1. بسم الله الرحمن الرحيم

2. Acute Versus Chronic Renal Failure Manal Elshamaa , MD of pediatrics National Research Centre
*trademark

3. Anatomy
2 Kidneys
2 Ureters
Bladder
Urethra

4. What do
the kidneys do??

5. Kidney Function Detoxify blood Increase calcium absorption
calcitriol
Stimulate RBC production
erythropoietin
Regulate blood pressure and electrolyte balance
renin

8. Classifications Acute versus chronic Pre-renal, renal, post-renal
Anuric, oliguric, polyuric

9. Acute Versus Chronic Acute Chronic
sudden onset
rapid reduction in urine output
Usually reversible
Tubular cell death and regeneration
Chronic
Progressive
Not reversible
Nephron loss
75% of function can be lost before its noticeable

10. Acute Renal Failure Definition
Renal function is diminished to the point where body fluid hemostasis can no longer be maintained.

13. Prerenal Causes The most common cause of acute renal failure.
Hypovolemia
Hemorrhage
Gastroenteritis
Hypoproteinemia
Burns
Renal or adrenal disease with salt wasting
Hypotension
Septicemia
DIC
Hypothermia
Congestive heart failure
Hypoxia
RDS and pneumonia
Aortic calmping

14. Prerenal Azotemia In severe cases hypovolemic shock.
Oliguria is present in most individuals.
Normal or increased urine output indicates either
Aminogycoside or ATN
nephrotoxicity

15. Prerenal ARF of Newborns and Infants
Causes
Peri-natal hemorrhage - Twin-twin transfusion, complications of amniocentesis, birth trauma
Neonatal hemorrhage - Severe intra-ventricular hemorrhage, adrenal hemorrhage.
Perinatal asphyxia and hyaline membrane disease.
Other causes as NIC &renal vein thrombosis

16. Prerenal ARF of Children
The most common cause of ARF
Prerenal ARF:
The most common cause of hypovolemia in children is gastroenteritis.
Congenital and acquired heart diseases are important causes of ARF in this age group.

17. Intrinsic Renal Failure
Glomerulonephritis
Localized intravascular coagulation
Acute tubular necrosis
Acute interstitial nephritis
Tumors
Developmental abnormalities
Hereditary

18. Intrinsic Renal Failure
Glomerular diseases: The most common causes in older children
Nephritic syndrome of hematuria and edema is synonymous with a glomerular etiology of ARF.

19. Intrinsic Renal Failure
*Localized intravascular coagulation
Acute dehydration HUS
The most common causes of ARF in toddlers

20. Acute Tubular Necrosis
Tubular diseases:
Acute tubular necrosis
(Absence of arterial or glomerular lesions).
There are major histologic changes that take place in ATN:
(1) tubular necrosis with sloughing of the epithelial cells
(2) occlusion of the tubular lumina by casts and by cellular debris
(3)Back leak of filtrate

21. Major Causes of Acute Tubular Necrosis
Renal Ischemia:
* Severe pre-renal disease from any cause.
Exposure to Nephrotoxins:
* Amphotericin B
Aminoglycosides * Heme Pigments * NSAID's (hemoglobinuria/myoglobinura)
Require a period of dialysis before spontaneous resolution occurs.

22. Intrinsic Renal Failure
Interstitial diseases
* Acute interstitial nephritis,
drug reactions
* infiltrative disease (lymphoma)
* infectious agents.

23. Intrinsic ARF of Children
Hemolytic uremic syndrome (HUS) is the most common cause of ARF in children.
The disease is associated with a diarrheal prodrome caused by Escherichia coli
Children usually present with microangiopathic anemia, thrombocytopenia, colitis, mental status changes, and renal failure.

24. Post-renal ARF Uretropelvic junction Obstructive uropathy
Uretrocele
Urethral valves
Tumors
Vesicouretral reflux
Acquired
Stones
Blood clots

25. Symptoms of ARF Decrease urine output (70%)
Edema, esp. lower extremity
Mental changes
Heart failure
Nausea, vomiting
Pruritus
Anemia
Tachypenic
Cool, pale, moist skin

26. Diagnostic Evaluation:
Urinalysis shows proteinuria, hematuria, casts.
Serum creatinine and BUN levels are elevated; arterial blood gas levels, serum electrolytes may be abnormal.
Renal untrasonography rules out treatable obstructive uropathy.

27. Laboratory Findings in the Differential Diagnosis of Acute Renal Failure:

28. FeNa Calculation of fractional excretion of sodium (FeNa)
FeNa = (urine Na/plasma Na)/(urine creatinine/plasma creatinine)
FeNa <1 % = prerenal ARF
FeNa >1% = ATN

29. Therapeutic and Pharmacologic Interventions:
Surgical relief of obstruction .
Correction and control of biochemical imbalances.
Restoration and maintenance of blood pressure
Low protein diet with supplemental amino acids and vitamins.
Initiation of dialysis, or continuous renal replacement therapy for patients with progressive azotemia .

30. Continuous Hemofiltration (HF)
It is useful in patients with ARF.
Continuous AVHF Continuous VV HF
Blood is pumped By a pump
through fillter
by patient heart

31. ARF: Life Threatening Conditions
Hyperkalemia
Volume overload
Vascular access

32. Hyperkalemia Symptoms
EKG?
Weakness
Lethargy
Muscle cramps
Paresthesias
Dysrhythmias

33. Hyperkalemia & EKG K > 5.5 -6 Tall, peaked T’s Wide QRS Prolong PR
Diminished P
Prolonged QT

35. Hyperkalemia Treatment
Kayexalate
Calcium gluconate (carbonate)
Sodium Bicarbonate
Insulin/glucose
Lasix
Albuterol
Hemodialysis

36. Chronic Renal Failure
150–200 cases per million people = new cases each year
Chronic renal failure and ESRD affect more than 2 out of 1,000 people in the U.S
Mortality = 20%

37. Chronic Renal Failure Causes
Glomerular diseases 40% (after 5 yrs old)
Anatomic abnormalities 20% (under 5 yrs old)
Hereditary renal diseases 15% (after 5 yrs old)
Pylonephritis with reflux nephropathy 15%
Miscellaneous10%: Vascular, HUS, JDM, wilms tumor.

38. CRF Symptoms Growth failure Weakness Fatigue Neuropathy CHF Anorexia
Nausea
Vomiting
Seizure
Constipation
Peptic ulceration
Diverticulosis
Anemia
Pruritus
Jaundice
Abnormal hemostasis

39. Problems Related to ESRD
Metabolic – K/Ca
Volume overload
Anemia, platelet disorder, GI bleed
Pericarditis
Peripheral neuropathy, dialysis dementia
Abnormal immune function

40. Dialysis ½ of patients with CRF eventually require dialysis
Diffuse harmful waste out of body
Control BP
Keep safe level of chemicals in body
2 types
Hemodialysis
Peritoneal dialysis

41. Hemodialysis 3-4 times a week Takes 2-4 hours Machine filters
blood and
returns it to
body

42. Types of Access Temporary site AV fistula AV graft
Surgeon constructs by combining an artery and a vein
3 to 6 months to mature
AV graft
Man-made tube inserted by a surgeon to connect artery and vein
2 to 6 weeks to mature

43. Temporary Catheter

44. AV Fistula & Graft

45. What This Means For You No BP on same arm as fistula
Protect arm from injury
Control obvious hemorrhage
Bleeding will be arterial
Maintain direct pressure
No IV on same arm as fistula
A thrill will be felt – this is normal

46. Access Problems AV graft thrombosis AV fistula or graft bleeding
AV graft infection
Steal Phenomenon
Early post-op
Ischemic distally
Apply small amount of pressure to reverse symptoms

47. Peritoneal Dialysis Abdominal lining filters blood 3 types
Continuous ambulatory
Continuous cyclical
Intermittent

48. Dialysis Related Problems
Lightheaded –give fluids
Hypotension
Dysrhythmias
Disequilibration Syndrome
At end of early sessions
Confusion, tremor, seizure
Due to decrease concentration of blood versus brain leading to cerebral edema

49. Thank you