RENAL FAILURE The term Renal Failure means failure of renal excretory function due to depression of GFR. ACUTE RENAL FAILURE Acute renal failure (ARF) is defined as sudden and usually reversible deterioration of renal function occurring over a period of hours to days OR rarely weeks and results in uremia leading to ARF Acute renal failure (ARF) is defined as sudden and usually reversible deterioration of renal function occurring over a period of hours to days OR rarely weeks and results in uremia leading to ARF Dr S Chakradhar 1

How it occurs ? Anything that reduces renal blood flow Anything that reduces renal blood flow Anything that affects the kidneys Anything that affects the kidneys Anything that causes obstruction of renal system Anything that causes obstruction of renal system Dr S Chakradhar 2

Causes (Classification) of Acute renal failure: A) Pre-renal ARF: (Most common) Reduced Circulatory Blood Volume Hemorrhage from any cause Hemorrhage from any cause Loss of Plasma from as in burns. Loss of Plasma from as in burns. Sodium & water depletion : GIT in severe vomiting, diarrhea, acute intestinal obstruction etc. GIT in severe vomiting, diarrhea, acute intestinal obstruction etc. In Urine due to diuretics, Diabetic Ketoacidosis In Urine due to diuretics, Diabetic Ketoacidosis From Skin due to sweating From Skin due to sweatingRhabdomyolysis Cardiogenic Shock, Septicaemia Bilateral renal vessel obstruction (Thrombosis, embolism) Dr S Chakradhar 3

PathogenesisPrerenal Hypovolaemia : hypo perfusion----Reduced GFR---- Oliguria. Hypovolaemia : hypo perfusion----Reduced GFR---- Oliguria. (Hypoperfusion of an otherwise functioning kidney leads to enhanced reabsorption of Na and water, resulting in oliguria with high urine osmolality and low urine Na.) (Hypoperfusion of an otherwise functioning kidney leads to enhanced reabsorption of Na and water, resulting in oliguria with high urine osmolality and low urine Na.) Dr S Chakradhar 4

B) Renal ARF Acute Tubular Necrosis Acute Tubular Necrosis Rapidly progressive GN (AGN) Rapidly progressive GN (AGN) Acute Interstitial Nephritis Acute Interstitial Nephritis Vasculitis Vasculitis Dr S Chakradhar 5

Pathogenesis PathogenesisRenal Glomerular permeability: Post Streptococcal GN---Decrease perfusion-- Oliguria Glomerular permeability: Post Streptococcal GN---Decrease perfusion-- Oliguria Acute tubular necrosis : 1. ischaemia 2. Toxic--- damage to tubular cells Acute tubular necrosis : 1. ischaemia 2. Toxic--- damage to tubular cells (Tubular damage impairs reabsorption of Na, so urinary Na tends to be elevated) (Tubular damage impairs reabsorption of Na, so urinary Na tends to be elevated) Dr S Chakradhar 6

Biochemical characteristics of ARF Dr S Chakradhar 7

C) Post Renal: (5%-10% of all cases) ARF is caused by obstruction of the urinary tract at any point in its course ARF is caused by obstruction of the urinary tract at any point in its course Dr S Chakradhar 8

Pathogenesis Post-Renal (Obstructive) Can occur within the tubules when crystalline or proteinaceous material precipitates 1. Increases pressure in urinary space of the glomerulus, reducing GFR 2. Affects renal blood flow….initial reducing afferent arteriolar resistance Later ….. renal blood flow is reduced because of increased resistance of renal vasculature Dr S Chakradhar 9

CLINICAL FEATURES 1.Pre-oliguric (0-2 days) Occurrence of the precipitating event until beginning of oliguria. Occurrence of the precipitating event until beginning of oliguria. Symptoms of the primary cause are dominant Symptoms of the primary cause are dominant 2.Oliguric phase (8-14days) Urine Volume markedly decreases to ml/Day Urine Volume markedly decreases to ml/Day After some days symptoms of Uremia develops After some days symptoms of Uremia develops Initially – anorexia, nausea, vomiting, mental confusion Initially – anorexia, nausea, vomiting, mental confusion Later- muscular twitching, fits, drowsiness, coma & bleeding disorders. Later- muscular twitching, fits, drowsiness, coma & bleeding disorders. Respiratory rate is often raised due to acidosis & pulmonary Oedema Respiratory rate is often raised due to acidosis & pulmonary Oedema Dr S Chakradhar 10

3. Diuretic phase (about 10 days) In the number of patients a diuretic Phase develops In the number of patients a diuretic Phase develops Urine output is about 3 to 5 L per day Urine output is about 3 to 5 L per day Usually the persists for 3 to 4 days Usually the persists for 3 to 4 days 4. Recovery phase (4 – 6months) Period of stabilization of serum lab values until the patient attains either totally normal or optimal renal function. Period of stabilization of serum lab values until the patient attains either totally normal or optimal renal function. Dr S Chakradhar 11

Investigation: TC, DC, ESR, Hb. TC, DC, ESR, Hb. Urine R/E and C/S Urine R/E and C/S Blood urea and Creatinine Blood urea and Creatinine Blood sodium and potassium. calcium Blood sodium and potassium. calcium X-ray KUB region X-ray KUB region USG USG Intravenous Urogram / CT Intravenous Urogram / CT Renal biopsy Renal biopsy Dr S Chakradhar 12

AIM OF Management Correction of reversible causes Correction of reversible causes Prevention of additional injury Prevention of additional injury Use of metabolic support during the maintenance and recovery phases of the syndrome Use of metabolic support during the maintenance and recovery phases of the syndrome Attempts to convert oliguric to nonoliguric renal failure Attempts to convert oliguric to nonoliguric renal failure Dr S Chakradhar 13

Treatment 1. EMERGENCY RESUSCITATION MEASURES: Hyperkalemia: Must be corrected to prevent cardiac arrhythmias. Must be corrected to prevent cardiac arrhythmias. 10 % Calcium Gluconate, 10 ml. i v infusion over 5 to 10 minutes 10 % Calcium Gluconate, 10 ml. i v infusion over 5 to 10 minutes Inj. Regular insulin (5-10units) + 50 mL 50% glucose Inj. Regular insulin (5-10units) + 50 mL 50% glucose Acidosis : Corrected with I/V 10% sodium bicarbonate and dialysis Corrected with I/V 10% sodium bicarbonate and dialysisHypovolemia: is corrected with blood transfusion or appropriate fluids is corrected with blood transfusion or appropriate fluids Pulmonary edema: Diuretics Diuretics Hemodialysis / Peritoneal dialysis Hemodialysis / Peritoneal dialysis Dr S Chakradhar 14

2. General management Bed rest Bed rest Fluid requirement- 500 ml + previous day output Fluid requirement- 500 ml + previous day output Nutrition- Restriction of protein, & Potassium rich diet Nutrition- Restriction of protein, & Potassium rich diet Symptomatic - Infection - antibiotic Symptomatic - Infection - antibiotic Hypertension - antihypertensive Hypertension - antihypertensive 3. Treatment of underlying cause 4. Monitoring electrolyte balance and input Output chart 5. Dialysis (if indicated)- heamodialysis or Peritoneal dialysis Dr S Chakradhar 15

Complication: Hyperkalemia Hyperkalemia Hyponatremia Hyponatremia Fluid overload Fluid overload Pulmonary Oedema Pulmonary Oedema Septicaemia Septicaemia Anaemia Anaemia Metabolic acidosis Metabolic acidosis Infections Infections Cardiac arrhythmia Cardiac arrhythmia Dr S Chakradhar 16

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