Kidney failure

(renal failure with uraemia, or azotaemia)

What is kidney failure? The function of the kidneys is, among other things, to get rid of the waste products that result from the body's metabolism. One of the major by-products of the metabolism of protein (muscle) is urea. The kidneys remove the waste products by extracting them from the blood and sending them along the ureter to the bladder, from where they are excreted in the urine. If the kidney function fails, the waste products accumulate in the blood and the body. The term for this build-up is azotaemia.

Term watch Azotaemia is the build up of waste products that accumulate in the blood and the body when the If the kidney (or renal) failure is of kidneys fail to sufficient degree to cause symptoms, it function. is called uraemia. Very mild levels of azotaemia may give little or no symptoms, but if the kidney failure continues then symptoms will start to appear. What causes renal failure? Renal failure can happen rapidly - over days, weeks or months (acute renal failure) or slowly over a period of years (chronic renal failure). Acute renal failure This may occur with any serious illness or operation, particularly those complicated by severe infection. If the blood supply to the kidneys is reduced considerably from blood loss, a fall in blood pressure, severe dehydration or lack of salt, then the kidneys may be damaged. If this problem lasts long enough there can be permanent damage to the kidney tissue. Sudden blockage to the drainage of urine from the kidney can cause damage. A kidney stone is a possible

cause of this. Acute kidney damage can occur as a rare side effect of some medications and other rare conditions. Chronic renal failure There are many causes of chronic renal failure, including inflammatory conditions affecting the kidney tissue, as a complication of long-standing diabetes mellitus (sugar diabetes), chronic blockage to the drainage of the kidneys and as a result of certain inherited conditions such as polycystic kidney disease. Often, the cause has occurred many years earlier and cannot be identified. What are the symptoms? Acute renal failure Here the symptoms are largely those of the condition causing the kidney failure, such as:

blood loss, causing a drop in blood pressure. vomiting and diarrhoea, causing dehydration. crush injuries. If large amounts of muscle are damaged there is a release of toxic protein substances that are harmful to the kidneys. Sudden blockage of urine drainage.

Chronic renal failure The damage to the kidneys is usually 'silent' and not noticed at an early stage. It may be discovered incidentally from blood or urine tests done for other reasons. High blood pressure very commonly occurs with it. Symptoms are uncommon unless kidney failure is far advanced, when any of the following may be present:

tiredness itching loss of appetite

nausea and vomiting breathlessness fluid retention, shown as ankle swelling (oedema) weakness.

How is renal failure treated? Acute renal failure Most causes of acute renal failure can be treated and the kidney function will return to normal with time. Replacement of the kidney function by dialysis (artificial kidney) may be necessary until kidney function has returned. Chronic renal failure Chronic kidney damage is usually not reversible and if extensive, the kidneys may eventually fail completely. Dialysis or kidney transplantation will then become necessary. Chronic kidney failure is a serious condition which needs urgent attention when it is diagnosed, but the kidney damage is usually 'silent' and not noticed at an early stage. Occasionally it may be possible to identify and treat the cause of the renal failure itself. More commonly the treatment has to be non-specific. In all cases, careful blood pressure control is extremely important in slowing the progress of kidney failure. One or more medicines to lower blood pressure may be given. Changes in diet may be necessary and include reducing salt intake, avoiding foods containing a lot of potassium and reducing the amount of protein and phosphate in the diet. Anaemia commonly results from chronic renal failure, but can be easily treated with injections of the hormone erythropoietin, as epoetin alfa (Eprex) or epoetin beta (NeoRecormon).

Supplements of vitamin D in the form of alfacalcidol (eg One-Alpha) or calcitriol (eg Rocaltrol) help to prevent a bone condition that can occur in chronic renal failure, called renal osteodystrophy. Itching is a common complaint in people with renal failure, and antihistamines such as chlorphenamine may be prescribed to control this. It is important to avoid certain medications, eg nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, that may worsen kidney function. You can ask your doctor about this. Dialysis There are two main types: peritoneal dialysis and haemodialysis. Peritoneal dialysis The peritoneum is the clear membrane that covers the internal organs inside the abdomen. To carry out dialysis, a plastic tube is placed within the abdomen and led out to the skin surface on the tummy (the tube can be left in place for a long time). Specially made fluid is run into the abdomen, left for a few hours and then run out again to wash out the toxic substances from the body. This is a successful form of treatment that most people can learn to carry out themselves at home, with support from the renal team and the family practice. Haemodialysis This is carried out by leading the person's blood through an 'artificial kidney' machine that cleans the blood and returns it by tubing to a vein. It can be carried out over a few hours, and needs to be repeated, on average, every couple of days. It is done in a specialised dialysis unit attached to a hospital. If renal failure is irreversible (a condition known as end stage renal failure or ESRF), then long-term dialysis becomes necessary. Kidney transplantation is carried out whenever possible.

Kidney Failure
What are the kidneys?
The kidneys play key roles in body function, not only by filtering the blood and getting rid of waste products, but also by balancing levels of electrolytes in the body, controlling blood pressure, and stimulating the production of red blood cells. The kidneys are located in the abdomen toward the back, normally one of each side of the spine. They get their blood supply through the renal arteries directly from the aorta and send blood back to the heart via the renal veins to the vena cava. (The term "renal" is derived from the Latin name for kidney.) The kidneys have the ability to monitor the amount of body fluid, the concentrations of electrolytes like sodium and potassium, and the acid-base balance of the body. They filter waste products of body metabolism, like urea from protein metabolism and uric acid from DNA breakdown. Two waste products in the blood can be measured: blood urea nitrogen (BUN) and creatinine (Cr). When blood flows to the kidney, sensors within the kidney decide how much water to excrete as urine, along with what concentration of electrolytes. For example, if a person is dehydrated from exercise or from an illness, the kidneys will hold onto as much water as possible and the urine becomes very concentrated. When adequate water is present in the body, the urine is much more dilute, and the urine becomes clear. This system is controlled by renin, a hormone produced in the kidney that is part of the fluid and blood pressure regulation systems of the body. Kidneys are also the source of erythropoietin in the body, a hormone that stimulates the bone marrow to make red blood cells. Special cells in the kidney monitor the oxygen concentration in blood. If oxygen levels fall, erythropoietin levels rise and the body starts to manufacture more red blood cells. After the kidneys filter blood, the urine is excreted through the ureter, a thin tube that connects it to the bladder. It is then stored in the bladder awaiting urination, when the bladder sends the urine out of the body through the urethra.

What causes kidney failure?

Kidney failure can occur from an acute situation or from chronic problems. In acute renal failure, kidney function is lost rapidly and can occur from a variety of insults to the body. The list of causes is often categorized based on where the injury has occurred. Prerenal causes (pre=before + renal=kidney) causes are due to decreased blood supply to the kidney. Examples of prerenal causes are:

Hypovolemia (low blood volume) due to blood loss Dehydration from loss of body fluid (vomiting, diarrhea, sweating, fever ) Poor intake of fluids Medication, for example, diuretics ("water pills") may cause excessive water loss. Loss of blood supply to the kidney due to obstruction of the renal artery or vein.

Renal causes (damage directly to the kidney itself) include:

Sepsis: The body's immune system is overwhelmed from infection and causes inflammation and shutdown of the kidneys. This usually does not occur with urinary tract infections. Medications: Some medications are toxic to the kidney, including nonsteroidal anti-inflammatory drugs like ibuprofen and naproxen. Others are antibiotics like aminoglycosides [gentamicin (Garamycin), tobramycin], lithium (Eskalith, Lithobid), iodine-containing medications such as those injected for radiology dye studies. Rhabdomyolysis: This is a situation in which there is significant muscle breakdown in the body, and the degeneration products of muscle fibers clog the filtering system of the kidneys. Often occurring because of trauma and crush injuries, it can also be caused by some medications used to treat high cholesterol. Multiple Myeloma Acute glomerulonephritis or inflammation of the glomeruli, the filtering system of the kidneys. Many diseases can cause this inflammation including systemic lupus erythematosus, Wegener's granulomatosis, and Goodpasture syndrome.

Post renal causes (post=after + renal= kidney) are due to factors that affect outflow of the urine:

Obstruction of the bladder or the ureters can cause back pressure when there is no place for the urine to go as the kidneys continue to work. When the pressure increases enough, the kidneys shut down. Prostatic hypertrophy or prostate cancer may block the urethra and prevents the bladder from emptying. Tumors in the abdomen that surround and obstruct the ureters. Kidney stones

Chronic renal failure develops over months and years. The most common causes of chronic renal failure are related to:

Poorly controlled diabetes Poorly controlled high blood pressure Chronic glomerulonephritis

Less common causes:

Polycystic Kidney Disease Reflux nephropathy

Kidney stones Prostate disease

What are the symptoms of kidney failure?

In the beginning, kidney failure may be asymptomatic (not producing any symptoms). As kidney function decreases, the symptoms are related to the inability to regulate water and electrolyte balances, to clear waste products from the body, and to promote red blood cell production. Lethargy, weakness, shortness of breath, and generalized swelling may occur. Unrecognized or untreated, life-threatening circumstances can develop. Metabolic acidosis, or increased acidity of the body due to the inability to manufacture bicarbonate, will alter enzyme and oxygen metabolism, causing organ failure. Inability to excrete potassium and rising potassium levels in the serum (hyperkalemia) is associated with fatal heart rhythm disturbances (arrhythmias). Rising urea levels in the blood (uremia) can affect the function of a variety of organs ranging from the brain (encephalopathy) with alteration of thinking, to inflammation of the heart lining (pericarditis), to decreased muscle function because of low calcium levels (hypocalcemia). Generalized weakness can be due to anemia, a decreased red blood cell count, because lower levels of erythropoietin do not adequately stimulate the bone marrow. A decrease in red cells equals a decrease in oxygen-carrying capacity of the blood, resulting in decreased oxygen delivery to cells for them to do work; therefore, the body tires quickly. As well, with less oxygen, cells more readily use anaerobic metabolism (an=without + aerobic=oxygen) leading to increased amounts of acid production that cannot be addressed by the already failing kidneys. As waste products build in the blood, loss of appetite, lethargy, and fatigue become apparent. This will progress to the point where mental function will decrease and coma may occur. Because the kidneys cannot address the rising acid load in the body, breathing becomes more rapid as the lungs try to buffer the acidity by blowing off carbon dioxide. Blood pressure may rise because of the excess fluid, and this fluid can be deposited in the lungs, causing congestive heart failure.

How is kidney failure diagnosed?

Diagnosis of kidney failure is confirmed by blood tests measuring the buildup of waste products in the blood. BUN and creatinine become elevated, and the glomerular filtration rate decreases.

This is the rate with which blood is filtered through the kidneys and can be calculated based upon the creatinine level, age, race, and gender. Urine tests may be done to measure the amount of protein, detect the presence of abnormal cells, or measure the concentration of electrolytes. Protein in the urine is not normal and can be a clue that damage to the kidneys has occurred. Abnormal aggregations of red and white blood cells called casts can be seen in the urine with kidney disease. Comparing the concentrations of electrolytes in the blood and urine can help decide whether the kidneys are able to appropriately monitor and filter blood. Other tests are used to diagnose the type of kidney failure. Abdominal ultrasound can assess the size of the kidneys and may identify whether any obstruction exists. Biopsy of the kidney uses a thin needle that is placed through the skin into the kidney itself to get bits of tissue to examine under the microscope.

What is the treatment for kidney failure?

Prevention is always the goal with kidney failure. Chronic disease such as hypertension and diabetes are devastating because of the damage that they can do to kidneys and other organs. Lifelong diligence is important in keeping blood sugar and blood pressure within normal limits. Specific treatments are dependent upon the underlying diseases. Once kidney failure is present, the goal is to prevent further deterioration of renal function. If ignored, the kidneys will progress to complete failure, but if underlying illnesses are addressed and treated aggressively, kidney function can be preserved, though not always improved.

Diet
Diet is an important consideration for those with impaired kidney function. Consultation with a dietician may be helpful to understand what foods may or may not be appropriate. Since the kidneys cannot easily remove excess water, salt, or potassium, they may need to be consumed in limited quantities. Foods high in potassium include bananas, apricots, and salt substitutes. Phosphorus is a forgotten chemical that is associated with calcium metabolism and may be elevated in kidney failure. Too much phosphorus can leech calcium from the bones and cause osteoporosis and fractures. Foods with high phosphorus content include milk, cheese, nuts, and cola drinks.

Medications
Medications may be used to help control some of the issues associated with kidney failure.

Phosphorus-lowering medications [calcium carbonate (Caltrate), calcitriol (Rocaltrol), sevelamer (Renagel)] Red blood cell production stimulation [erythropoietin, darbepoetin (Aranesp)] Red blood cell production (iron supplements) Blood pressure medications 9

Vitamins

Once the kidneys fail completely, the treatment options are limited to dialysis or kidney replacement by transplantation.

Dialysis
Dialysis cleanses the body of waste products in the body by use of filter system. There are two types of dialysis.

Hemodialysis
Hemodialysis uses a machine filter called a dialyzer or artificial kidney to remove excess water and salt, to balance the other electrolytes in the body, and to remove waste products of metabolism. Blood flows through tubing into the machine, where it passes next to a filter membrane. A specialized chemical solution (dialysate) flows on the other side of the membrane. The dialysate is formulated to draw impurities from the blood through the filter membrane. Blood and dialysate never touch in the artificial kidney machine. For this type of dialysis, access to the blood vessels needs to be surgically created so that large amounts of blood can flow into the machine and back to the body. Surgeons can build a fistula, a connection between a large artery and vein in the body, usually in the arm, that causes a large amount of blood flow into the vein. This makes the vein larger and its walls thicker so that it can tolerate repeated needle sticks to attach tubing from the body to the machine. Since it takes many weeks for a fistula to mature enough to be used, significant planning is required if hemodialysis is to be considered as an option. If the kidney failure happens acutely and there is no time to build a fistula, special catheters may be inserted into the larger blood vessels of the arm, leg, or chest. These catheters may be left in place for up to three weeks. In some diseases, the need for dialysis will be temporary, but if the expectation is that dialysis will continue for a prolonged period of time, these catheters act as a bridge until a fistula can be planned, placed, and matured. Dialysis treatments normally occur three times a week and last a few hours at a time. Most commonly, patients travel to an outpatient center to have dialysis, but home dialysis therapy is becoming an option for some.

Peritoneal dialysis
Peritoneal dialysis uses the lining of the abdominal cavity as the dialysis filter to rid the body of waste and to balance electrolyte levels. A catheter is placed in the abdominal cavity through the abdominal wall by a surgeon and is expected to remain there for the long-term. The dialysis solution is then dripped in through the catheter and left in the abdominal cavity for a few hours and then is drained out. In that time, waste products leech from the blood normally flowing through the lining of the abdomen (peritoneum). There are benefits and complications for each type of dialysis. Not every patient can choose which type he or she would prefer. The treatment decision depends on the patient's illness and their past medical history along with other issues. Usually, the nephrologist (kidney specialist) will have a long discussion with the patient and family to decide what will be the best option available.

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Kidney failure, acute

Definition
Acute kidney failure is the sudden loss of your kidneys' ability to perform their main function eliminate excess fluid and electrolytes as well as waste material from your blood. When your kidneys lose their filtering ability, dangerous levels of fluid, electrolytes and waste accumulate in your body. Acute kidney failure is most common in people who are already hospitalized, particularly people who need intensive care. Acute kidney failure tends to occur after complicated surgery, after a severe injury or when blood flow to your kidneys is disrupted. Acute kidney failure can be serious and generally requires intensive treatment. However, acute kidney failure may be reversible. If you're otherwise in good health, you can recover normal kidney function.

Symptoms
Signs and symptoms of acute kidney failure may include:

Decreased urine output, although occasionally urine output remains normal Fluid retention, causing swelling in your legs, ankles or feet Drowsiness Shortness of breath Fatigue Confusion Seizures or coma in severe cases Chest pain related to pericarditis, an inflammation of the sac-like membrane that envelops your heart

Because acute kidney failure is usually a complication of some other serious disorder, initially the signs and symptoms may go unnoticed or be attributed to the underlying disease.

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Causes
Kidney cross section

Each kidney contains approximately 1 million nephrons, each consisting of a tuft of capillary blood vessels (glomerulus) and tiny tubules that lead into larger collecting tubes. Every tuft of capillaries filters fluid from your bloodstream.

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Acute kidney failure has many possible causes, generally grouped according to the part of kidney function they affect. All your blood flows through your kidneys, which are the key organs in the complex system that removes excess fluid and waste material from the blood. Your kidneys receive blood through your renal arteries, which branch off the main artery (the abdominal aorta) carrying oxygenated blood away from your heart. On entering the kidneys, blood is diffused through an intricate network of filtering structures. These structures consist of nephrons approximately 1 million of them each containing a tuft of capillary blood vessels and tiny lobules that lead to larger collecting tubes. The capillary tufts (glomeruli) filter fluid from your blood, extracting both waste products and substances your body needs continuously sugar, amino acids, calcium and salts. The filtered fluid then enters the tubules, from which the bloodstream reabsorbs these vital materials. What remains is waste, which is excreted in your urine. Underlying causes Three types of conditions can cause acute kidney failure:

Prerenal conditions, which disrupt blood flow on its way to the kidneys Renal conditions, which directly damage the structures of the kidneys Postrenal conditions, which interfere with the urinary excretion of waste from the filtering process

Prerenal causes

Extremely low blood pressure. Severe bleeding, infection in the bloodstream (sepsis), dehydration or shock can all lead to a drastic drop in blood pressure that prevents an adequate amount of blood from reaching your kidneys. Dangerously low blood pressure tends to follow traumatic injury. Poor heart function. A heart attack or congestive heart failure can severely limit blood flow to your kidneys. Low blood volume. Severe dehydration diminishes the volume of blood in your body and the amount available to your kidneys.

Renal causes Reduced blood supply within your kidneys. Your kidneys don't just process blood for the rest of your body they depend on an adequate blood supply of their own. Reduced blood flow to the kidneys, especially to the renal tubules, can result in acute renal failure. In atherosclerosis, for example, deposits of cholesterol on the inner walls of arteries (plaques) may break up, releasing solid fragments into the bloodstream. These fragments (emboli) can get into the kidneys' circulation and accumulate in small vessels, severely restricting the blood supply and causing acute kidney failure, also known as atheroembolic kidney disease.

Hemolytic uremic syndrome. Hemolytic uremic syndrome associated with certain strains of Escherichia coli (E. coli) bacteria is a leading 13

cause of acute kidney failure in children. The bacterium causes inflammation of the intestine. It also produces a toxin that causes damage and swelling in the lining of blood vessels, especially the small blood vessels (glomerular capillaries) in the kidneys. As red blood cells travel through the damaged blood vessels, they're often broken apart (hemolysis). This complex condition may result in acute kidney failure.
Inflammation in the kidneys. Acute kidney failure may result from sudden inflammation of the spaces between the glomeruli and the tubules (acute interstitial nephritis) and inflammation of the glomeruli (acute glomerulonephritis). Acute interstitial nephritis is usually associated with an allergic reaction to a drug. Examples include certain antibiotics especially streptomycin and gentamicin and common pain medications, such as aspirin and ibuprofen (Advil, Motrin, others). Antibiotics pose a greater risk of acute kidney failure for people who already have liver or kidney disease or who use diuretics or other drugs that affect the kidneys. Acute glomerulonephritis may follow a bacterial or viral infection, such as strep throat or hepatitis. Immune system diseases, such as lupus or IgA nephropathy (Berger's disease), also may trigger acute glomerulonephritis.

Toxic injury. Your kidneys are particularly vulnerable to toxic injury from alcohol, cocaine, heavy metals, solvents and fuels. Sometimes, these toxins can induce acute kidney failure. Some medications, including certain chemotherapy drugs and contrast dyes used in medical tests, have a similar effect in vulnerable people.

Postrenal causes Conditions that block the passage of urine out of the body (urinary obstructions) can, without treatment, also lead to acute kidney failure.

Ureter obstruction. Kidney stones in both of the tubes leading from your kidneys to your bladder (ureters) or in a single ureter if only one kidney is functioning can prevent the passage of urine, as can tumors pushing in on the ureters. Bladder obstruction. In men, prostate enlargement is a common cause of urinary retention due to obstruction at the bladder outlet. Other obstructive bladder causes, in both men and women, include a bladder stone, blood clot, tumor or a nerve disorder that prevents the bladder from contracting properly.

Risk factors
Conditions that increase your risk of acute kidney failure include:

Advanced age Chronic infection Diabetes High blood pressure

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Heart failure Various blood disorders Immune disorders, such as lupus, IgA nephropathy and scleroderma Kidney diseases Liver diseases Prostate gland enlargement Bladder outlet obstruction

Acute kidney failure almost always occurs in connection with another medical condition or event. In fact, most people who experience acute kidney failure are already in the hospital for other reasons, such as severe injury, complicated surgery or overwhelming infection.

Tests and diagnosis

When signs and symptoms point to acute kidney failure, blood and urine tests pin down the diagnosis. Changes associated with acute kidney failure include:

Daily urine output usually falls to less than 2 cups (500 milliliters). Blood urea and creatinine levels rise rapidly. Blood electrolyte concentrations levels of minerals such as sodium, potassium and calcium that regulate fluid balance and muscle function, plus many other vital processes become unstable, causing swelling (edema) and lung congestion. Blood potassium, in particular, rises rapidly, often to life-threatening levels.

Ultrasound is the imaging test most commonly used in diagnosing kidney failure, but your doctor may also order an abdominal computerized tomography (CT) or magnetic resonance imaging (MRI) scan. In a few cases, your doctor may remove a small sample (biopsy) of kidney tissue and send it to a laboratory for microscopic examination to identify the cause of acute kidney failure.

Complications
The sooner the cause of your acute kidney failure is resolved, the more likely you'll be to recover your kidney function. Occasionally, acute kidney failure causes permanent loss of kidney function, or end-stage renal disease. People with end-stage renal disease require either permanent dialysis a mechanical filtration system for removing toxins and waste from your body or a kidney transplant to survive. Acute kidney failure may be fatal. Death rates are highest when the kidneys fail after surgery or trauma or in the context of severe, chronic medical problems. Other factors that can adversely affect the outcome of acute kidney failure include multiorgan failure, multiple blood transfusions, a recent history of stroke or heart attack, or a postoperative stroke, advanced age, infection, gastrointestinal bleeding and pre-existing malnutrition.

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Treatments and drugs

The first goal is to treat the illness or injury that originally damaged your kidneys. Once that's under control, the focus will be on preventing the accumulation of excess fluids and wastes in your blood while your kidneys heal. This is best accomplished by limiting your fluid intake and following a high-carbohydrate, low-protein, low-potassium diet. Your doctor may prescribe calcium, glucose or sodium polystyrene sulfonate (Kayexalate) to prevent the accumulation of high levels of potassium in your blood. Too much potassium in the blood can cause dangerous irregular heartbeats (arrhythmias). Dialysis Most of the time, you also need to undergo temporary hemodialysis often referred to simply as "dialysis" to help remove toxins and excess fluids from your body while your kidneys heal. Dialysis, which is a mechanical way of filtering waste from your blood, is an imperfect but lifesaving substitute for kidney function. In acute kidney failure, dialysis is usually done at a hospital or dialysis center, not at home. The treatment relies on an artificial kidney (dialyzer) to take over kidney function. Blood is pumped out of your body to the artificial kidney through one of two routes a catheter placed surgically in one of your main blood veins, or a surgically created junction between a vein and artery in your arm. Inside the artificial kidney, your blood moves across membranes that filter out waste before being returned to your body. Less than 1 cup (237 milliliters) of blood is outside your body in the dialyzer and tubing at any one time.

Prevention
Acute kidney failure is often impossible to prevent. But you may reduce your risk by following these suggestions:

Don't abuse alcohol or drugs, including over-the-counter pain medications such as aspirin, acetaminophen and ibuprofen. Avoid longterm exposure to heavy metals, such as lead, as well as to solvents, fuels and other toxic substances. Carefully follow all of your doctor's recommendations for managing any chronic medical condition that increases your risk of kidney failure.

If you're at high risk of kidney damage induced by contrast dye used for certain X-rays for example, if you have diabetes or multiple myeloma your doctor may prescribe a dose of acetylcysteine before the procedure. This medicine can help prevent acute kidney failure under these circumstances.

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