acute renal failure (arf)
DESCRIPTION
Acute renal failure (ARF) . acute kidney injury AKI is a sudden and usually reversible loss of renal function which develops over days or weeks and is usually accompanied by a reduction in urine volume. A rasied creatinine level can be due to acute, acute on chronic of chronic kidney disease. - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/1.jpg)
Acute renal failure (ARF) acute kidney injury AKI is a sudden
and usually reversible loss of renal function which develops over days or weeks and is usually accompanied by a reduction in urine volume.
A rasied creatinine level can be due to acute, acute on chronic of chronic kidney disease.
![Page 2: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/2.jpg)
Two small kidneys on ultrasound indicate chronicity.
![Page 3: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/3.jpg)
Causes of ARF Pre renal
Systemic Heart failure Blood/ fluid loss/ shock called hypovolemia Local Renal artery stenosis Disease affecting arterioles
Under perfusion initially causes rapidly reversible changes,. Subsequently, acute tubular necrosis that may lead to intrinsic renal failure.
![Page 4: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/4.jpg)
Intrinsic renal disease Toxic /septic renal failure 85% glomerular diseases 5%
Primary Component of systemic disease
Interstitial disease 10%
![Page 5: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/5.jpg)
Post renal causes Obstruction Stones Tumor Enlarged prostate
![Page 6: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/6.jpg)
Reversible pre renal acute renal failure
![Page 7: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/7.jpg)
Pathogenesis The kidneys can regulate its own
blood flow and GFR over a wide range of perfusion pressure
When the perfusion pressure falls—as in hypovolaemia, shock, heart failure or narrowing of renal arteries—the resistance vessels in kidneys dilate. It is mediated by prostaglandins.
(this is impaired by NSAIDS)
![Page 8: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/8.jpg)
if autoregualtion of blood is fails, the GFR can stillbe maintained by selective constriction of efferent arteriols by rennin angiotensin mechanism ( it is inhibited by ACE inhibitors)
![Page 9: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/9.jpg)
More sever or prolonged under perfusion of kidneys may lead to failure of these compensatory responses, and acute fall in GFR. This leads to formation of low volume concentrated urine (osmolality >600mOsm/kg) but low in sodium (<20mmol/l)
Note these changes may be absent in patient with pre existing renal impairment or those who received diuretics
![Page 10: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/10.jpg)
Clinical features: Marked hypotension Signs of hypoperfusion such as
delayed capillary return, cool peripheries etc.
Postural hypotension is reliable sign of early hypovolemia.
![Page 11: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/11.jpg)
The causes reduces renal hypo perfusion The sign suggesting following may be
present Shock Blood loss Crush injuries Burns SepsisThese causes should be assessed
![Page 12: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/12.jpg)
Management Establish and correct the under lying causes is very
important step. Treat hypovolemia with restore blood volume as soon
as possible ( with blood, plasm, isotonic saline 0.9%) Optimize systemic haemodynamics. Monitoring the
central venous pressure and pulmonary wedge pressure is necessary for fluid administration.
Note: Meta analysis trials do not support the role of low dose dopamine in ARf.
Correct the metabolic acidosis Restoring the blood volume will correct the acidosis by
restoring the kidney function. Sodium bi carbonate (50 ml of 8.4%) may be used
severe acidosis.
![Page 13: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/13.jpg)
Prognosis
Good full recovery of renal function if early treatment is given.
In some case treatments is ineffective and renal failure becomes established.
![Page 14: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/14.jpg)
Established acute renal failure (ARF) Acute renal failure (ARF) may develop
follwing severe and prolonged underperfusion of kidneys when the histological pattern of acute tubular necrosis is usually seen.
Acute tubular necrosis (ATN) It is necrosis of renal tubular cells may
result from ischemia of nephrotoxicity caused by chemicals, bacterial toxins or combination.
![Page 15: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/15.jpg)
Drugs includes Aminoglycosides antibiotics like
gentamicin, the cytotoxic drugs cisplastin, anti fungal amphotericin B.
![Page 16: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/16.jpg)
Fortunately there is good recovery because renal tubular cells can regenerate and reform basement membrane.
![Page 17: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/17.jpg)
Features of established ARF These show the causal conditions Urea and creatinine
Raised urea and creatinine Alterationin urine volume
Oliguria/ anuria
![Page 18: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/18.jpg)
Disturbance in fluid, electrolytes and acid base balance
Hyperkalaemia Due massive tissue breakdown,
hemolysis, and metabolic acidosis. Dilutional hyponatraemia
Oliguric patient continue to drink of excessive fluid is given
![Page 19: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/19.jpg)
Metabolic acidosis Hypocalcaemia
Reduced renal production of 1,25 dihydroxychlocalciferol
![Page 20: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/20.jpg)
Uremia
Uremic features: Anorexia Nausea and vomiting Drowsiness Apathy, confusion Hiccups Fits, coma and death.
![Page 21: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/21.jpg)
Respiratory features
Inc resp. rate due to acidosis infection pulmonary edema due to excessive
fluid administration
![Page 22: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/22.jpg)
Blood anemia
Bloold loss Hemolysis Dec.erythropoetin secretion.
Platelets and cogulation dysfunctions. Severe infection
Depressed immunity.
![Page 23: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/23.jpg)
Management Initial Management is targeted at
following priorities: Hyperkalemia Pulmonary edema Infection Uremia itself
![Page 24: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/24.jpg)
Hyperkalemia i.v calcium gluconate (10ml of 10%
solution) Inhaled β2 agonist e.g salbutamol i.v glucose (50ml of 50% solution) Insulin 5 U actrapid Intravenous sodium bicarbonate. Iv lasix and normal saline. Ion exchange resin ( resonium) orally or
rectally Dialysis
![Page 25: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/25.jpg)
Immediate fluid management
Volume replacement CVP monitoring Pulmonary edema may require dialysis to
remove water and sodium from the body. Temporary respiratory support
CPEP IPPVSevere acidosis may require sodium bi carbonate if
volume status allows
![Page 26: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/26.jpg)
Addressing the underlying causes of ARF Remove post renal obstruction
Uretric dilation Prostate surgery Percutaneous nephrostomy
![Page 27: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/27.jpg)
No specifis treatment of ATN immuno suppressive drugs for
rapidly progressive glomerulo nephritis.
Plasma exchange in micro angiopathic disease.
![Page 28: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/28.jpg)
FlUID AND ELECTROLYTE BALANCE After initial resusitation,
Maintain I/O chart Daily weight
Daily intake should equal the urinr out put plus 500 ml to cover insensible loss.
![Page 29: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/29.jpg)
Protein and energy intake By dietary protein restriction ( 40g
per day), in whom dialysis is likely to be avoided.
Patients on dialysis may require more dietary proteins ( 1 g / kg proteins daily and 10-12g nitrogen).
Adequate energy is needed in hypercatabolic states like sepsis and burns.
![Page 30: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/30.jpg)
Infection control Treated accordingly with porper
antibiotics. dose adjustment is required. Drugs like NSAIDS and ACE inhibitors
should usually be avoided.
![Page 31: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/31.jpg)
Renal replacement therapy This may be required as supportive
management in ARF.
![Page 32: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/32.jpg)
Prognosis In uncomplicated ARF, due to blood
loss, hypovolemia, mortality is low. In ARF associated with serious
infection/ sepsis and multi organ failure , mortality is 50 to 70 %.
![Page 33: Acute renal failure (ARF)](https://reader034.vdocuments.net/reader034/viewer/2022051003/5681649c550346895dd67f55/html5/thumbnails/33.jpg)
THANK YOU