1. Staging with RIFLE Criteria
Acute Renal Failure
Diagnosis
Staging with RIFLE Criteria
Lab evaluation
Clinical features
Pathophysiology

2. Acute Renal Failure Definition may depend on whom you ask
Surgeon - - low urine output
Intensivist-- severe acidemia
Nephrologist-- rising serum creatinine
Frequency - depends on clinical setting
1% of all admissions to hospital
2-5% of all individuals during a hospitalization
4-15% during cardiopulmonary bypass
10-30% of all admissions to ICU

3. Definition
‘…a sudden and severe decrease in the glomerular filtration rate (GFR) sufficient to cause increases in BUN and Scr (azotemia), Na/H2O retention (edema), and development of acidemia and hyperkalemia…’
review of 27 studies showed no 2 used the same definition “chronic renal confusion”

4. What’s in a name? lack of a universally recognized definition of ARF
2004 consensus conference
proposed the term acute kidney injury (AKI) to reflect the entire spectrum of ARF recognizing that an acute decline in kidney function is often secondary to an injury that causes functional or structural changes in the kidneys

5. Newest Definition: Mehta CritCare 2007
An abrupt (within 48 h) reduction in kidney function currently defined as:
an absolute increase in serum creatinine of either >= 0.3 mg/dl,
or a percentage increase of >= 50 % or a reduction in UOP (documented oliguria of < 0.5 ml/kg per h for > 6)

6. The differential for any lab abnormality is:
Lab error
Iatrogenic
Polypharmacy
Real disease
IN THIS ORDER!

7. Acute renal failure (ARF)
Differential for Lab abnormality: Causes:
A rise in the BUN level can occur without renal injury, such as in GI or mucosal bleeding, steroid use, or protein loading (such as IV nutrition)
A rise in the creatinine level can result from medications (eg, cimetidine, trimethoprim) that inhibit the kidney’s tubular secretion, or an increase in creatinine production such as seen in Rhabdomyolysis. (muscle breakdown)
True Anuria is most commonly the result of an obstructed foley catheter, or an error in recording output. The worst cause of anuria is cortical necrosis.

8. Acute renal failure (ARF)
An abrupt or rapid decline in renal function
Marked by a rise in BUN (azotemia) or serum creatinine concentration
Immediately after a kidney injury, BUN or creatinine levels may be normal
The only sign of a kidney injury may be decreased urine production
Use RIFLE Criteria to evaluate Risk.

9. Acute Dialysis Quality Initiative
RIFLE Criteria Helps risk stratify patients with renal failure.
Increased mortality seen with increases in creatinine of 0.3 to 0.5 mg/dl (70 % increase for all pts, 300 % increase in cardiac surgery pts

10. RIFLE criteria
Risk low uop for 6 hours, creat up 1.5 to 2 times baseline
Injury creat up 2 to 3 times baseline, low uop for 12 hours
Failure Creat up > 3 times baseline or over 4, anuria
Loss of Function Dialysis requiring for > 4 weeks
ESRD Dialysis requiring for > 3 months
AKIN Acute Kindey Injury Network scale uses only first three
Risk = AKIN stage 1
Injury = stage 2
Failure = Stage 3

11. (RIFLE Criteria for Acute Renal Failure)Bellomo R - Crit Care Clin -APR-2005; 21(2): 223-37

12. RIFLE estimate of Mortality
Two studies Uchino Hoste
No renal failure 4.4 % 5.5
Risk % 8.8
Injury %
Failure % 26%
Loss of Function
ESRD
Crit Care Med 2006; 34:1913-7, Hoste CCM 2006; 10:R73

13. RIFLE criteria
When markers of severity of illness are looked at excluding renal data, no difference in groups is seen.

14. Evaluation of a patient with Acute renal failure (ARF)
History and Physical examination:
Nephrotoxic drug ingestion
History of trauma or unaccustomed exertion
Blood loss or transfusions
Congestive heart failure
Exposure to toxic substances, such as ethyl alcohol or ethylene glycol

15. Acute renal failure (ARF)
History and Physical examination:
Exposure to mercury vapors, lead, cadmium, or other heavy metals, which can be encountered in welders and miners
Hypotension
Volume contraction
Vomiting/Diarrhea/Sweating/Nursing Home
Evidence of connective tissue disorders or autoimmune diseases

16. Pathophysiology ARF may occur in 3 clinical patterns BUN:Cr > 20:1

17. Pathophysiology ARF may occur in 3 clinical patterns
Suggested by labwork:
BUN:Cr > 20:1 Pre-Renal or Post-Renal
BUN:Cr 10-20:1 Intra-Renal
BUN:Cr < 10:1 Extrinsic Production of Creatinine
or a dialysis patient.

18. Acute renal failure (ARF)
Patients can have:
Oliguria
Daily urine volume of less than 400 mL/d and has a worse prognosis, except in prerenal failure
Anuria is urine output of less than 100 mL/d and, if abrupt in onset, is suggestive of bilateral obstruction or catastrophic injury to both kidneys
Rapid or slow rise in creatinine levels
Differences in urine solute concentrations and cellular content

19. Prerenal ARF
Prerenal ARF represents the most common form of kidney injury and often leads to intrinsic ARF if it is not promptly corrected
From any form of extreme volume loss
GI, renal (diuretics, polyuria), cutaneous (eg, burns), and internal or external hemorrhage can result in this syndrome
Systemic vasodilation or decreased renal perfusion
Anesthetics
Drug overdose
Heart failure
Shock (eg, sepsis, anaphylaxis)

20. Prerenal ARF
Afferent Arteriolar vasoconstriction leading to prerenal ARF
Hypercalcemic states
Radiocontrast agents
NSAIDs
Amphotericin
Calcineurin inhibitors
Norepinephrine
Other pressor agents
Hepatorenal syndrome
Functional renal failure
develops from diffuse
vasoconstriction in vessels supplying the kidney.

21. Prerenal ARF
Efferent arteriolar vasodilation can induce prerenal ARF in volume-depleted states in the face of :
ACE Inhibitors
ARBs
Otherwise safely tolerated and beneficial in most patients with chronic kidney disease
Both cause afferent and efferent dilation, but efferent more

22. Intrinsic ARF Structural injury in the kidney
Most common form is acute tubular necrosis (ATN)
Either ischemic or cytotoxic 
Loss of brush borders
Flattening of the epithelium
Detachment of cells
Formation of intratubular casts
Dilatation of the lumen
Although these changes are observed predominantly in proximal tubules, injury to the distal nephron can also be demonstrated. The distal nephron may also be subjected to obstruction by desquamated cells and cellular debris. 

23. Intrinsic ARF
Intrarenal vasoconstriction is the dominant mechanism for the reduced glomerular filtration rate (GFR) in patients with ATN.
Tubular injury seems to be an important concomitant finding
Urine backflow and intratubular obstruction (from sloughed cells and debris) = reduced net ultrafiltration.
Stressed renal microvasculature is more sensitive to potentially vasoconstrictive drugs and otherwise tolerated changes in systemic blood pressure.  
Injured kidney vasculature has an impaired vasodilatory response and loses its autoregulatory behavior
Dialysis may re-injure the kidneys as a result

24. Intrinsic ARF Tubular Cytotoxic Crystals Tumor lysis syndrome
Ethylene glycol poisoning
Megadose vitamin C
Acyclovir
Indinavir
Methotrexate
Drugs
Aminoglycosides
Lithium
Amphotericin B
Pentamidine
Cisplatin
Ifosfamide
Radiocontrast agents

25. A few words about markers of renal failure

26. Relationship Between GFR and Serum Creatinine in ARF
120 80
GFR
(mL/min) 40 6
Serum
Creatinine
(mg/dL) 4 2 7 14 21 28
Days

27. Serum Creatinine
Creatinine is more specific at assessing renal function than BUN but it corresponds only loosely to GFR [13–15].
For example, a serum creatinine (SCrt)of 1.5 mg/dL (133 mmol/L), at steady-state, corresponds to a GFR of approximately 36 mL/min in an 80-year-old white woman, but approximately77 mL/min in a 20-year-old AA man.

28. Creatinine and the critically ill patient
Creatinine is formed from nonenzymatic dehydration of creatine in the liver; 98% of the creatine pool is in muscle.
Critically ill patients may have abnormalities in liver function and markedly decreased muscle mass.
Additional factors that influence creatinine levels include conditions of increased production (eg, trauma, fever, immobilization) or conditions of decreased production (eg, liver disease, decreased muscle mass, aging).

29. Creatinine and the critically ill patient
In addition, tubular reabsorption (‘‘back-leak’’) may occur in conditions that are associated with decreased urine flow rate.
Finally, the volume of distribution (VD) for creatinine (total body water) influences SCrt and may be increased dramatically in critically ill patients; in the short term, its concentration in plasma can be altered dramatically by rapid plasma volume expansion. The creatinine is diluted by extra volume.

30. Urine Output
commonly measured parameter of renal function in the ICU and is more sensitive to changes in renal hemodynamics than biochemical markers of solute clearance; however, it is far less specific except when severely reduced or absent
severe ARF can exist despite normal urine output (ie, nonoliguric ARF) but changes in urine output often occur long before biochemical changes are apparent
nonoliguric ARF has a lower mortality rate than oliguric ARF, thus urine output is used to differentiate ARF conditions
Classically, oliguria is defined (approximately) as urine output of less than 5mL/kg/d or 0.5 mL/kg/h; however, no study exists to diagnose when oliguria is a true early marker of developing renal failure

31. Modification of Diet in Renal Disease (MDRD) Calculation for GFR
Cockcroft Equation: GFR = AGE X Pt WT X
Serum Creat for female
The Cockcroft-Gault formula is calculated from the patient's age,
body weight, and serum creatinine level.
The MDRD uses the serum creatinine level and age alone to estimate GFR,
with adjustments for sex and African American race. (>90 = normal)

32. New markers for ARF Creatinine is not very sensitive
Cystatin C may identify ARF 1.5 days earlier than creatinine
KI 2004; 60:
KIM-1 Kidney Integrelin Molecule
NGAL another Integrelin, which leaks into the urine after tubular cell death.

33. Acute Kidney Injury Network (AKIN)

34. Clinical Features of Acute Renal Failure
General Management
Pre-renal
Pathophysiology of ATN
Other Intrinsic Causes of ARF.

35. Reason for Nephrology Consultation
25%
15%
60%
Ref: Paller Sem Neph 1998, 18(5), 524.

36. Approach to ARF Pre-Renal Intra-Renal Post- Renal Pseudo-ARF
There are other things which can raise the BUN and Creatinine!

37. Approach to ARF Pre-Renal Most common
Due to NPO, Diuretics, ACE inhibitors, NSAIDS
Due to renal artery disease, CHF with poor EF.
Usually BUN / creat ratio over 20.
Usually creat < 2.5

38. Approach to ARF Intra-Renal
Most commonly pre-renal tipping over into true renal injury.
Acute Tubular Necrosis is result (70%)
Tubulo-Interstitial Nephritis (20%)
Acute vasculitis/GN rare (5-10 %)

39. Intrinsic Renal Failure
Prerenal ARF
Intrinsic ARF
acute tubular necrosis
acute interstitial nephritis
acute glomerulonephritis
acute vascular syndromes
intratubular obstruction
Postrenal ARF

40. Instigating Factors for ARF in a Referral Hospital
11% 5%
30%
30%
12%
12%
Ref: Paller Sem Neph 1998, 18(5), 524.

41. Approach to ARF Post- Renal
Most commonly due to obstruction at bladder outlet
Prostate problems
Neurogenic bladder
Stone
Urethral stricture (esp after CABG)

42. Post renal = obstruction

43. Initial Treatment of ARF
Goal Directed Fluid Resuscitation
Always place Foley Catheter
Stop offending agents
NSAIDS, Contrast, ACE/ARB, potassium
Watch labs
Consider diuretics/Natrecor

44. Acute Renal Failure Definitions
Azotemia - the accumulation of nitrogenous wastes
Uremia - symptomatic renal failure
Oliguria - urine output < mL/24 hours
Anuria - urine output < 100 mL/24 hours

45. Acute Renal failure: Cause
Acute renal failure is an abrupt renal impairment, presenting in a fall of GFR within hours or days.
The result is a severe imbalance of fluid and electrolyte homeostasis accompanied by accumulation of nitrogenous waste.
Occurs in response to a variety of insults
Hemodynamic
Immunological
Toxic
obstructive

46. Acute Renal failure Causes of acute renal failure
Differentiation between Pre-renal, renal and post-renal causes
Prerenal
Intrinsic Renal
Postrenal
Hypovolemia
Decreased active blood volume
Decreased cardiac output
Renovascular obstruction
Acute tubular necrosis
Interstinal nephritis
Glomerular disease (acute glomerulonephritis)
Small vessel diease
Intrarenal vasoconstriction (in sepsis)
Tubular obstruction
Bilateral ureteric obstruction
Unilateral ureteric obstruction
Bladder outflow obstruction
Often result of renal ischemia  death of tubular cells
or direct toxic injury by endogenous chemicals such as myoglobin (from muscle  rhabdomyolysis)
Integrity of tubule is destroyed
obstructions, back-leakage

47. Acute Renal failure Complications of acute renal failure
Hyperkalemia ( ECG abnormalities)
Decreased bicarbonate (acidosis)
Elevated urea
Elevated creatinine
Elevated uric acid
Hypocalcemia
Hyperphosphatemia

48. In many cases kidney can recover from acute renal failure
The function may have to be temporarily replaced by dialysis for 2 days to 2 weeks
disturbed fluid or electrolyte homeostasis must be balanced
primary causes like necrosis, drug toxicity or obstruction must be treated

49. Manifestations of ARF Azotemia progressing to uremia Hyperkalemia
Metabolic acidosis
Volume overload
Hyperphosphatemia
Accumulation and toxicity of medications excreted by the kidney

50. Pathogenesis of Prerenal Azotemia
Congestive
Heart Failure
Low Cardiac
Output
Liver
Failure
Volume
Depletion
Sepsis
Septic Shock
Renal
Vasoconstriction
Angiotensin II
Adrenergic nerves
Vasopressin +
Nitric oxide
Prostaglandins -
Decreased
GFR

51. Prerenal Acute Renal Failure
BUN:Creatinine ratio
> 20:1
Urine indices
Oliguria
usually < 500 mL/24 hours; but may be non-oliguric
Elevated urine concentration
UOsm > 700 mmol/L
specific gravity > 1.020
Evidence of high renal sodium avidity
UNa < 20 mmol/L
FENa < 0.01
Inactive urine sediment

52. Classification of the Etiologies of Acute Renal Failure
Prerenal
ARF
Postrenal
Intrinsic
Acute
Tubular
Necrosis
Interstitial
Nephritis GN
Vascular
Syndromes
Intratubular
Obstruction

53. Intrinsic Acute Renal Failure
Acute tubular necrosis (ATN)
Acute interstitial nephritis (AIN)
Acute glomerulonephritis (AGN)
Acute vascular syndromes
Intratubular obstruction

54. Acute Tubular Necrosis

55. Acute Tubular Necrosis
Ischemic
prolonged prerenal azotemia
hypotension
hypovolemic shock
cardiopulmonary arrest
cardiopulmonary bypass
Sepsis
Nephrotoxic
drug-induced
radiocontrast agents
aminoglycosides
amphotericin B
cisplatinum
acetaminophen
pigment nephropathy
hemoglobin
myoglobin

56. Pathophysiology of ATN: Tubular Epithelial Cell Injury and Repair
Ischemia/ Reperfusion
Necrosis
Apoptosis
Normal Epithelium
Loss of polarity
Cell death
Differentiation & Reestablishment of polarity
Sloughing of viable and dead cells with luminal obstruction
Proliferation
Adhesion molecules
Migration , Dedifferentiation of Viable Cells
Na+/K+-ATPase

57. Pathophysiology of ATN
Ischemia
Endothelial Injury
Capillary Obstruction
&
Continued Ischemia
Inflammation
Tubular Injury
Disruption of Cytoskeleton
Loss of Cell Polarity
Desquamation of Cells
Tubular Obstruction
Backleak
Apoptosis
Necrosis
Activation of Vasoconstrictors
Impaired Vasodilation
Increased Leukocyte Adhesion

58. Pathophysiology of Acute Tubular Necrosis
Mechanisms of decreased renal function
Vasoconstriction
Tubular obstruction by sloughed debris
Backleak of glomerular filtrate across denuded tubular basement membrane

59. Acute Tubular Necrosis Urinary Findings

60. Acute Tubular Necrosis
Urine indices
Urine volume
may be oliguric or non-oliguric
Isosthenuric urine concentration
UOsm  300 mmol/L
specific gravity  1.010
Evidence of renal sodium wasting
UNa > 40 mmol/L
FENa > 0.02
Urine sediment
tubular epithelial cells
granular casts
BUN: Creatinine ratio = 10:1
Evidence of toxin exposure

61. Phases of Ischemic ATN GFR Time: 2 days to 2 weeks typical Prerenal
Initiation
GFR
Extension
Recovery
Maintenance
Time: 2 days to 2 weeks typical

62. Prognosis of Acute Tubular Necrosis
Mortality dependent upon comorbid conditions
overall mortality ~ 50%
Recovery of renal function seen in ~ 90% of patients who survive - although not necessarily back to prior baseline renal function

63. Time for a break