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10.03.08(a): Approach to the Patient with Acute Renal Failure
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10.03.08(a): Approach to the Patient with Acute Renal Failure


Slideshow is from the University of Michigan Medical School's M2 Renal sequence …

Slideshow is from the University of Michigan Medical School's M2 Renal sequence

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  • 1. Attribution: University of Michigan Medical School, Department of Internal MedicineLicense: Unless otherwise noted, this material is made available under the terms ofthe Creative Commons Attribution–Noncommercial–Share Alike 3.0 License: have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability touse, share, and adapt it. The citation key on the following slide provides information about how you may share and adaptthis material.Copyright holders of content included in this material should contact with any questions,corrections, or clarification regarding the use of content.For more information about how to cite these materials visit medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or areplacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to yourphysician if you have questions about your medical condition.Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
  • 2. Citation Key for more information see: + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation LicenseMake Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
  • 3. Acute Renal Failure/Acute Kidney InjuryIncrease of BUN and/or creatinine of recent, abruptonset reflecting a sudden loss of net, effective clearancecapacity of the kidney.Urine output can vary. Oliguria refers to < 400 cc./day;many forms are non-oliguric.
  • 4. Schrier, Diseases of the Kidney
  • 5. Schrier, Diseases of the Kidney
  • 6. 50-75% of inpatient general nephrologyactivities relate to the diagnosis andmanagement of acute renal failuresecondary to renal ischemia, drugs anddiagnostic tests, and other toxins.
  • 7. Incidence of ARF (any ARF)•  1-2% of all hospital admissions•  20-30% of Post-operative cases•  10-25% of ICU admissions•  20-30% of Acute sepsis•  Up to 40% in Hematologic malignancy•  The kidney fails when other organs fail . . . Lanore, Crit Care Med 1991; Nolan, J Am Soc Neph 1998; Shusterman, Am J Med 1987; others R.D Swartz
  • 8. Impact of ARF•  ARF (any) increases hospital mortality x 5 Levy et al, JAMA 1996•  ARF needing RRT carries 45-65% mortality somewhat better survival over last 5-10 yr Nolan et al, J Am Soc Neph 1998•  ARF in critically ill - 27% 6 mo survival Adj-life-yr cost: $274K/yr in worst cases $ 62K/yr in best cases Hamel et al, Ann Int Med 1996 R.D. Swartz
  • 9. Levy et al. JAMA 275: 1489, 199616,000 patients undergoing contrast procedure.183 developed ARF34% mortality compared to 7% without ARF matched for age, baseline creatinine,and contrast procedure.After comorbidity adjustment, odds ratio of dying after ARF was 5.5.
  • 10. Mechanisms of Acute Renal Failure and Approach to the PatientIllustrative Case A 73 year old man develops severe abdominal painradiating to the back and collapses at home. In the emergencyroom a blood pressure of 80 and an acute abdomen arepresent. At laparotomy, a ruptured, infrarenal abdominal aorticaneurysm is found and repaired during an 8 hour procedure inwhich 40 units of red blood cells and fresh frozen plasma areused. Postoperatively, the patient is putting out less than 200cc urine/day and creatinine increases between 1 and 1.5 unitsdaily until dialysis is started. Three weeks later, progressiveincreases in urine volume are noted along with smallerincreases of creatinine between dialysis treatments. During thenext week, sufficient renal function returns to discontinuedialysis and the patient ultimately leaves the hospital with aserum creatinine of 1.8 (as compared to 1.2 before this illness).
  • 11. Mechanisms of Acute Renal Failure Objectives1. Appreciate why the kidney is susceptible to diverseinsults resulting in acute renal failure.2. Understand the contributions of the major relevantcell types in the vascular and tubular compartments.3. Understand how the vascular and tubular eventscombine to produce whole organ dysfunction.4. Be aware of the processes required for recovery andthe time frame over which they occur.
  • 12. Why are cells in the kidney particularly susceptible todiverse insults?• High rates of oxidative metabolism• Marginal oxygenation relative to work demands andcomplex microcirculation highly susceptible toinflammatory factors• Reabsorptive functions and resulting urinaryconcentration expose both exterior and interior of cellsto high levels of solutes.• Metabolic transformation leading to toxic activation
  • 13. Source Undetermined
  • 14. Source UndeterminedFig 2-3
  • 15. Guder and Ross
  • 16. Bastin, J. et al. Kidney Int. 31:1239,1987
  • 17. Source Undetermined
  • 18. Source Undetermined
  • 19. Source Undetermined
  • 20. Source Undetermined
  • 21. Source Undetermined
  • 22. Schrier, Diseases of the Kidney
  • 23. Schrier, Diseases of the Kidney
  • 24. Source Undetermined
  • 25. Source Undetermined
  • 26. Source Undetermined
  • 27. Predominant Actions of Regulatorsof Renal Hemodynamics With Potential Effects During Acute Renal Failure Vasoconstricting VasodilatingMacula Prostaglandinsdensa-mediated PGI2tubuloglomerular PGE2feedback Nitric oxideAngiotensin II Atrial NatriureticArachidonic Acid PeptidesProducts Thromboxane Dopamine Leukotrienes P450 metabolites KininsEndothelins HistamineAdenosine AcetylcholinePlatelet activatingfactorAdrenergic nerves
  • 28. Leukocyte Activation in Ischemic ARFActivated Ischemic Kidney!Leukocytes! Local production of inflammatory mediatorsCD3 - cytokines (TNF", IL-1), chemokines (IL-8, MCP-1) 5 - complement activation products CD11c/ - platelet activating factor (PAF) CD18 - metabolites of arachidonic acid CD11b/ - reactive oxygen species (ROS) CD18 procoagulant Increased expression of effects! adhesion molecules on endothelial cells ! ICAMs ICAMs selectins VCAM selectins VCAM iC3b iC3b Endothelial Cell Release of ROS, proteases, elastases, leukotrienes, PAF University of Michigan Medical School, Department of Internal Medicine
  • 30. Amelioration of experimental acute renal failure byinhibition of leukocyte infiltration:anti-neutrophil serumanti-ICAM-1 mAbICAM-1 antisense oligonucleotidesICAM-1 knockoutanti-CD11 mAbP-selectin glycoprotein ligand-1blockade of the CD28-B7 costimulatory pathwayAdenosine A2A receptor antagonists
  • 31. Source Undetermined
  • 32. Source Undetermined
  • 33. Source Undetermined
  • 34. Source Undetermined
  • 35. Source Undetermined
  • 36. Source Undetermined
  • 37. Han, 2008
  • 38. Han, 2008
  • 39. Schrier, Diseases of the Kidney
  • 40. Source Undetermined
  • 41. Faber, Kupin, Krishna, Narins
  • 42. 10SERUM CREATININE CONCENTRATION 9 8 7 (mg/100 ml) 6 5 4 3 2 1 0 0 1 2 3 4 5 6 DAYS OF GFR DECREASE TO 10 Source Undetermined
  • 43. Source Undetermined
  • 44. The Recovery Processa) In the absence of cell loss - simple reprocessing andresynthesis of structural macromolecules andtransporters with recovery of polarity and tight junctions.b) After cell loss - • Spreading and simplification of adjacent cells to seal the epithelium. • Proliferation under the control of autocrine and both local and distant paracrine growth factors. • Redifferentiation with recovery of polarity and tight junctions.c) The time required for this recovery process after cellloss helps explain why recovery of function in ischemicacute renal failure often begins only after a delay of 1-2weeks.
  • 45. Source Undetermined
  • 46. Source Undetermined
  • 47. Source Undetermined
  • 48. Pathophysiology of Ischemic and Toxic Acute Renal Failure MICROVASCULAR O2/TOXINS TUBULARGlomerula Medullary rVasoconstriction Cytoskeletal endothelin, adenosine, breakdown angiotensin II, thromboxane A2, leukotrienes, sympathetic nerve Loss of polarity Inflammatory activity and Apoptosis andVasodilation vasoactive Necrosis nitric oxide, PGE2, acetylcholine mediators Desquamation of bradykinin viable and necroticEndothelial and vascular smooth cellsmuscle cell structural damage Tubular obstructionLeukocyte-Endothelial adhesion vascular obstruction, leukocyte Backleak activation, and inflammation
  • 49. Approach to the Patient with Acute Renal Failure Objectives1. Understand the three element etiological approach to acute renal failureand be aware of the major disease entities in each category.2. Be able to calculate fractional sodium excretions and use them in theevaluation of acute renal failure.3. Know the urinary sediment abnormalities that provide clues to theetiology of acute renal failure.4. Understand the use and interpretation of ultrasound examination of thekidneys in the diagnosis of ARF.5. Know the general indications for dialysis.6. Be aware of specific considerations in approaching some commoncauses of ARF, i.e. NSAIDs, angiotensin blockade, contrast nephropathy,aminoglycosides.
  • 50. Acute Renal Failure/Acute Kidney InjuryIncrease of BUN and/or creatinine of recent, abruptonset reflecting a sudden loss of net, effective clearancecapacity of the kidney.Urine output can vary. Oliguria refers to < 400 cc./day;many forms are non-oliguric.
  • 52. PRERENAL ETIOLOGIES- Hypovolemia Gastrointestinal, renal, or skin fluid and electrolyte losses Hemorrhage Third spacing - burns, pancreatitis, peritonitis, anaphylaxis, sepsis, portal hypertension - Cardiac failure Infarction Cardiomyopathy Valvular disease- Hepatorenal syndrome- Nonsteroidal anti-inflammatory drugs- Angiotensin blockade - ACEI, ARB
  • 53. Schrier, Diseases of the Kidney
  • 54. Schrier, Diseases of the Kidney
  • 55. POST RENAL ETIOLOGIESExtrarenal obstruction - Urethral stricture - Bladder, pelvic, prostatic or retroperitoneal neoplasms - Prostatic hypertrophy - Surgical complications - Stones - Hematoma - Anticholinergics - Neurogenic bladderBladder rupture
  • 56. MAJOR INITIAL ELEMENTS OF THE WORKUPMedication issues Nonsteroidals ACE inhibitors Contrast studies Antibiotics Direct nephrotoxicity Hypersensitivity reactionsVolume statusUrinalysisUrine chemistryBladder emptying capacity and renal ultrasound
  • 57. Assessment of Volume Status During Acute Renal Failure- Physical examination Blood pressure with orthostatic changes Jugular venous pressure Temperature of the extremities Skin color and turgor- BUN/Cre ratio >20 - prerenal ~10 - renal- Pulmonary artery catheter RA and wedge pressure Cardiac output and peripheral resistance
  • 58. Use of the Urinary Sediment in the Differential Diagnosis of Intrinsic Acute Renal FailureRed Blood Cells- Favor glomerular rather than tubulointerstitial processes- Even more strongly suggestive of glomerular disease if dysmorphic and/orpresent as red cell casts- Red colored, strongly heme positive urine without substantial numbers of RBCssuggests pigment nephropathy.Tubule epithelial cells and granular casts- Present in ischemic and toxic ATN, but may also be seen during prerenalazotemia, interstitial nephritis, and acute glomerulonephritis.- Highly colored in pigment nephropathyPyuria and WBC casts- Pyelonephritis- Identify eosinophils by Wrights or Hansels stains- Need to discriminate WBCs from tubule epithelial cells - Sternheimer-MalbenstainCrystals- Uric acid during uric acid nephropathy- Oxalate after polyethylene glycol intoxication
  • 59. Urinary Chemical Indices in the Diagnosis of OliguriaSource Undetermined
  • 60. CAUSES OF ARF ASSOCIATED WITHLOW FRACTIONAL SODIUM EXCRETION - PRERENAL Intravascular volume depletion due to hemorrhage, GI losses, third spacing Low cardiac output secondary to myocardial dysfunction NSAIDs Hepatorenal syndrome - RENAL Acute GN Contrast Early pigment nephropathy - POSTRENAL Early obstruction
  • 61. COMPLICATING FACTORS IN THE USE OF LOW FRACTIONAL SODIUM EXCRETION IN THE DIAGNOSIS OF ARF•  Recent use of drugs with diuretic effects including loopdiuretics, mannitol, dopamine•  Heavy glycosuria or mannitol treatment•  Continuing excretion of contrast agent•  Recent aggressive fluid replacement•  Alkalemia with increased bicarbonate excretion•  Patient not oliguric
  • 62. RADIOLOGICAL ASSESSMENT DURING ACUTE RENAL FAILURE Plain abdominal film IVP Retrograde pyelogram Computed tomography Angiography Ultrasound Radioisotope studiesFactors that determine usefulness - Sensitivity forproviding the necessary information, invasiveness, needfor IV contrast.
  • 63. ROLE OF ULTRASOUND IN THE DIAGNOSIS OF ARFNon-invasive, no IV contrast or other toxicityRelatively cheap and widely available
  • 64. ROLE OF ULTRASOUND IN THE DIAGNOSIS OF ARF Determination of renal size Quality of renal parenchyma Rule out obstruction 98% sensitive 74% specific 15% false positive False negatives due to: Early (1-3d) obstruction Infiltrative (tumor, fibrosis) processes
  • 65. CLUES TO TYPES OF UNDERLYING KIDNEY DISEASE FROM MEASUREMENTS OF KIDNEY SIZE•  Equal, normal sized kidneys in a patient with renal insufficiency strongly favor a process of recentonset.•  Bilaterally small kidneys favor a chronic process that has affected both kidneys similarly and led tosubstantial parenchymal loss, e.g. chronic glomerulonephritis, nephrosclerosis secondary tohypertension.•  Assymetrical kidneys suggest large vessel renovascular disease.•  Large kidneys with nephrotic syndrome accompanied by renal insufficiency suggest diabetes oramyloidosis. Quality of renal parenchyma Rule out obstruction 98% sensitive 74% specific 15% false positive False negatives due to: Early (1-3d) obstruction Infiltrative (tumor, fibrosis) processes
  • 66. ROLE OF ULTRASOUND IN THE DIAGNOSIS OF ARF Determination of renal size Quality of renal parenchyma Rule out obstruction 98% sensitive 74% specific 15% false positive False negatives due to: Early (1-3d) obstruction Infiltrative (tumor, fibrosis) processes
  • 67. Source Undetermined
  • 68. MANAGEMENTWithdraw offending drugsCorrect hypotension or fluid deficitsMonitor I/O, weight, BUN, Creatinine, lytes, PO4 dailyDose adjust renally excreted medicationsIf oliguric: ??? Diuretics
  • 69. INDICATIONS FOR DIALYSISUnmanageable fluid overloadHyperkalemiaAcidosisUremia, BUN > 80-100Uremic complications - bleeding, mental statusTiming of initiation depends on: Severity of labs and clinical findings Trajectory
  • 70. 10SERUM CREATININE CONCENTRATION 9 8 7 (mg/100 ml) 6 5 4 3 2 1 0 0 1 2 3 4 5 6 DAYS OF GFR DECREASE TO 10 Source Undetermined
  • 71. No Calcium Dialysate DFR 2000 ml/hr UFR 300-500/hr BFR 200 ml/min ACD CaCl2 (citrate) iCa++ measurement Ex-corp Systemic R.D. SwartzContinuous renal replacement therapy during ARF withCVVHD using citrate anticoagulation
  • 72. Organ System Disease & Outcome Lohr et al, Am J Kid Dis, 1988 Patients with ARF requiring RRT 80 Factors: CHF Low BP Ventilator GI dysf Sepsis Coma 60 Survival (%)) 40 Average survival = 25% 20 0 0 1 2 3 4 5 Number Factors Present R.D. Swartz
  • 73. Schrier, Diseases of the Kidney
  • 75. Intravenous Contrast- RENAL form of ARF in that the agents are direct tubuletoxins and the renal dysfunction is not immediatelyreversible.- PRERENAL form of ARF in that FENa is often low andvasoconstriction is a major factor.- High risk groups - Diabetics > other causes of CRF.
  • 76. CONTRAST NEPHROPATHY•  Serum creatinine increase > 0.5 mg/dl in 3.3% of 7586patients.•  Cre < 1.1 – 3.7% in diabetics, 2% in nondiabetics•  Cre 1.2-1.9 – 4.5% in diabetics, 1.9% in nondiabetics•  Cre 2–2.9 – 22.4%•  Cre > 3 – 30.6%•  22% mortality with ARF, 1.4% without, odds ratio 10.3 Rihall et al, 2002
  • 77. GROUPS AT RISK FOR CONTRAST NEPHROPATHY•  GFR < 60 estimated by MDRD or Cockroft Gault•  Diabetics•  Repeat administration within 36 hours•  Emergent studies•  Shock
  • 78. PREVENTING CONTRAST NEPHROPATHY•  Hold NSAIDs, diuretics, ? ACEI/ARB•  Diuretics, mannitol non-specific endothelin blockade ineffective andpossibly deleterious.•  Volume expansion prior to and following procedure has wellestablished benefit – NaHCO3 > isotonic NaCl > ! NS.•  Minimize amount of contrast used.•  Risk from low osmolarity contrast < isosmolar contrast << highosmolarity contrast.•  Oral N-acetylcysteine of uncertain benefit, but inexpensive,nontoxic.•  Benefit of fenoldopam, theophylline not established.
  • 79. Source Undetermined
  • 80. Aminoglycosides- Every course is toxic. Hypotension or ischemia plusaminoglycosides are potentially synergistic in their toxicity. Dont useunless absolutely necessary. Switch if cultures and clinical conditionallow you to.- Dose by the estimated clearance taking into account size (musclemass), age, and sex, not the absolute level of creatinine.- Dose adjustments for decreased renal function should be bylengthening the interval as opposed to reducing the dose.- Levels are important as a guide to how you are doing, but hightroughs frequently indicate that problems that are destined to beprogressive have already begun.- If you must continue dosing despite nephrotoxicity, use levels as aguide to when to next dose.- Course of nephrotoxicity - anticipate full expression of acute renalfailure well after you have stopped dosing.
  • 81. Additional Source Information for more information see: 4: Schrier. Diseases of the Kidney. Little, Brown, 1992. 5th ed.Slide 5: Schrier. Diseases of the Kidney. Little, Brown, 1992. 5th edSlide 9: Levy et al. JAMA 275:1489,1996Slide 13 :Source UndeterminedSlide 14: Source Undetermined (Fig 2-3)Slide 15: Guder and RossSlide 16: Bastin, J. et al. Kidney Int. 31:1239,1987Slide 17: Source UndeterminedSlide 18: Source UndeterminedSlide 19: Source UndeterminedSlide 20: Source UndeterminedSlide 21: Source UndeterminedSlide 22: Schrier. Diseases of the Kidney. Little, Brown, 1992. 5th edSlide 23: Schrier. Diseases of the Kidney. Little, Brown, 1992. 5th edSlide 24: Source UndeterminedSlide 25: Source UndeterminedSlide 26: Source UndeterminedSlide 28: Source UndeterminedSlide 31: Source UndeterminedSlide 32: Source UndeterminedSlide 33: Thadani and Bonventre NEJMSlide 33: Source UndeterminedSlide 34: Source UndeterminedSlide 35: Source UndeterminedSlide 36: Source UndeterminedSlide 37: Han, 2008Slide 37: Han, 2008Slide 39: Schrier. Diseases of the Kidney. Little, Brown, 1992. 5th edSlide 40: Source UndeterminedSlide 41: Faber, Kupin, Krishna, NarinsSlide 42: Source UndeterminedSlide 43: Source UndeterminedSlide 45: Source UndeterminedSlide 46: Source Undetermined
  • 82. Slide 47: Source UndeterminedSlide 53: Schrier. Diseases of the Kidney. Little, Brown, 1992. 5th edSlide 54: Schrier. Diseases of the Kidney. Little, Brown, 1992. 5th edSlide 59: Source UndeterminedSlide 67:Source UndeterminedSlide 70: Source UndeterminedSlide 71: R.D. SwartzSlide 72: R.D. SwartzSlide 73: Schrier. Diseases of the Kidney. Little, Brown, 1992. 5th edSlide 79: Source Undetermined