ACUTE RENAL FAILURE

ACUTE RENAL FAILURE:

ACUTE RENAL FAILURE

INTRODUCTION:

INTRODUCTION ARF – Rapid decline in GFR – Hours to Days – Oliguria, Anuria Retention of Nitrogenous waste products - Azotemia Disturbed ECF, Electrolyte & Acid Base Balance Renal Blood flow : 20 to 25% cardiac output 1000 to 1250 ml / minute GFR : 120 ml / minute

AETIOLOGY:

AETIOLOGY Pre-Renal – 55% Intrinsic renal – 40% Post Renal – 5%

PRE -RENAL ARF:

PRE -RENAL ARF Hypovolemia – Loss of blood, Loss of plasma, Loss of fluid & electrolytes Low cardiac output Systemic vasodilatation – Sepsis, Anaphylaxis Impaired renal autoregulation – NSAIDs, ACEI

INTRINSIC RENAL ARF:

INTRINSIC RENAL ARF Renal artery / Renal vein obstruction Glomerulonephritis / Vasculitis Toxemia of pregnancy, SLE, DIC, TTP, HUS, Malignant Hypertension, Radiation Nephritis

INTRINSIC RENAL ARF:

INTRINSIC RENAL ARF ACUTE TUBULAR NECROSIS Prolonged Ischemia (Pre-renal ARF) Toxins 1. Exogenous – VIPER BITE, Radiocontrast Cyclosporin, Aminoglycoside, Cisplatin 2. Endogenous – Myoglobin, Hemoglobin, FALCIPARUM MALARIA, Incompatible Blood Transfusion, Uric Acid

INTRINSIC RENAL ARF:

INTRINSIC RENAL ARF INTERSTITIAL NEPHRITIS Allergic – Antibiotics – Beta Lactums, Sulpha, COT, NSAIDs, ACEI Infection – Leptospirosis, Pyelonephritis Infiltration – Lymphoma, Leukemia

POST RENAL ARF:

POST RENAL ARF Ureter – Calculi, Clot, Cancer, Sloughed papillae Bladder Neck – BHP, Ca Prostate, Blood Clot, Neurogenic Bladder Urethra – Stricture, Valve, Phimosis

CLINICAL FEATURES:

CLINICAL FEATURES Altered consciousness, drowsiness, stupor, seizures, coma, asterixis Puffiness of face, periorbital swelling, pallor, purpura Nausea, Vomiting, coffee ground vomitus, Hiccups Arterial pulse – low volume, regular / irregular Venous pulse – Low JVP / elevated JVP BP – Hypotension / Severe Hypertension Respiration – Kusmaul’s Dependant oedema

CLINICAL FEATURES:

CLINICAL FEATURES PRE RENAL ARF Volume depletion – Thirst, Postural / Absolute Hypotension, Tachycardia, Low JVP, Dry Mucous Membrane / Axillae, Weight Loss, Use of NSAIDs, ACEI Urine–No albumin, casts, no RBC, FE Na < 1% (U Na x P Cr ) / (P na x U cr ) x 100

CLINICAL FEATURES:

CLINICAL FEATURES INTRINSIC RENAL FAILURE History of IHD, AF, Angiography, severe HTN History of recent Infection, Sinusitis, Ulcers, Hemoptysis, Purpuric rash, Arthritis Radiocontrast study, Nephrotoxic antibiotic, anti cancer agents Urine – Proteinuria, Hematuria, Red cell or Granular casts, FE Na > 1%

CLINICAL FEATURES:

CLINICAL FEATURES POST RENAL ARF Abdominal / flank pain Palpable bladder

INVESTIGATIONS:

INVESTIGATIONS Complete Urine examination Complete Hemogram, Blood smear, ESR Urea, Creatinine, Na, K, Bicarbonate, Cal, Phos, Uric Acid, CK, S. Proteins USG Abdomen and Pelvis X-Ray chest ECG

DAILY OBSERVATIONS:

DAILY OBSERVATIONS Daily weight of the patient Urine output chart Intake chart BP chart JVP / Arrhythmias / Signs of Pulmonary Oedema

MANAGEMENT:

MANAGEMENT Pre-Renal ARF – Restore systemic hemodynamics and renal perfusion Nephrotoxic ARF – Eliminate nephro toxin, forced alkaline diuresis Urinary bladder Catheterisation

FLUID CHALLENGE:

FLUID CHALLENGE Oliguria – No volume overload 500 to 1000 ml normal saline – 30 to 60 minutes (check CVS / RS) Frusemide 100 to 400 mg IV

GENERAL CARE:

GENERAL CARE FLUID REPLACEMENT : Urine output + Other drainage fluids + 500 ml for insensible loss ENERGY : Carbohydrate and fat – 35 Kcal / Kg / day Protein : 0.8 gm / Kg / day

TREATMENT OF COMPLICATIONS:

TREATMENT OF COMPLICATIONS INTRAVASCULAR VOLUME OVERLOAD Salt 1–2 gm/day, Water – 1 L/day Diuretics – Frusemide Dialysis

TREATMENT OF COMPLICATIONS:

HYPONATREMIA Restrict water intake to 1 L/day Avoid Hypotonic IV solution TREATMENT OF COMPLICATIONS

TREATMENT OF COMPLICATIONS:

HYPERKALEMIA ECG – tall tented T waves, prolonged PR, QRS widening, absent P waves, VF Restrict dietary K Eliminate K sparing diuretics Potassium binding ion exchange resin – sodium polystyrene sulphonate Glucose 50 ml 50% Dextrose + 10 units regular insulin Calcium gluconate 10 ml 10% IV – dialysis TREATMENT OF COMPLICATIONS

TREATMENT OF COMPLICATIONS:

TREATMENT OF COMPLICATIONS METABOLIC ACIDOSIS Restrict dietary protein 0.6 gm / Kg / Day Sodium Bicarbonate – 500 ml 1.26 % ( Check CVS / RS) Dialysis

TREATMENT OF COMPLICATIONS:

TREATMENT OF COMPLICATIONS HYPERPHOSPHATEMIA Restrict dietary phosphate < 800 mg / day Phosphate binding agent – Calcium Carbonate, Aluminium Hydroxide

TREATMENT OF COMPLICATIONS:

TREATMENT OF COMPLICATIONS HYPOCALCEMIA – Tetany, Muscle Cramps Calcium Carbonate tablets Calcium Gluconate 10 ml 10% IV

TREATMENT OF COMPLICATIONS:

TREATMENT OF COMPLICATIONS SYSTEMIC HYPERTENSION Anti Hypertensive Drugs not reducing renal blood flow – Clonidine, Prazosyn, CCB

INDICATION FOR DIALYSIS:

INDICATION FOR DIALYSIS Clinical and biochemical evidence of uremia Intractable intravascular volume overload Severe Hyperkalemia / Metabolic Acidosis Uremic pericarditis Uremic encephalopathy

PRESCRIBING OF MEDICATIONS:

PRESCRIBING OF MEDICATIONS CHOICE OF AGENTS Avoid Cyclo-oxygenase Inhibitors, NSAIDs, Nephrotoxic antibiotics, Radio-contrast, ACEI DRUG DOSING Adjust dose and frequency