Acute Renal Failure

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Acute Renal Failure

• Du Juan
• Department of Nephrology
• Renmin Hospital of Wuhan University

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Definitions

• Acute Renal Failure (ARF) is a syndrome
  characterized by rapid (hours to weeks) decline
  in glomerular filtration rate (GFR) and retention
  of nitrogenous waste products such as creatinine

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Definitions

• Clinical Syndrome
• Abrupt Sustained Decline in GFR
• Occurs over Hours or Days
• Rising Serum Creatinine(44.2µmol/L /day)
• Clinical Results

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Definition of AKI

• Functional or structural abnormalities or
• markers of kidney damage including
• abnormalities in blood , urine or tissue
  tests
• or imaging studies present forlt3 months

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• ??????????3????????????,???????????????????????
  ?

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Criteria for AKI

• 48???Scr??26.5µmol/L(0.3mg/dl)
• ?????50
• ????,lt0.5ml/kg/h ,??6????(????????????)

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Staging of AKI
Phase Scr Criteria Urine Output Criteria
1 ?0.3mg/dl or?50 lt0.5ml/kg/h6hr
2 ?200-300 lt0.5ml/kg/h12hr
3 ?300 Oliguria 4.0mg/dl (lt0.3ml/kg/h24hr ) (Acute rise0.5mg/dl ) or Anuria12hr
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Classification
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Prerenal ARF (1)
Intravascular Volume Depletion
Hemorrage
Gastrointestinal Losses
Renal Losses
Skin and Mucous Losses
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Prerenal ARF (2)
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Postrenal ARF
Bilateral Ureteric Obstruction
Bladder Neck Obstruction
Urethral Obstruction
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Intrarenal ARF (1)
Diseases of Glomeruli
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Intrarenal ARF (2)
Tubulointerstitial Nephritis
Renal Biopsy
Rash
Fever
Hematuria
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Intrarenal ARF (3)
Diseases of Large Renal Vessels

Thrombosis
Atheroembolism
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Intrarenal ARF (4)
Acute Tubular Necrosis(ATN)
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• Acute Tubular Necrosis

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ATN

• Etiology
• Pathogenisis
• Pathology
• Clinical Presentations
• Laboratory Examinations
• Diagnosis Differentiation
• Management

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Etiology
Ischemic ATN
Severe or prolonged renal hypoperfusion
Nephrotoxic ATN
Many medications and poisons
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Pathogenesis

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• ????????
• ???????,???????
• ?????(Intratubular Obstruction)
• ?????(Tubular Fluid Backleak)
• ???????????

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Ischemic / Toxic Renal Injury
Tubular Damage
Hemodynamic Abnormalities
Endothelial Swelling Reduced EDRF Vasoconstrictor
Release Endothelin Angiotensin Thromboxane Norepin
ephrine
? Tubuloglomerular Feedback
Afferent Arteriolar Constriction
Tubular Obstruction
Backleak
?Kf
? Glomerular Capillary Pressure
? RBF
Reduced Glomerular Filtration Rate
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Events Following the Initiation of Renal Ischemia
Renal Ischemia
? Supply of O2 Nutrients to Kidney
ATP ?
Nephrotoxins ? Lipid Peroxidation
? Oxygen-Derived Free Radicals ? Scavenging
Systems ?
Tubular Sodium PumpIinhibition Na, Cl- ? pH
? Cell Volume
Abnormal Metabolic Levels Adenosine
? Hypoxanthine ?
Cell structure changes Membrane
Integrity Cytoskeleton Damaged Mitochondria Swell
Pathologic Changes Tubular Dysfunction Leakage,
Obstruction, Loss of Filtration,
Necrosis Intrarenal Vessel Constriction
Increased Ischemia Cell death
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Pathology
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• Normal

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Tubule vacuolization (green arrow)
Tubule dilation and brush border losses
(black arrows)
Mild ATN

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Severe ATN
Denuded basement membrane and the presence of
intraluminal casts

• Degenerated and sloughed,
• frank necrosis tubular cells

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Clinical Course of ATN

• Initiation Phase
• Maintenance Phase
• Recovery Phase

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• ???
• ???
• ???

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Initiation Phase

• Reversible Fall in GFR Preventive
• Hypotension
• Sepsis
• Renal Toxins

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Maintenance Phase

• Oliguria Phase
• 714d or Even 46w of Duration
• OliguriaUrine Outputlt400ml/d
• AnuriaUrine Outputlt100ml/d
• Nonoliguria

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Clinical Presentations (1)

• Disturbance of Water?Electrolyte Base- Acid
  Homeostasis
• Hyponatremia(????)
• Hyperkalemia(????)
• Hypocalcemia (????)
• Hyperphosphatemia(????)
• Metabolic Acidosis(??????)

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Clinical Presentations (2)

• Systemic Complications Infection
• The most common and serious
• complications of ARF
• Occurring in 50 to 90 of cases
• Aaccouting for up to 75 of deaths

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Clinical Presentations (3)

• Systemic Complications
• Gastrointestinal Symptoms Anorexia, Nausea,
  Vomiting, Hemorrhage
• Cardiac Complications Hypertension, Congestive
  Heart Failure, Arrhythmias

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Clinical Presentations (4)

• Pulmanary Complications Infection, Adult
  Respiratory Distress Syndrome
• ?????????ARDS
• Neruopsychiatric Disturbance Confusion, Delirium
  or Coma, Seizure
• ??????????????? ??

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Recovery Phase

• Volume of Urine
• 3000-5000ml/d Duration 1-3w
• Complications
• Hyponatremia?Hypokalemia
• Infection
• Redecreased Volume of Urine
• Renal Biopsy Show Everlasting Renal Pathological
  Changes in Minority of Patients

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Laboratory Examinations

• Blood Analysis
• Urinalysis
• Imaging Evaluation
• Renal Biopsy

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Blood-Rt and BCA

• Serum Creatinine BUN?
• Serum Potassium ?
• Serum Sodium ?
• Serum Calcium ?
• Serum HCO3- ?
• Mild-Moderate Anemia
• Serum BUN/Scr

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Urinalysis

• Urine Output ????????????
• Urine Sediment ???????
• Urine Specific Gravity ???lt1.015
• Urine Osmotality ?????lt350mOsmol/L
• Urinary Na Concentration ??2060mmol/L
• Urinary Creatinine/Plasma Creatinine Ratio
• 
  ???/???lt20

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Renal Tubular Epithelial Cell Casts
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• Imaging Investigations
• Ultrasound B?
• Plain Abdomen ????
• Excretory Urography/Cystourethrography
• ???????/??????
• CT Scanning
• Isotope Renography or Renal Angiography
• ?????????
• Renal Biopsy

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Diagnosis

• History
• Abrupt Sustained Decline in Renal Function
• Increased Absolute Scr 44.2umol/L/d
• Increased Relative Scr 25 Over Baseline/d
• Clinical Manifestations
• Laboratory Examinations

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Differential Diagnosis

• ARF Secondary to CKD
• Prerenal ARF
• Postrenal ARF
• Intrinsic ARF

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Postrenal ARF

• Primary Disease of Urinary Obstruction
• Abrupt Oliguria or Even Anuria
• Renal Angina
• Tenderness or Percussion
• Signs of Urine Retention
• Renal Imaging

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Prerenal ARF

• Transfusion Test
• History of Body Fluids Losses
• Signs of Hypovolemia
• IV.drop 5 Glucose 200250ml IV. Frusemide
  40100mg

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Differential Diagnosis Between Pre-renal ARF and
ATN
Diagnosis Index Prerenal ARF ATN
Urine Gravity gt1.018 lt1.015
Urine Osmotality(mmol/L) gt500 lt350
Urine Natrium Concentration (mmol/L) lt20 gt20
Serum BUN/Scr gt20 lt15
ARF Index lt1 gt1
Natrium Filtration Fraction lt1 gt1
Urine Sediment Clarity Cast Brown Granular Casts
Transfusion Test -

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Treatment (1)

• Prevention(??????,??????)
• Identify at Risk Patients(??????)
• Pre-existing CKD, Diabetes, Elderly
• Optimise Renal Perfusion
• IV Fluids, Blood Transfusion
• Avoid Nephrotoxic Agents
• NSAIDS, Radiocontrast, Aminoglycosides,ACEI
• Maintain Adequate Diuresis?
• Frusemide

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Treatment ( 2 )

• Management of Volume Homeostasis
• Record I/O
• Fluid Urine Output 500ml
• Diuretics
• Dialysis

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Treatment (3)

• Management of Electrolyte Homeostais
• Hyponatremia
• Hyperkalemia
• Hypocalcemia
• Hyperphosphatemia

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Methods of Treatment
DURATION 30 minutes 1 - 4 hours 1 - 8 hours
DOSE 10 ml of 10 50 ml of 50 10U 100ml200ml
of 5
DRUG Calcium Glucose Glucose Insulin Natrium
Bicarbonate Na polysterne sulfonate Dialysis
There is always dialysis!
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Treatment (4)

• Nutritional Support
• Calorie 35Kcal/kg/d
• Maximal Carbohydrate and Lipid
• Minimal Recommand Protein Intake 0.8g/kg/day
• Limit Na?K?Cl Intake
• IV. Essence Amino Acid

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Treatment (5)

• Heart Failure
• Digoxine
• Diuretics
• Vessel Dilative Agents
• Dialysis Most Effective
• Infection

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Treatment (6)

• Absolute Indications
• Volume Overload
• Hyperkalemia
• Metabolic Acidosis
• Overt Uremic Symptoms

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• Prophylaxis Dialysis
• Relieve Retention of Excess Water and Toxins
• Maintain Electrolyte and Acid-Base Homeostais
• For Nutritional Therapy
• Avoid MOSD

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Dialysis Pattern

• Intermittent Hemodialysis(IHD)
• Continuous Renal Replacement Therapy
• Peritoneal Dialysis(PD)

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?????

• ?????
• ???? 6.5mmol/L??
• BUN21.4mmol/L?Scr442umol/L
• ???????
• ??BUN??8.9mmol/L?Scr??176.8umol/L,????1mmol/
  L

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• ??2????4???
• ??? CO2CPlt13mmol/L, pHlt7.25
• ??2?????????????
• ???? ????? ??gt6.0mmol/L,????????

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??????

• ?????
• ????????????
• ??????
• ???????
• ???????
• ?????????

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Prognosis

• ATN Without Complications 7-23
• ATN With MOSD 50-80

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Questions

• Whats the Difference between Acute Renal Failure
  and ATN?
• How to Deal with Hyperkalemia in ARF Patients?
• What is the Indication of Hemodialysis in ARF
  Patients?

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THANK YOU