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بسم الله الرحمن الرحيم.

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Presentation on theme: "بسم الله الرحمن الرحيم."— Presentation transcript:

1 بسم الله الرحمن الرحيم

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

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

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