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Chronic renal failure (CRF) Acute renal failure (ARF) Hypertension Asymptomatic proteinuria and persistent urinary abnormalities Nephrotic syndrome (NS) Urinary tract infection (UTI) Acute nephritis Obstructive nephropathy Renal stones Renal tubular defects
Acute renal failure (ARF) is a clinical characterized by an abrupt decline in glomerular filtration rate (GFR) and the accumulation of nitrogenous waste (urea nitrogen and creatinine)
Prerenal
Prerenal Hipovolemia Reduced effective extra cellular volume Renal Arterial Occlusion Intrarenal vascular Vasculitis Hemolytic uremic syndrome Trombotic thrombocytopenic purpura Accelerated hypertension Glomerulonephritis
Renal
Renal parenchymal
Ischemic acute tubular necrosis (ATN) Toxic ATN Endogenous toxin Exogenous toxin Interstitial Acute allergic interstitial nephritis Bilateral acute pyelonephritis Intrarenal Obstruction Casts Crystal's Renal Vein occlusion
Postrenal
Hypovolemia
Hemorrhage Fluid loss : gastrointestinal, renal, skin, respiratory, surgical Hypoalbuminemia Third spacing Cardiac failure
Systemic Vasodilatation
Sepsis Myocardial dysfunction Cirrhosis Valvular dysfunction Anaphylaxis
Preglomerular vasoconstriction Sepsis Hypercalcemia Hepatorenal syndrome Postglomerular vasoconstriction ACE inhibitors
Cardiac tamponade
Anesthesia Pulmonary hypertension Pharmacologic vasodilatation
Hypovolemia
Baroreceptor activation
Neurohormonal responses
Vasopressin
Renal blood flow maintained Initially through : Local myenteric reflex prostaglandin synthesis actions of angiotensin II
Vasoconstriction Mesangial cell contraction Avid salt and water reabsorption Reduce sweating Thirst and salt appetite
Homeostatic goal : Restore intravascular volume And blood pressure to maintain Perfusion of essential organs
Prerenal acute renal failure Dramatic reduction in renal Blood flow, glomerular filtration, Urine flow
Clinical evaluation of ARF is achieved by answering the following five question Is it ARF or acute on chronic renal failure ? Is there renal tract obstruction ? Is there reduction in effective ECF volume ? Has there been a major vascular occlusion ? Is there parenchymal renal disease other than ATN ?
Proteinuria
-
Hematuria Microscopy
-
Normal
Normal Dysmorphic red cells, red cell cast, granular casts White cell (pyuria) and occasionally white cell cast
Glomerulonephritis
+++
+++
++
+/-
Normal
Muddy brown granular ATN casts, tubular epithelial cell casts (fewer casts, sometimes none in nonoliguric ATN)
Indication
Obstructive nephropathy Chronic intrinsic renal disease
Normal size kidneys echogenic Acute glomerulonephritis, acute normal echo pattern tubular necrosis Prerenal azotemia, renal artery occlusion Enlarged kidneys Malignant infiltration, renal vein thrombosis, HIV-associated nephropathy, amyloid
aPC
Information Sought
Clues to the cause of acute renal failure Indicators of severity of metabolis disturbance Estimate of volume status (hydration) Markers of glomerular or tubulointerstitial inflammation, urinary tract infection or crystal uropathy To assess extent of GFR reduction and metabolic consequences To differentiate prerenal from established renal failure To determine presence of anemia, leucocytosis, and platelet consumption
Information Sought
To determine kidney size, presence of obstruction, abnormal renal parenchymal texture To define structural abnormalities of the kidneys or urinary tract To assess abnormal renal perfusion To evaluate / relieve urinary tract obstruction To define pathology of renal parenchymal disease
Elevated creatinine
Elevated uric acid Hypocalcaemia
hyperphosphataemia
Management of ARF
Renal Arterial Occlusion Intrarenal vascular Vasculitis Hemolytic uremic syndrome Trombotic thrombocytopenic purpura Accelerated hypertension
Management
Reduced effective Renal Renalarterial blood volume parenchymal cardiac failure sepsis
Drug impaired autoregulation
Postrenal
Renal Arterial Occlusion Intrarenal vascular Vasculitis Hemolytic uremic syndrome Trombotic thrombocytopenic purpura Accelerated hypertension Glomerulonephritis Causes of renal failure
Management
Postrenal
Renal Arterial Occlusion Intrarenal vascular Vasculitis Hemolytic uremic syndrome Trombotic thrombocytopenic purpura Accelerated hypertension
Management
Intrarenal vasculature Ischemic acute tubular necrosis (ATN) Renal RenalVasculitis Immunosuppressant parenchymal Toxic ATN Hemolytic uremic syndrome/ Plasma exchange/plasma infusion Endogenous toxin Exogenous toxin Trombotic thrombocytopenic Interstitial purpura Acute allergic interstitial nephritis Bilateral acute pyelonephritis Accelerated hypertension Lower blood pressure; sodium Intrarenal Obstruction nitroprusside, labetalol, etc
Casts Crystal's Renal Vein occlusion
Postrenal
Renal Arterial Occlusion Intrarenal vascular Vasculitis Hemolytic uremic syndrome Trombotic thrombocytopenic purpura Accelerated hypertension
Management
Consider Immunosuppressant Antibiotics of endocarditis Toxic ATN Endogenous toxin Supportive care if postinfectioous Exogenous toxin
Ischemic acute tubular necrosis (ATN)
Postrenal
Renal Arterial Occlusion Intrarenal vascular Vasculitis Hemolytic uremic syndrome Trombotic thrombocytopenic purpura Accelerated hypertension Glomerulonephritis Causes of renal failure
Management
Postrenal
Renal Arterial Occlusion Intrarenal vascular Vasculitis Hemolytic uremic syndrome Trombotic thrombocytopenic purpura Accelerated hypertension Glomerulonephritis Causes of renal failure
Management
Postrenal
Renal Arterial Occlusion Intrarenal vascular Vasculitis Hemolytic uremic syndrome Trombotic thrombocytopenic purpura Accelerated hypertension
Management
Glomerulonephritis
Interstitial disease Ischemic acute tubular necrosis (ATN) Renal Renal Allergic interstitial nephritis Discontinue offending drugs ; consider corticosteroid parenchymal Toxic ATN Bilateral acute pyelonephritis Antibiotics Endogenous toxin Exogenous toxin Malignant infiltration Chemotherapy
Interstitial Acute allergic interstitial nephritis Bilateral acute pyelonephritis
Intrarenal Obstruction Casts Crystal's Renal Vein occlusion
Postrenal
Renal Arterial Occlusion Intrarenal vascular Vasculitis Hemolytic uremic syndrome Trombotic thrombocytopenic purpura Accelerated hypertension
Management
Glomerulonephritis
Ischemic acute tubular necrosis (ATN) Intrarenal obstruction Renal Renal Myeloma cast parenchymal Consider plasma exchange and chemotherapy Toxic ATN Endogenous toxin drugs Exogenous crystals Stop offending Exogenous toxin Endogenous crystals Alkaline diuresis for rhabdomyolysis or acute urate Interstitial nephropathy Acute allergic interstitial nephritis Bilateral acute pyelonephritis Intrarenal Obstruction Casts Crystal's Renal Vein occlusion
Postrenal
Renal Arterial Occlusion Intrarenal vascular Vasculitis Hemolytic uremic syndrome Trombotic thrombocytopenic purpura Accelerated hypertension Glomerulonephritis Causes of renal failure
Management
Anticoagulation Toxic ATN Treat glomerular disease if Endogenous toxin Exogenous toxin nephrotic
Interstitial Acute allergic interstitial nephritis Bilateral acute pyelonephritis
Intrarenal Obstruction Casts Crystal's Renal Vein occlusion
Postrenal
Renal Arterial Occlusion Intrarenal vascular Vasculitis Hemolytic uremic syndrome Trombotic thrombocytopenic purpura Accelerated hypertension
Management
Renal Renal parenchymal Toxic ATN Bladder catheter / nephrostomy toxin Urinary tract obstructionEndogenous Exogenous toxin Radiologic / surgical treatment of
Interstitial Acute allergic interstitial nephritis Bilateral acute pyelonephritis
Intrarenal Obstruction Casts Crystal's Renal Vein occlusion
obstructing lesion
Postrenal
Treatment
Restrict salt (1-2g/day) and water (usually <1L/day) Diuretics (usually loop diuretics - thiazide) Restrict enteral water intake (<1Uday). Avoid hypotonic intravenous solutions (including dextrose solutions) Restrict dietary K' intake (usually <40mmol/day) Eliminate K` supplements and K'-sparing diuretics Potassiumbinding ion-exchange resins e.g. sodium polystyrene sulfonate (calcium resonium') Glucose (50mL of 50% dextrose) and insulin (10 units regular) Sodium bicarbonate (usually 50-100mmol) (32 Agonist (e.g. albuterol 10-20 mg inhaled or 0.5-1mg i.v.) Calcium gluconate (10mL of 10% solution over 2-5 minutes)
Hyperkalemia
Metabolic acidosis
Restrict dietary protein (usually 0.6g/kg per day of high biologic value) Sodium bicarbonate (maintain serum bicarbonate >15mmol/L and arterial pH >7.2)
Treatment
Restrict dietary phosphate intake (usually <800mg/day) Phosphate-binding agents (calcium carbonate, calcium acetate, aluminum hydroxide) Calcium carbonate (if symptomatic or if sodium bicarbonate to be administered) Calcium gluconate (10-20mL of 10% solution)
Hypocalcemia
Hypermagnesemia
Hyperuricemia Nutrition
Characteristics
Obtundation, asterixis, seizures, nausea and vomiting. pericarditis
Hyperkalemia
Fluid overload Metabolic acidosis