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Acute Renal Failure Fall Medical/ Surgical Conference Lubbock-Crosby-Garza County Medical Society Sandra Sabatini PhD, MD Neil A Kurtzman MD • Acute Kidney Injury now the preferred term • It's imprecise • Some forms of ARF are not associated with tissue injury • We'll stick with ARF An elevated serum creatinine during hospitalisation is an independent risk factor for mortality, progression to CKD, end-stage renal disease, and reduced long-term survival. Patients with chronically elevated serum creatinine (i.e., impaired baseline renal function) have a higher risk for acute kidney injury during hospital stays and are more often dialysis-dependent at hospital discharge than those without. http://bestpractice.bmj.com/best-practice/monograph/935.html ARF is an acute decline in the glomerular filtration rate (GFR) from baseline, with or without oliguria/anuria. It may be due to various insults such as impaired renal perfusion, exposure to nephrotoxins, outflow obstruction, or intrinsic renal disease. Three General Mechanisms • Pre-renal • Renal • Post-Renal ARF vs CRF adaptation • • • • • • • BP Edema - fluid overload Acid-Base RBC Ca PO4 K Pre-Renal • • • • • • • • • • Decreased renal perfusion Contracted EABV CHF Blood loss Vomiting Diarrhea Sweating Decreased fluid intake Cirrhosis Pre-glomerular vascular disease Evaluation • History • PE - Pulse and BP - Edema - Signs of other diseases • Urine NaCl • BUN/Cr • Uric Acid Treatment and Implications • Depends on cause • Fluid loss different from CHF different from Cirrhosis • Vol contraction predisposes to ATN - more soon Post Renal • • • • • Prostatism Advanced Cervical Cancer Retroperitoneal Fibrosis Retroperitoneal Lymphoma Bilateral Renal Calculi Features • Anuria if complete • Collecting duct dysfunction • • • • Polyuria - NDI Metabolic acidosis Hyperkalemia NaCl loss Treatment • Relieve obstruction if possible • Dialysis and supportive care if obstruction is irreversible Renal • • • • • • Acute glomerulonephritis Acute vasculitides Acute interstitial nephritis Toxins Acute tubular necrosis (ATN) Acute papilary necrosis Toxins -Ethylene Glycol Ethylene Glycol - Anti-Freeze Dog kidney - polarized light Manifestations • CNS • Metabolic Acidosis • Renal failure Diagnosis • • • • • History CNS - "drunk", seizures Anion gap metabolic acidosis Oxaluria Acute renal failure Treatment • • • • • Ethanol Fomepizole (inhibits alcohol dehydrogenase) Hemodialysis Prognosis - good early treatment Prognosis - bad late treatment Acute Interstitial Nephritis • Can be infectious • Usually non-infectious inflammatory • Commonly drug induced • Allergic reaction to a drug (acute interstitial allergic nephritis) • Autoimmune disorders such as anti-tubular basement membrane disease, Kawasaki’s disease, Sjogren syndrome, systemic lupus erythematosus, or Wegener’s granulomatosis • Acetaminophen, aspirin, NSAIDS • Penicillin, ampicillin, methicillin, sulfonamide • Furosemide, thiazide diuretics, omeprazole, triamterene, and allopurinol • Hypokalemia • Hypercalcemia, hyperuricemia Kidney International (2001) 60, 804–817 Kidney International (2001) 60, 804–817 Kidney International (2001) 60, 804–817 Treatment • Stop offending drug • Treat underlying disease • Steroids may hasten recovery Acute Papillary Necrosis • • • • Chronic more common Diabetes Infection Often a catastrophic illness ATN • Requires an underperfused kidney • Nephrotoxins (Hg, Pt) • Major surgery (due to multiple factors) • Third-degree burns covering > 15% of BSA • The heme pigments myoglobin and hemoglobin • Tumor lysis or multiple myeloma • Herbal and folk remedies, such as ingestion of fish gallbladder in Southeast Asia (uncommon) Am J Med Sci. 2007, 334(2):115-24. Cisplatin nephrotoxicity: a review. Yao X1, Panichpisal K, Kurtzman N, Nugent K. • Common nephrotoxins include the following: • • • • • • • Aminoglycosides Amphotericin B Cisplatin and other chemotherapy drugs Radiocontrast agents NSAIDs Colistimethate Calcineurin inhibitors (cyclosporine, tacrolimus) ATN • ATN is more likely to develop in patients with the following: • Preexisting hypovolemia or poor renal perfusion • Preexisting chronic kidney disease • Diabetes mellitus • Older age Crush Syndrome J Am Soc Nephrol 11: 1553–1561, 2000 J Am Soc Nephrol 11: 1553–1561, 2000 Contrast Induced ARF • • • • • Systolic blood pressure <80 mm Hg Intraarterial balloon pump Congestive heart failure Age >75 y Hematocrit level <39% for men and <35% for women • • • • • Diabetes especially with ↑Cr Contrast media volume Renal insufficiency Serum creatinine level >1.5 g/dL Estimated Glomerular filtration rate < 60 ml/min • Gadolinium enhance MRI risks NSF and CRI Prevention • • • • • • Avoid use in high risk patients Isotonic saline Saline and furosemide if CHF present HCO3 of uncertain utility N-acetylcysteine probably ineffective Prophylactic hemodialysis not proven effective Prostaglandins and the Kidney NSAIDS and Renal Disease • • • • • • AIN Pre renal azotemia ATN Nephrotic Syndrome Hyperkalemia Hyponatremia NSAIDS and ARF • • • • • • Relatively uncommon Incidence increases with age ACE inhibitors and ARBs increase incidence Volume contraction Diuretics Pre-existing renal disease Prognosis • 65% recover to baseline in 7-10 days • Dialysis needed <1% of patients • 18% who need HD remain on it • Maioli M, Toso A, Leoncini M, Gallopin M, Musilli N, Bellandi F. Persistent renal damage after contrast-induced acute kidney injury: incidence, evolution, risk factors, and prognosis. Circulation. Jun 26 2012;125(25):3099-107 The Centre for Adverse Reactions Monitoring, NZ 2000 Antibiotic induced ARF Aminoglycosides Martínez-Salgado et al. / Toxicology and Applied Pharmacology 223 (2007), 86–98 Renal Under perfusion always present Amphotericin Nephrotoxicity • • • • • Renal Underperfusion Hypokalemia Renal tubular acidosis Liposomal formulation likely lower incidence Acute renal failure Pre-renal ATN UTO Urine Na ↓ Urine Na ↑ Urine Na ↑ Urine K ↑ Urine K ↑ Urine K ↓ Urine Osm ↑ Urine Osm ↓ Urine Osm ↓ Fractional Excretion FEx= Cx/Ccr X 100 Cx= UxV/Px FEx FENa (<0.5%) FEurea (<35%) Rx Oliguric ARF • • • • A fluid challenge is a substitute for thought HD a soon as diagnosis is made Daily until clinical status improves Better avoided than treated http://medicine-opera.com/2014/11/acute-renal-failure/