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

Anatomy 2 Kidneys 2 Ureters Bladder Urethra

What do the kidneys do??

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

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

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

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

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

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

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

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.

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

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.

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

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

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.

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

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.

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

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

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.

Laboratory Findings in the Differential Diagnosis of Acute Renal Failure:

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

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 .

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

ARF: Life Threatening Conditions Hyperkalemia Volume overload Vascular access

Hyperkalemia Symptoms EKG? Weakness Lethargy Muscle cramps Paresthesias Dysrhythmias

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

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

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%

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.

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

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

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

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

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

Temporary Catheter

AV Fistula & Graft

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

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

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

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

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