This document summarizes the pathogenesis and management of acute renal failure. It discusses the causes and stages of pre-renal, intrinsic renal, and post-renal acute kidney injury. Key factors in preventing acute renal failure in surgical patients include adequate hydration, maintaining renal perfusion pressure, avoiding nephrotoxins, and aggressive treatment of complications such as hyperkalemia. Treatment may involve renal replacement therapies like hemodialysis when criteria for initiation are met.

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

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. RIFLE criteria

7. CLASSIFICATION

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. HYPOVOLEMIA- extrinsic

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. 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

20. Toxins….

21. Contrast nephropathy FEATURES REVERSIBLE ACUTE ONSET [24-48 HRS] PEAK 3-5 DAYS RESOLUTION IN ONE WEEK B UREA & S CREATININE INCREASE

26. Clinical features

30. INVESTIGATIONS

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. Assessment of GFR

44. Prevention of ARF- in perioperative period

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

51. Adequate oxygenation

52. Pharmacologic strategies

60. Treatment of complications of ARF

63. Renal replacement therapy

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