ACUTE RENAL FAILURE

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Highlights the aetiopathogenesis, management and perioperative concerns of Acute Renal Failure

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ACUTE RENAL FAILURE

  1. 1. AETIOPATHOGENESIS & MANAGEMENT OF ACUTE RENAL FAILURE PRESENTER Dr Unnikrishnan P COORDINATOR Dr Sugandha MODERATORS Dr Sheela Rani Dr Suneesh DEPT OF ANESTHESIOLOGY, MCH-TVM
  2. 2. . <ul><li>Human beings are essentially big bags of water, the volume of which must be kept under tight control, to prevent us from either drying out or drowning….. </li></ul>
  3. 3. Highlights… <ul><li>FOLLOWING THE TRENDS…. </li></ul><ul><li>CAPTURE THE KEYS TO OPEN THE DOOR </li></ul><ul><li>HOW TO PREVENT ARF [Anesthetist Rested during Failure] </li></ul><ul><li>NEVER ENDING CONTRAVERSIES </li></ul><ul><li>REPLACING KIDNEY […very difficult] </li></ul>
  4. 4. ‘ ACUTE KIDNEY INJURY’ <ul><li>Abrupt reduction [<48 hrs] in kidney function, defined as an absolute increase in S creatinine of ≥0.3 mg/dL </li></ul><ul><li>A percentage increase in S creatinine of ≥ 50% [1.5 fold from baseline] or </li></ul><ul><li>a reduction in urine output-- documented oliguria of < 0.5 ml/kg/hr, for more than six hours. </li></ul>
  5. 5. STAGING SYSTEM FOR A.K.I. STAGE S.CREATININE CRITERIA URINE OUTPUT CRITERIA 1 INCREASE IN S.CREATININE ≥0.3mg/dL OR INCREASE TO ≥ 150-200% FROM BASELINE <0.5 ml/kg/hr FOR >6HRS 2 INCREASE IN S.CREATININE TO >200-300%[2-3 FOLD] FROM BASELINE <0.5 ml/kg/hr FOR >12 HRS 3 INCREASE IN S. CREATININE TO >300%[>3 FOLD] FROM BASELINE OR S.CREATININE OF ≥4mg/dL WITH AN ACUTE INCREASE OF ATLEAST 0.5 mg/dL <0.3ml/kg/hr FOR 24 HRS OR ANURIA FOR 12 HRS
  6. 6. RIFLE criteria
  7. 7. CLASSIFICATION
  8. 8. AETIOPATHOGENESIS <ul><li>. </li></ul>
  9. 9. PRERENAL ARF <ul><li>Most common </li></ul><ul><li>Renal hypo perfusion </li></ul><ul><li>Important form in perioperative period </li></ul>
  10. 10. . CAUSES-PRERENAL ARF HYPOVOLEMIA >HEMORRHAGE >G-I LOSSES >DECREASED INTAKE >URINARY LOSSES >SKIN LOSSES >OTHERS:BURNS,PANCREATITIS,SEVERE HYPOALBUMINEMIA ALTERED RENAL HEMODYNAMICS LOW CARDIAC OUTPUT STATES >CHF >VALVULAR HEART DISEASE >PPV > REDUCED VENOUS RETURN SYSTEMIC VASODILATION >SEPSIS >ANTIHYPERTENSIVES >VASODILATORS >ANAPHYLAXIS RENAL VASOCONSTRICTION >CATECHOLAMINES >HYPERCALCEMIA IMPAIREMENT OF RENAL AUTOREGULATION >NSAIDs >ACE-I >ARBs HEPATORENAL SYNDROME
  11. 11. HYPOVOLEMIA- extrinsic
  12. 12. HYPOVOLEMIA- intrinsic <ul><li>Tubuloglomerular feedback </li></ul><ul><li>Afferent arteriolar vasodilatation </li></ul><ul><li>Preferential efferent arteriolar vasoconstriction </li></ul><ul><li>Aim is to utilize the existing filtration reserve maximally </li></ul>
  13. 13. In short…. <ul><li>EXTRINSIC  INCREASE MAP, IMPROVE INTRAVASCULAR VOLUME </li></ul><ul><li>INTRINSIC  IMPROVE RENAL PLASMA FLOW, GFR & GLOMERULAR PRESSURE </li></ul>
  14. 14. When the insult cross the limits…. <ul><li>Compensatory mechanisms overwhelmed  renal perfusion decrease  GFR fall </li></ul><ul><li>Decreased O2 delivery  needs to decrease its work  decrease filtration  oliguria </li></ul><ul><li>Increased Na reabsorption = more work by medulla  blood flow towards medulla ,i.e. away from cortex  GFR decrease  oliguria </li></ul><ul><li>“ acute renal success” </li></ul><ul><li>Increase perfusion pressure </li></ul><ul><li>If we wait …..ATN </li></ul>
  15. 15. Hepatorenal syndrome <ul><li>Unique form of prerenal ARF </li></ul><ul><li>Structurally normal </li></ul><ul><li>Profound renal vasoconstriction </li></ul><ul><li>Correction of liver disease  resolution </li></ul>
  16. 16. INTRINSIC ARF CAUSES RENOVASCULAR >ATHEROEMBOLISM >MALIGNANT HTN > >HUS > DIC >PREECLAMPSIA GLOMERULAR >AGN TUBULES -ATN ISCHEMIA >MAJOR CARDIOVASCULAR Sx >TRAUMA >HEMORRHAGE >HYPOVOLEMIA TOXINS Exogenous: Radiocontrast dye,Antibiotics-Aminoglycosides,Chemotherapeutic agents-Cisplatin, Amphotericin-B, Ethylene glycol Endogenous: myoglobin,hemoglobin,calcium,bilirubin SEPSIS INTERSTITIUM Allergic: Antibiotics : b-lactam ,quinolone , rifampin NSAIDs B/L pyelonephritis INTRATUBULAR OBSTRUCTION acyclovir, methotrexate , indinavir , myeloma proteins
  17. 17. Ischemic ATN 4 PHASES INITIATION:GFR DECREASE , OBSTRUCTION BY DEBRIS , BACKLEAK EXTENSION : CONTINUED…. MAINTENANCE : GFR LOWEST , URINE O/P LOWEST, UREMIC COMPLICATIONS MAY OCCUR RECOVERY : EPITHELIAL CELL REGENERATION , GFR RETURNS
  18. 18. The so called diuretic phase… <ul><li>Recovery phase </li></ul><ul><li>Filtration recovers early </li></ul><ul><li>Recovery of epithelial function lags behind </li></ul>
  19. 19. Nephrotoxic ATN <ul><li>RISK FACTORS </li></ul><ul><li>Advanced age </li></ul><ul><li>Preexisting kidney disease </li></ul><ul><li>Hypovolemia </li></ul><ul><li>CCF </li></ul><ul><li>Multiple myeloma </li></ul>
  20. 20. Toxins….
  21. 21. Contrast nephropathy FEATURES REVERSIBLE ACUTE ONSET [24-48 HRS] PEAK 3-5 DAYS RESOLUTION IN ONE WEEK B UREA & S CREATININE INCREASE
  22. 22. Atheroembolic ATN <ul><li>After manipulation of aorta or renal arteries during surgery / angiography / trauma </li></ul><ul><li>In patients with atherosclerosis </li></ul><ul><li>Frequently irreversible </li></ul>
  23. 23. POSTRENAL ARF <ul><li>Obstruction is always the most likely cause when there is anuria </li></ul><ul><li>B/L ureteric </li></ul><ul><li>U/L ureteric if single functioning kidney </li></ul><ul><li>Bladder neck obstruction </li></ul><ul><li>Urethral </li></ul>
  24. 24. Perioperative oliguria - pathophysiology <ul><li>Anesthetic agents: no renal vasodilation per se ; effects by reducing CO & BP </li></ul><ul><li>EDB & high spinal anesthesia reduce sympathetic tone </li></ul><ul><li>PPV decrease renal blood flow </li></ul><ul><li>ACE-I cause significant reduction in perfusion pressure during anesthesia </li></ul><ul><li>Narcotics can increase ADH response </li></ul>
  25. 25. Raised intra abdominal pressure <ul><li>Normal 0-17mm of Hg </li></ul><ul><li>>20 mm of Hg  compression of pelvis  anuria </li></ul><ul><li>Improvement occurs only after decompression </li></ul><ul><li>May also cause false high CVP readings due to decreased venous return </li></ul>SITUATIONS EMERGENCY LAPAROTAMIES LEAKING ABD AORTIC ANEURISMS INTESTINAL DISTENSION PARALYTIC ILEUS ASCITES
  26. 26. Clinical features
  27. 27. Pre renal <ul><li>vomiting , diarrhoea </li></ul><ul><li>Intestinal obstruction…. </li></ul><ul><li>Carry over cases..NPOOOOOOO </li></ul><ul><li>Look for </li></ul><ul><li>Thirst </li></ul><ul><li>Reduced JVP </li></ul><ul><li>Decreased skin turgor </li></ul><ul><li>Dry mucus membrane </li></ul>
  28. 28. Intrinsic renal <ul><li>oliguria,edema,hypertension  AGN </li></ul><ul><li>Intake of nephrotoxic drugs </li></ul><ul><li>h/o atrial fibrillation : renal artery thrombus </li></ul><ul><li>h/o vascular surgeries : atheroembolic ARF </li></ul><ul><li>Muscle trauma : rhabdomyolysis </li></ul>
  29. 29. Post renal <ul><li>Anuria </li></ul><ul><li>Flank pain </li></ul><ul><li>h/o prostatic disease </li></ul>
  30. 30. INVESTIGATIONS
  31. 31. URINE MICROSCOPY CONDITION FINDINGS PRERENAL TRANSPARENT HYALINE CAST POSTRENAL HYALINE CAST/PUS CELLS/HEMATURIA ATN MUDDY BROWN GRANULAR/EPITHELIAL CAST INTERSTITIAL NEPHRITIS WBCs, RBC CASTS, NON-PIGMENTED GRANULAR CAST,EOSINOPHILS, LYMPHOCYTES AGN RBC CASTS
  32. 32. Assessment of GFR
  33. 33. Blood urea <ul><li>15-40mg/dL </li></ul><ul><li>Increased in dehydration , post G-I bleed </li></ul><ul><li>May be a better guide in timing dialysis to avoid uremic complications </li></ul>
  34. 34. Serum creatinine <ul><li>Normal: <1.5 mg/dL </li></ul><ul><li>Overestimate GFR </li></ul><ul><li>Lags behind renal injury & recovery </li></ul><ul><li>Rise by 1-2 mg/dL in ARF,>2mg/dL in rhabdomyolysis </li></ul><ul><li>Critically ill patient: a “normal” value may not be normal </li></ul>condition creatinine prerenal fluctuate ATN Peak by 7-10 days Contrast nephropathy Ischemic ATN Rise within 24-48hrs, peak in 3-5 days , reach baseline in 7-10 days AMINOGLYCOSIDE Rise delayed till 2 nd week
  35. 35. Creatinine clearance <ul><li>Volume of plasma cleared off creatinine per unit time </li></ul><ul><li>Earlier warnings, 2hr samples </li></ul><ul><li>[140-age] x body wt / S.Creatinine x 72 </li></ul><ul><li>91-130 ml / min </li></ul><ul><li>CrCl = U. Creatinine [mg/dL] x volume [mL/min] </li></ul><ul><li>P Creatinine[mg/dL] </li></ul><ul><li>S cystatin C </li></ul>
  36. 36. Assessment of tubular function <ul><li>Renal Failure Indices </li></ul>PRERENAL INTRINSIC FENa <1 >1 URINARY Na <20 >40 URINE OSM >400 250-300 URINE:PLASMA OSMOLALITY 1.4:1 1:1 Ur.Cr : P. Cr >50:1 <20:1 BUN/Cr >20 <10 SPECIFIC GRAVITY >1.018 <1.015
  37. 37. Assessment of tubular function <ul><li>Differentiate pre renal from intrinsic renal failure </li></ul><ul><li>FeNa is the most useful </li></ul><ul><li>Ratio of Na clearance to Creatinine clearance </li></ul><ul><li>Prerenal  intact tubules  Na reabsorption avidly takes place  Cr Cl high  FENa <1 </li></ul><ul><li>ATN  Na absorption impaired  FENa > 1 </li></ul><ul><li>CKD & diuretics also FENa >1 </li></ul><ul><li>Metabolic alkalosis  FECl better </li></ul>
  38. 38. Radiology <ul><li>Abdominal USG </li></ul><ul><li>Small  Htve Nephrosclerosis , CRF </li></ul><ul><li>Normal / large  DM , Amyloidosis </li></ul><ul><li>Large kidneys with large dilated pelvis and ureters </li></ul><ul><li>Pyelography : localization </li></ul><ul><li>MRA/ Doppler US : arterial /venous obstruction </li></ul>
  39. 39. Others <ul><li>renal biopsy </li></ul><ul><li>Increased potassium ,phosphorus , CK-MM, Uric Acid, decreased Calcium  rhabdomyolysis </li></ul>
  40. 40. Complications <ul><li>. </li></ul>
  41. 41. Complications <ul><li>. </li></ul>
  42. 42. Complications <ul><li>. </li></ul>
  43. 43. Also… <ul><li>hyperphosphatemia </li></ul><ul><li>Infection </li></ul><ul><li>Uremic syndrome </li></ul><ul><li>Hypovolemia due to vigorous diuresis in recovery </li></ul>
  44. 44. Prevention of ARF- in perioperative period
  45. 45. Identify patients at risk PATIENT FACTORS TYPE OF SURGERY CKD CARDIOPULMONARY BYPASS ELDERLY AORTIC ANEURYSM SURGERY NEPHROTOXINS HEPATIC/RENAL TRANSPLANTATION HYPOVOLEMIA/HYPOTENSION SURGERY IN TRAUMA/BURNS SEPSIS HEMORRHAGE LIVER DISEASE/JAUNDICE DM,HTN MULTIPLE MYELOMA PREECLAMPSIA MASSIVE BLOOD TRANSFUSION ATHEROSCLEROTIC DISEASE CARDIAC DYSFUNCTION
  46. 46. Adequate pre-intra & post op hydration <ul><li>Large bore cannula </li></ul><ul><li>Calculate for deficit correction ,maintenance,3 rd space losses </li></ul><ul><li>Fluid challenge:250-500mL of NS over 10-15 mins </li></ul><ul><li>If CVP monitoring established: </li></ul><ul><li> small elevation[1-2mm]= need more </li></ul><ul><li> large increase[5mm] = be slow </li></ul><ul><li>Colloid Controversies  over use </li></ul><ul><li> in sepsis </li></ul>
  47. 47. Maintain renal perfusion pressure <ul><li>Maintain MAP at 70-100 mm of Hg </li></ul><ul><li>Catecholamines may help if there is a cause for hypotension other than hypovolemia </li></ul>
  48. 48. Hemodynamic &urinary output monitoring <ul><li>Blood pressure </li></ul><ul><li>CVP </li></ul><ul><li>PAWP </li></ul><ul><li>Urine output  ensure catheter is not compressed </li></ul><ul><li> ensure good urine flow from start </li></ul><ul><li> monitor output hourly </li></ul><ul><li> ensure output >1ml/kg/hr </li></ul>
  49. 49. Avoid nephrotoxins <ul><li>ACE-I & ARB </li></ul><ul><li>NSAIDs </li></ul><ul><li>AMINOGLYCOSIDES </li></ul><ul><li>AMPHOTERICIN-B </li></ul><ul><li>CISPLATIN </li></ul><ul><li>ASPIRIN </li></ul><ul><li>CYCLOSPORIN </li></ul><ul><li>LMW-DEXTRAN </li></ul><ul><li>ACYCLOVIR,INDINAVIR </li></ul><ul><li>METHOTREXATE </li></ul>
  50. 50. Aggressive fluid loading <ul><li>Trauma </li></ul><ul><li>Compartment syndrome </li></ul><ul><li>Limb revascularization </li></ul><ul><li>… .high chance for rhabdomyolysis </li></ul>
  51. 51. Adequate oxygenation
  52. 52. Pharmacologic strategies
  53. 53. Mannitol <ul><li>Improve urinary flow </li></ul><ul><li>Plasma expansion </li></ul><ul><li>Osmotic hemodilution </li></ul><ul><li>Free radical scavenging </li></ul><ul><li>Volume increase  volume depletion </li></ul><ul><li>Increase O2 consumption </li></ul><ul><li>Pulmonary edema, intra renal vasoconstriction </li></ul>
  54. 54. Mannitol <ul><li>6.25-12.5g is given 15 mins prior to the defined insult / repeated 4-6 hrs </li></ul><ul><li>24 hr cumulative dose not >1.5 mg/kg </li></ul><ul><li>Aortic surgeries </li></ul><ul><li>Renal transplantation </li></ul><ul><li>CABG </li></ul><ul><li>rhabdomyolysis </li></ul>
  55. 55. Frusemide <ul><li>Inhibit Na-K ATPase in mTAL </li></ul><ul><li>Renal vasodilation </li></ul><ul><li>Clear debris </li></ul><ul><li>oliguric to non oliguric conversion </li></ul><ul><li>segmental blockade with thiazide e.g. metolazone 2.5-5.0mg po </li></ul><ul><li>Ototoxicity, interstitial nephritis </li></ul><ul><li>Shouldn’t be given if pt is not adequately fluid loaded </li></ul>
  56. 56. Frusemide <ul><li>Pigment nephropathy[ 2-3 times the normal dose with aggressive hydration] </li></ul><ul><li>Contrast nephropathy [with saline] </li></ul><ul><li>May reverse medullary hypoxia induced by toxins </li></ul><ul><li>2-10 mg/kg for converting oliguric to non oliguric renal failure </li></ul><ul><li>Continuous infusion 1-10mg/hr after a LD of 10-20mg </li></ul>
  57. 57. Dopamine <ul><li>Non specific DA1+DA2 agonist </li></ul><ul><li>“ subpressor dopamine has proved ineffective in clinical trials , may trigger arrhythmias and should not be used as a renoprotective agent in this setting” </li></ul><ul><li>S/E: increased myocardial O2 consumption, decrease hypoxic drive, intestinal ischemia </li></ul>
  58. 58. Others <ul><li>Fenoldapam </li></ul><ul><li>Nor adrenaline </li></ul><ul><li>Dopexamine </li></ul><ul><li>CCBs </li></ul><ul><li>PGE1 </li></ul><ul><li>ANP </li></ul><ul><li>ADENOSINE </li></ul><ul><li>AMINOSTEROIDS </li></ul>
  59. 59. ALSO NOTE… <ul><li>FORCED ALKALINE DIURESIS IN RHABDOMYOLYSIS </li></ul><ul><li>N-ACETYL CYSTINE IN ACETAMINOPHEN INDUCED INJURY </li></ul><ul><li>CONTRAST NEPHROPATHY  hydration , n-acetyl cystiene , theophylline/aminophyllin, bicarbonate containing IVFs[rather than saline] </li></ul>
  60. 60. Treatment of complications of ARF
  61. 61. Hyperkalemia <ul><li>regular insulin 10 u + glucose [50 mL 50% dextrose </li></ul><ul><li>Ca gluconate 105 10 mliv </li></ul><ul><li>Inhaled salbutamol 5 mg nebulised </li></ul><ul><li>Kayexelate,Na polystyrene sulfonate </li></ul><ul><li>NaHCO3 50-100 mEq iv </li></ul><ul><li>dialysis </li></ul>
  62. 62. others <ul><li>Metabolic acidosis: NaHCO3 to keep its level >15mmol/L or pH >7.2 </li></ul><ul><li>Hyperphosphatemia :Ca carbonate, Al(OH)3 </li></ul><ul><li>Hypocalcemia :Ca gluconate , CaCl2 </li></ul><ul><li>Nutrition </li></ul><ul><li>Anemia </li></ul><ul><li>Rx of CHF </li></ul>
  63. 63. Renal replacement therapy
  64. 64. Criteria for initiation of RRT <ul><li>Anuria </li></ul><ul><li>Oliguria </li></ul><ul><li>Pulmonary edema </li></ul><ul><li>Hyperkalemia >6.5mmol/L </li></ul><ul><li>Severe acidemia <7.2 </li></ul><ul><li>Uremic encephalopathy </li></ul><ul><li>Uremic pericarditis </li></ul><ul><li>Drug overdose with dialyzable toxins </li></ul>
  65. 65. Dialysis <ul><li>dialyser,dialysate,blood delivery system </li></ul><ul><li>Vascular access </li></ul><ul><li>Diffusion technique </li></ul><ul><li> heparinized blood and dialysate flows in opp direction through a synthetic membrane down a conc. gradient </li></ul><ul><li>Convection technique </li></ul><ul><li> similar to what happens in glomeruli. Blood passes across a filter which has pores of different sizes so as to filter various molecules </li></ul>
  66. 66. hemodialysis <ul><li>ADVANTAGES </li></ul><ul><li>Efficient solute removal in short period of time </li></ul><ul><li>Lower cost </li></ul><ul><li>more suitable in severe hyperkalemia </li></ul><ul><li>more effective than PD in ARF </li></ul>
  67. 67. hemodialysis <ul><li>DISADVANTAGES </li></ul><ul><li>Need for large bore venous access </li></ul><ul><li>Need for anticoagulation </li></ul><ul><li>No removal of cytokines </li></ul><ul><li>Unsuitable if hemodynamically unstable </li></ul>
  68. 68. Complications <ul><li>Hypotension: poor tolerance to fluid removal or due to acetate component. Treatment  decrease blood flow rate , IVFs </li></ul><ul><li>Hypoxemia : loss of CO2 via dialyzer , bronchospasm ,Treatment:Adr / b-agonist / aminophylline </li></ul><ul><li>Hemorrhage : 1mg of protamine  100iu of heparin </li></ul><ul><li>Arrhythmias </li></ul><ul><li>Dialysis disequilibrium syndrome: headache, nausea, delirium, seizures </li></ul>
  69. 69. hemodialysis <ul><li>Intermittent HD: 3-4hrs per day,3-4 times per week </li></ul><ul><li>Slow Low Efficiency Dialysis ^-12 hrs per day </li></ul>
  70. 70. Continuous RRT <ul><li>When intermittent HD fails </li></ul><ul><li>When patient is not tolerating intermittent HD due to hemodynamic instability </li></ul>
  71. 71. Types <ul><li>Arteriovenous </li></ul><ul><li>Venovenous </li></ul>
  72. 72. Venovenous <ul><li>Continuous venovenous hemodialysis </li></ul><ul><li>Continuous venovenous hemofiltration </li></ul><ul><li>Continuous venovenous hemodiafiltration </li></ul>
  73. 73. Advantages <ul><li>.better hemodynamic stability </li></ul><ul><li>Less arryhthmias </li></ul><ul><li>Improved nutritional support </li></ul><ul><li>Better pulmonary gas exchange </li></ul><ul><li>Better fluid control </li></ul>
  74. 74. Disadvantages <ul><li>High risk of bleeding </li></ul><ul><li>Immobilization prolonged </li></ul><ul><li>Costly </li></ul><ul><li>Difficult vascular access </li></ul><ul><li>Filter problems </li></ul>
  75. 75. peritoneal dialysis <ul><li>Less effective than HD </li></ul><ul><li>Useful if </li></ul><ul><li>HD not available </li></ul><ul><li>Bleeding diathesis </li></ul><ul><li>Impossible to attain vascular access </li></ul><ul><li>Hemodynamically unstable </li></ul><ul><li>No anticoagulation is needed </li></ul>
  76. 76. disadvantages <ul><li>Impaired drainage </li></ul><ul><li>Peritonitis </li></ul><ul><li>Protein loss </li></ul><ul><li>Compromised lung function </li></ul><ul><li>Abnormal blood sugar & electrolyte values </li></ul><ul><li>Very slow and ineffective when rapid correction is needed </li></ul>
  77. 77. Peritoneal dialysis <ul><li>Access via a peritoneal catheter </li></ul><ul><li>1.5-3L of a dextrose containing solution infused </li></ul><ul><li>Allowed to dwell for a short period of time[2-4hrs] </li></ul><ul><li>Convective + diffusive clearance </li></ul>
  78. 78. . <ul><li>“ Recent evidence suggest that more intensive hemodialysis [e.g. daily rather than alternative day intermittent dialysis] may be clinically superior and confers improved survival in ARF , once dialysis is required.” </li></ul>
  79. 79. References <ul><li>Harrisons principles of internal medicine,17 th e </li></ul><ul><li>Acute kidney injury network , akinet.org </li></ul><ul><li>Principles of critical care,2 nd e Farokh Erach Udwadia </li></ul><ul><li>Acute renal failure, Dr Rebecca Jacob, IJA 2003;47(5) </li></ul><ul><li>Anesthesia and coexisting disease,4 th e </li></ul><ul><li>ccmtutorials.com </li></ul><ul><li>Perioperative acute renal failure and its management, Dr D Mallikarjuna [isacon-2007 </li></ul>
  80. 80. THANK YOU

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