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Management of arf


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Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.

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Management of arf

  1. 1. Management of Acute Renal Failure Dr. Sachin Verma MD, FICM, FCCS, ICFC Fellowship in Intensive Care Medicine Infection Control Fellows Course Consultant Internal Medicine and Critical Care Web:- Mob:- +91-7508677495References Brenner & Rector’s The Kidney, 7 th ed. Harrison’s Principles of Internal Medicine, 16th ed. 29/9/05
  2. 2. Definition Acute renal failure is a syndrome characterized by a rapid (hours to week) decline in GFR and retention of nitrogenous waste products such a BUN and creatinine
  3. 3. Etiology & Classification of ARFA. Pre renal azotemia (55-60%) Intravascular volume depletion Decreased cardiac output Renal vasoconstrictionB. Acute intrinsic renal azotenia Disease involving large renal vessels Diseases of glomeruli and renal microvasculature Injury to renal tubules. Exogenous toxins and endogenous toxins Acute disease of tubulo interstitium.
  4. 4. Etiology & Classification of ARFC. Post renal azotemia Ureteric obstruction (Intraluminal, intramural, Extraureteric, periureteric) Bladder neck obstruction Uretheral obstruction
  5. 5. Clinical Approach to the Diagnosis of ARF History (Drug history) ↓ Physical examination (Fundus & Weight) ↓ Urinanalysis ↓ Flow chart of serial BP, Wt, BUN, S. Cr. Major clinical events interventions ↓ Routine blood chemistry ↓ Radiologic evaluation (plain abdominal film)Renal USG, IVP, renal angiography, MR angiography ↓ Renal Biopsy
  6. 6. Clinical AssessmentPre renal Fluid loss in any form Symptoms of thirst Orthostatic dizziness and hypotension Tachycardia Decreased skin turgor dry mucus membrane Decreased axillary sweatingDefinitive diagnosis Resolution of ARF after restoration of renal perfusion
  7. 7. Intrinsic Increased muscular activity (Rhabdomyolysis) Recent transfusion (Hemolysis) Flank pain Hyperreflexia and asterixisPost renal Suprapubic pain (Acute distension of bladder) Colicky flank pain radiating to groinDefinitive diagnosis Radiologic investigation and rapid improvement in renal function after relief of obstruction
  8. 8. Urinanalysis1. Urine volume2. Urine sediment  Acellular / Transparent hyaline cast (pre renal)  Pigmented “muddy brown” granular cast, tubule epithelial cell cast (renal)  Benign sediment, hematuria, pyuria (post renal)  Broad granular cast characteristics of chronic renal disease and reflect interstitial fibrosis and dilatation of tubules Granular cast  ATN, GN / vasculitis, Interstitial nephritis RBC cast  GN / Vasculitis, Malignant hypertension
  9. 9.  WBC cast  Acute interstitial nephritis, Severe pyelonephritis, Marked leukemic or lymphomatous infiltration3. Eosinophiluria (>5%)  Drug induced allergic interstitial nephritis4. Crystalluria  Uric acid crystals (pleomorphic), oxalate (envelop shaped), Hippurate (needle shaped)5. Tubule proteinuria (<1g/d) : proximal tubule cell injury, glomerular proteinuria (>1g/d) injury to glomerular ultrafiltration barrier6. Haemoglobinuria7. Myoglobinuria
  10. 10. Confirmatory test Plain abdominal film USG CT Scan Radio nuclide scan MRA Doppler USG and Spiral CT Contrast angiography (Gold standard) Renal biopsy
  11. 11. FENa (Fractional Excretion of Na+(%) Most sensitive index to differentiate pre renal azotemia from ATN UNa X Pcr <1 prerenal X100 PNa X Ucr >1 ATN
  12. 12. TreatmentPre renal azotemia Correction of Hypovolemia by packed red cells, isotonic saline, Hypotonic saline (0.45%) Loop blocking diuretic, (Frusemide high dose 20 – 160 mg orally or IV twice daily) to effect adequate diuresis and convert oliguric to non- oliguric RF. ARF with cirrhosis (fluid challenge) paracentesis with albumin administration Renal dose dopamine (1-3 mg/kg/min)
  13. 13. TreatmentIntrinsic ATN Optimization of CV function & intravascular volume Prophylactic oral acetylcysteine (600 mg BD 24 hour before and after procedure) Use of less nephrotoxic contrast agent (Gadolinium and CO2) Cautious use of diuretics, NSAIDs, ACE inhibitors Lipid encapsulated formulation of amphotericin B Allopurinol (Acute urate nephropathy) Amifostine an organic thiophosphate (Cisplatin)
  14. 14.  Forced diuresis and alkanization of urine (Rhabdomyolysis) N Acetylcysteine within 24 hour (Acetaminophen) Dimercaprol (Chelating agent) (heavy metal) Ethanol (ethylene glycol toxicity) Plasma pharesis (Myeloma cast nephropathy) Systemic arterial pressure control (malignant htpertensive nephrosclerosis) Acute GN (pulse glucocorticoid therapy)
  15. 15. ANP 28 amino acid polypeptide. Synthesized in cardiac atrial muscle. Increased GFR by triggering afferent arteriolar vasodilatation and increasing ultrafiltration. Inhibits Na transport and lower oxygen requirement.Post renal ARF Transuretheral or suprapubic placement of bladder catheter (obstruction of urethra or bladder neck) Percutaneous catheterization of dilated renal pelvis or ureter (ureteric obstruction) Removal of obstructing lesion percutaneously or bypassed by insertion of ureteric stent
  16. 16. Management of complicationIntravascular volume overload Salt (1-2 gm/day) and water (<1 lt/day) restriction Diuretics, usually loop + thiazide Ultrafiltration or dialysisHyponatremia Restriction of enteral free water intake (<1lt/day) Avoid hypotonic intravenous solution (including dextrose)
  17. 17. Hyperkalemia Restriction of dietary K+ intake (<40 mmol/day) Eliminate K+ supplement and K+ sparing diuretic, Potassium binding ion-exchange resin (Na polystyrene sulphonate) Glucose (50 ml of 50% Dextrose) and insulin (10 U regular) NaCO (50-100 mmol) 3 Calcium gluconate (10 ml of 10% solution) over 5 minute Dialysis (with low K+ dialysate)
  18. 18. Metabolic acidosis Restriction of dietary protein (0.6 g/Kg/day of high biologic value) Na bicarbonate (maintain serum bicarbonate >15 mmol/L or arterial pH >7.2) DialysisHyperphosphatemia Restriction of dietary phosphate intake (<800 mg/day) Phosphate binding agents (Ca carbonate, Aluminium hydroxide)
  19. 19. Hypocalcemia Calcium Carbonate Calcium gluconate (10 – 20 ml of 10% solution)Hypermagnesemia Avoid Mg2+ containing antacidsHyperuricemia Treatment usually not necessary (<15 mg/dl)Nutrition Restriction of dietary protein (0.6 g/kg/day) Carbohydrate (100 g/day) Enteral / Parenteral nutrition
  20. 20. Indication for Dialysis Clinical evidence (signs & symptoms) of uremia Intractable intravascular volume over load Hyperkalemia Severe acidosis (resistant to conservative measures) Prophylactic dialysis when urea >100-150 mg/dl or creatinine >8-10 mg/dl
  21. 21. Outcome Mortality rate approximately 50% Poor prognosis – Oliguria (<400 mg) or serum creatinine (>3 mg/dl), older debilitated patient and multiple organ failure at the time of presentation 50% subclinical impairment of renal function 5% never recover (require dialysis or transplantation) 5% progressive decline in GFR