Introduction

The kidneys play an incredibly important role in maintaining homeostasis in the body.
Most of us will live our entire lives without compromise to these vital organs, but they
can be injured through a number of mechanisms. If the injury to the kidneys is
significant and abrupt, the patient may experience acute renal failure, which can be
life-threatening. In other cases, the kidneys are injured over time and shut down due
to chronic renal failure. Its fairly common; one in 10 American adults will suffer from
some form of chronic kidney disease during their lifetime.1

Prehospital caregivers play a vital role in ensuring that renal failure patients are
quickly identified, properly treated and transported to an appropriate ED for
continued care.

Anatomy & Physiology

The kidneys are bean-shaped organs located in the retroperitoneal space at

approximately the level of the 12th ribs. The left kidney is positioned slightly higher
than the right. In adults, the kidneys are approximately four inches long, 2.5 inches
wide and 1.5 inches thick. A fatty pouch comprised of the renal capsule, adipose
capsule and renal fascia surrounds each kidney. Large renal arteries bring
approximately 1.2 liters of blood to the kidneys every minute for filtration and
production of urine. The blood passes through a complex system of vessels,
eventually leaving the kidneys through the renal veins.

The kidneys have two layers: the outer cortex and inner medulla. Although the two
layers are visible during dissection, they function as one complete unit in the healthy
individual. The outer cortex contains most of the glomeruli (described in more detail
later) and the vast amount of nephrons that function to create urine. The medulla is
the inner layer that is largely comprised of the renal pyramids. These cone-shaped
structures serve to channel urine into the renal calyces.

On a microscopic level, a kidneys main functional unit is the nephron, which consists
of the renal corpuscle (glomerulus and Bowmans capsule) and tubules. Filtration
occurs in the renal corpuscle where the glomerulus filters blood across Bowmans
capsule. Filtration is the first step in forming urine.
Reabsorption occurs through specialized capillaries known as peritubular capillaries.
Water, glucose, sodium and other nutrients and ions are brought back into the blood.
The next step in the formation of urine is known as secretion whereby the remaining
fluid and constituents pass through the loop of Henle and into the collecting tubule.
The urine then passes into larger ducts that eventually empty into a renal calyx.
From the renal calyx (plural is calyces), the urine then passes into the renal pelvis,
down the ureter and into the urinary bladder until it is passed through the process of
urination. Through filtration, reabsorption and secretion, the kidneys help to regulate
the bodys fluid, electrolyte and acid-base balance.

The kidneys also produce important hormones known as erythropoietin (EPO) and
calcitriol. EPO serves to stimulate production of red blood cells in the red marrow of
bone while calcitriol is the active form of vitamin D, which helps the body absorb
calcium from food and obtain calcium from the bone for distribution in the blood
stream. Lastly, the kidney secretes an enzyme known as renin. This important
enzyme helps

to maintain blood pressure through the renin-angiotensin-aldosterone pathway.

The causes of acute renal failure are commonly grouped into three major
categories: pre-renal, intrarenal and post-renal failure.3 Pre-renal is the most
common for renal failure and arises from such conditions as rhabdomyolysis,
hemorrhage, sepsis, burns, trauma and a host of other factors. Intrarenal causes
are classified by area affected: tubular, glomerular, interstitial and vascular.3
Diseases that can injure the kidneys include diabetes mellitus, systemic lupus
erythematosis, persistent hypertension, renal blood vessel occlusion and other
disease processes. Post-renal failure can occur when theres an obstruction in the
urinary tract. Kidney stones, trauma, bladder cancer and enlargement of the
prostate can lead to post-renal failure.
Re:Pre renal/Intra renal/ Post renal FAILURE
#2112785
usmedipro - 05/24/10 08:36

Pre Renal (ARF) Failure occurs when there is inadequate blood circulation (perfusion) of blood vessels
supplying the kidneys. In this situatio,n the kidneys are unable to filter the blood of toxins
adequately.

Major causes:
**********
Shock, sepsis
Dehydration,
Severe blood loss
Heart failure
Preexisting atherosclerosis
So, as you see above, all conditions result in reduced blood flow to the kidneys.

BUN /Cr elevated,>20

Ur NA < 20
FENa < 1
No/trace proteinuria
normal or few cells only

Trt is aimed at improving the renal perfusion and by treating the underlying conditions- dramatic
improvements with iv fluids.
*********************************************************************************
Intra renal Failure
Intrinsic renal failure is renal failure which is not caused by pre renal or post renal factors. In Intrinsic
renal failure there is damage and injury with both kidneys.

Major causes
***********
Vascular-
Glomerulonephritis due to any cause
Renal artery obstruction
Blood disorders- like Anemia, Thrombocytopenia-resulting in necrosis in renal tissues

Diseases of Tubules and renal interstitium

ATN- dueto ischemia, nephrotoxins-causing damge to the renal tubules.
Drug induced allergic interstitial nephritis-commonly by antibiotics,nsaids and chemotherapeutics,
radiocontrast dyes.
Also hypercalcemia, myoglobinuria as in rhabdomyolysis,alcohol,cocaine

Urine shows lots of WBCs and RBCs ,casts

BUN/Cr 20
FE Na>1
mild to moderate proteinuria
dark brown casts in urine, eosnophils,WBC and RBC

Blood-hypocalcemia,hyperkalemia, hyperphosphatemia, hypermagnisemia,uremia.

Trt aimed at underlying conditions trt, withdrawal of nephrotoxic drug, glucocorticoids,trt of
malignant hypertension, mngmt of acidosis,dialysis when needed.
*******************************************************************************
Post renal Failure
**************
Postrenal ARF is the result of an acute obstruction to the outflow of urine from one or both kidneys.
The obstruction results in back pressure

Major causes.
**********
Urinary bladder outlet obstruction- BPH or stones
Renal calculi in one or both ureters
Neurogenic bladder-pt unable to empty the bladder
postrenal injury due to accidents
retroperitoneal fibrosis
BUN/CR -10-15
Ur Na >40
FENa >1
mild to moderate proteins
RBC,WBC ,crystals

Trt of underlying outlet obstruction such as stones,BPH .