Acute Renal Failure

Pathogenesis and Treatment

Lestariningsih Subbag Nefrologi/Hipertensi Bagian Penyakit Dalam FK UNDIP/RS Dr. Kariadi Semarang

Definition
Abrupt sustained decline in GFR Rising serum urea and creatinine Loss of water and salt homeostasis Life threatening metabolic sequelae Occurs over hours or days Incidence approximately 140 p.m.p. per year 5% of all surgical and medical admissions

Subtypes
Acute or acute on chronic Single organ or multi-organ failure Oliguric or polyuric Mild or severe

Aetiology
Pre-renal ARF Intrinsic ARF Post-renal ARF

Pre-renal ARF
Reversible fall in GFR due to renal hypoperfusion Hypovolaemia Haemorrhage, burns, GI fluid loss, renal fluid loss Hypotension Cardiogenic shock, sepsis Renal hypoperfusion renal vasoconstriction, drugs, liver disease, renal vascular disease

Renal ARF
Disease of the renal parenchyma
ATN
Ischaemia, direct toxicity, myoglobin, sepsis

Vascular disease
Vasculitis, atheroemboli, infarction

Diseases of glomeruli/arterioles
RPGN, myeloma, HUS, vasculitis, SLE

Tubulo-interstitial nephritis
Drug related, paraneoplastic

Post-renal ARF
Renal failure secondary to urinary tract obstruction
Ureteric
Calculi, carcinoma, retroperitoneal fibrosis, stricture

Bladder neck
prostatic hypertrophy/malignancy, carcinoma, neuropathy, blocked catheter

Prevention
Identify at risk patients
pre-existing CRF, diabetes, jaundice, myeloma, elderly

Optimise renal perfusion

IV fluids, inotropes, central line

Maintain adequate diuresis

Mannitol, frusemide, NOT dopamine

Avoid nephrotoxic agents

ACE inhibitors, NSAIDS, radiological contrast, aminoglycosides

Cockcroft Gault equation

(140-age in years) x weight in kg serum creatinine (mol/L) (corrected for males x 1.23, females x 1.04)

Principles of investigation
Acute or acute on chronic? Exclude volume depletion Exclude renal tract obstruction Exclude major vascular occlusion Exclude renal parenchymal disease other than ATN

History
When did it start? What was the baseline renal function?
Pre -existing medical conditions

What were the likely insults?

Episodes of hypotension Nephrotoxic agents Sepsis

Symptoms of other diseases

Examination
Current volume status
Skin turgor, oedema, lung bases, heart sounds, central pressures, blood pressure

Bladder and kidneys Signs of systemic disease

rashes, anaemia,

Investigations
Laboratory
U+Es, Bone, Glucose, Urate, Bicarbonate Urine urea, sodium, creatinine, protein FBC, Clotting, ESR Urine microscopy, MSU, blood cultures CRP, ANA, ANCA, anti GBM, myeloma screen

Investigation
Radiology
Plain abdomen, renal U/S, IVU, CT scanning, renal angiography, isotope renography

Renal biopsy

Treatment
Correct renal perfusion
Optimise volume status Inotropes ( dopamin 3 ug/kgBB/jam )

Remove nephrotoxins Relieve obstruction - Bladder catheter

Nephrostomies

Treatment
Make the patient safe Hyperkalaemia
Volume overload Uraemia Acidosis

Specific treatments
Antibiotics, steroids

Methods of treatment
DRUG Calcium Gluconate Glucose + Insulin IV Na Bicarbonate Ventolin Nebuliser Resonium DOSE DURATION 30 minutes 1 - 4 hours 1 - 8 hours 1 - 4 hours days

10 ml of 10%
50 ml 50% + 8U 1l of 1.4% 5 ml 30 - 60 g (po/pr)

Bendrofluazide

5mg

days

and there is always dialysis!

Dialysis
Acute intermittent haemodialysis Continuous dialysis treatments Peritoneal dialysis

Outcome
Full recovery Partial recovery No recovery - progress to ESRF Death