nisms leading to acute renal failure (ARF). This syndrome ischaracterized by a sudden decrease in kidney function, with a conse-quence of loss of the hemostatic equilibrium of the internal medium.The primary marker is an increase in the concentration of the nitroge-nous components of blood. A second marker, oliguria, is seen in 50%to 70% of cases.In general, the causes of ARF have a dynamic behavior as theychange as a function of the economical and medical development of the community. Economic differences justify the different spectrum inthe causes of ARF in developed and developing countries. The settingwhere ARF appears (community versus hospital), or the place whereARF is treated (intensive care units [ICU] versus other hospital areas)also show differences in the causes of ARF.While functional outcome after ARF is usually good among the sur-viving patients, mortality rate is high: around 45% in general seriesand close to 70% in ICU series. Although it is unfortunate that thesemortality rates have remained fairly constant over the past decades, itshould be noted that today’s patients are generally much older anddisplay a generally much more severe condition than was true in thepast. These age and severity factors, together with the more aggressivetherapeutical possibilities presently available, could account for thisapparent paradox.As is true for any severe clinical condition, a prognostic estimationof ARF is of great utility for both the patients and their families, themedical specialists (for analysis of therapeutical maneuvers andoptions), and for society in general (demonstrating the monetary costsof treatment). This chapter also contains a brief review of the prog-nostic tools available for application to ARF.
Fernando Liaño Julio Pascua
C H A PT ER
 
8.2
Acute Renal Failure
Causes of Acute Renal Failure
RenalperfusionSudden causesaffectingInduce CalledParenchymalstructuresUrineoutputPrerenalParenchymatousAcuterenalfailureGFRObstructive
FIGURE 8-1
Characteristics of acute renal failure. Acute renal failure is asyndrome characterized by a sudden decrease of the glomerularfiltration rate (GFR) and consequently an increase in bloodnitrogen products (blood urea nitrogen and creatinine). It isassociated with oliguria in about two thirds of cases. Dependingon the localization or the nature of the renal insult, ARF is classi-fied as prerenal, parenchymatous, or obstructive (postrenal).
CAUSESOF PRERENAL ACUTE RENAL FAILURE
Decreased effective extracellular volumeRenal losses: hemorrhage, vomiting, diarrhea, burns, diureticsRedistribution: hepatopathy, nephrotic syndrome, intestinal obstruction, pancreatitis,peritonitis, malnutritionDecreased cardiac output: cardiogenic shock, valvulopathy, myocarditis, myocardialinfarction, arrhythmia, congestive heart failure, pulmonary emboli, cardiac tamponadePeripheral vasodilation: hypotension, sepsis, hypoxemia, anaphylactic shock, treatmentwith interleukin L2 or interferons, ovarian hyperstimulation syndromeRenal vasoconstriction: prostaglandin synthesis inhibition,
-adrenergics, sepsis, hepa-torenal syndrome, hypercalcemiaEfferent arteriole vasodilation: converting-enzyme inhibitors
FIGURE 8-2
Causes of prerenal acute renal failure (ARF).
Prerenal
ARF, alsoknown as prerenal uremia, supervenes when glomerular filtrationrate falls as a consequence of decreased effective renal blood supply.The condition is reversible if the underlying disease is resolved.
CAUSESOF PARENCHYMATOUSACUTE RENAL FAILURE
Acute tubular necrosisHemodynamic: cardiovascular surgery,* sepsis,* prerenal causes*Toxic: antimicrobials,* iodide contrast agents,* anesthesics, immunosuppressive orantineoplastic agents,* Chinese herbs, Opiaceous, Extasis, mercurials, organicsolvents, venoms, heavy metals, mannitol, radiationIntratubular deposits: acute uric acid nephropathy, myeloma, severe hypercalcemia,primary oxalosis, sulfadiazine, fluoride anesthesicsOrganic pigments (endogenous nephrotoxins):Myoglobin rhabdomyolisis: muscle trauma; infections; dermatopolymyositis;metabolic alterations; hyperosmolar coma; diabetic ketoacidosis; severehypokalemia; hyper- or hyponatremia; hypophosphatemia; severe hypothy-roidism; malignant hyperthermia; toxins such as ethylene glycol, carbonmonoxide, mercurial chloride, stings; drugs such as fibrates, statins, opioidsand amphetamines; hereditary diseases such as muscular dystrophy,metabolopathies, McArdle disease and carnitine deficitHemoglobinuria: malaria; mechanical destruction of erythrocytes with extracorporealcirculation or metallic prosthesis, transfusion reactions, or other hemolysis;heat stroke; burns; glucose-6-phosphate dehydrogenase; nocturnal paroxystichemoglobinuria; chemicals such as aniline, quinine, glycerol, benzene, phenol,hydralazine; insect venomsAcute tubulointerstitial nephritis (
see
Fig. 8-4)Vascular occlusionPrincipal vessels: bilateral (unilateral in solitary functioning kidney) renal arterythrombosis or embolism, bilateral renal vein thrombosisSmall vessels: atheroembolic disease, thrombotic microangiopathy, hemolytic-uremicsyndrome or thrombotic thrombocytopenic purpura, postpartum acute renalfailure, antiphospholipid syndrome, disseminated intravascular coagulation,scleroderma, malignant arterial hypertension, radiation nephritis, vasculitisAcute glomerulonephritisPostinfectious: streptococcal or other pathogen associated with visceral abscess,endocarditis, or shuntHenoch-Schonlein purpuraEssential mixed cryoglobulinemiaSystemic lupus erythematosusImmunoglobulinA nephropathyMesangiocapillaryWith antiglomerular basement membrane antibodies with lung disease(Goodpasture is syndrome) or without itIdiopathic, rapidly progressive, without immune depositsCortical necrosis, abruptio placentae, septic abortion, disseminated intravascularcoagulation
FIGURE 8-3
Causes of parenchymal acute renal failure (ARF). When the sud-den decrease in glomerular filtration rate that characterizes ARF issecondary to intrinsic renal damage mainly affecting tubules,interstitium, glomeruli and/or vessels, we are facing a
 parenchy-matous ARF 
. Multiple causes have been described, some of themconstituting the most frequent ones are marked with an asterisk.
 
8.3
Acute Renal Failure: Causes and Prognosis
MOST FREQUENT CAUSESOF ACUTETUBULOINTERSTITIAL NEPHRITIS
AntimicrobialsPenicillinAmpicillinRifampicinSulfonamidesAnalgesics, anti-inflammatoriesFenoprofenIbuprofenNaproxenAmidopyrineGlafenineOther drugsCimetidineAllopurinolImmunologicalSystemic lupus erythematosusRejectionInfections (at present quite rare)NeoplasiaMyelomaLymphomaAcute leukemiaIdiopathicIsolatedAssociated with uveitis
FIGURE 8-4
Most common causes of tubulointerstitial nephritis. During the lastyears, acute tubulointerstitial nephritis is increasing in importance asa cause of acute renal failure. For decades infections were the mostimportant cause. At present, antimicrobials and other drugs are themost common causes.
CAUSESOF OBSTRUCTIVE ACUTE RENAL FAILURE
Congenital anomaliesUreteroceleBladder diverticulaPosterior urethral valvesNeurogenic bladderAcquired uropathiesBenign prostatic hypertrophyUrolithiasisPapillary necrosisIatrogenic ureteral ligationMalignant diseasesProstateBladderUrethraCervixColonBreast (metastasis)
FIGURE 8-5
Causes of obstructive acute renal failure. Obstruction at any level of the urinary tract frequently leads to acute renal failure. These are themost frequent causes.
FINDINGSOF THE MADRID STUDY
Condition
Acute tubular necrosisPrerenal acute renal failureAcute on chronic renal failureObstructive acute renal failureGlomerulonephritis (primary or secondary)Acute tubulointerstitial nephritisVasculitisOther vascular acute renal failureTotal
Incidence (per million persons per year)
884629236.33.53.52.1209
95% CI
79–9740–5224–3419–274.8–8.31.7–5.31.7–5.30.8–3.4195–223
FIGURE 8-6
This figure shows a comparison of the percent-ages of the different types of acute renal failure(ARF) in a western European country in1977–1980 and 1991:
A
, distribution in a typi-cal Madrid hospital;
B
, the Madrid ARF Study[1]. There are two main differences: 1) theappearance of a new group in 1991, “acuteon chronic ARF,” in which only mild forms(serum creatinine concentrations between 1.5and 3.0 mg/dL) were considered, for method-ological reasons; 2) the decrease in prerenalARF suggests improved medical care. This lowrate of prerenal ARF has been observed byother workers in an intensive care setting [2].The other types of ARF remain unchanged.
ATN43.1%Arterial disease2.5%Other parenchymal6.4%Obstructive3.4%
AB
n
= 2021977
 – 
1980
n
= 7481991Prerenal40.6%Other parenchymal4.5%ATIN1.6%Arterial disease1%
Obstructive10%
Acute-on-chronic13%Prerenal21%ATN45%
FIGURE 8-7
Incidences of different forms of acute renalfailure (ARF) in the Madrid ARF Study [1].Figures express cases per million persons peryear with 95% confidence intervals (CI).
Retroperitoneal fibrosisIdiopathicAssociated withaortic aneurysmTraumaIatrogenicDrug-inducedGynecologic non-neoplasticPregnancy-relatedUterine prolapseEndometriosisAcute uric acid nephropathyDrugs
-Aminocaproic acidSulfonamidesInfectionsSchistosomiasisTuberculosisCandidiasisAspergillosisActinomycosisOtherAccidental urethralcatheter occlusion

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