ACUTE RENAL FAILURE

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AETIOPATHOGENESIS & MANAGEMENT OF ACUTE RENAL FAILURE PRESENTER Dr Unnikrishnan P COORDINATOR Dr Sugandha MODERATORS Dr S...

. <ul><li>Human beings are essentially big bags of water, the volume of which must be kept under tight control, to prevent...

Highlights… <ul><li>FOLLOWING THE TRENDS…. </li></ul><ul><li>CAPTURE THE KEYS TO OPEN THE DOOR </li></ul><ul><li>HOW TO PR...

‘ ACUTE KIDNEY INJURY’ <ul><li>Abrupt reduction [<48 hrs] in kidney function, defined as an absolute increase in S creatin...

STAGING SYSTEM FOR A.K.I. STAGE S.CREATININE CRITERIA URINE OUTPUT CRITERIA 1 INCREASE IN S.CREATININE ≥0.3mg/dL OR INCREA...

RIFLE criteria

CLASSIFICATION

AETIOPATHOGENESIS <ul><li>. </li></ul>

PRERENAL ARF <ul><li>Most common </li></ul><ul><li>Renal hypo perfusion </li></ul><ul><li>Important form in perioperative...

. CAUSES-PRERENAL ARF HYPOVOLEMIA >HEMORRHAGE >G-I LOSSES >DECREASED INTAKE >URINARY LOSSES >SKIN LOSSES >OTHERS:BURNS,PA...

HYPOVOLEMIA- extrinsic

HYPOVOLEMIA- intrinsic <ul><li>Tubuloglomerular feedback </li></ul><ul><li>Afferent arteriolar vasodilatation </li></ul><u...

In short…. <ul><li>EXTRINSIC  INCREASE MAP, IMPROVE INTRAVASCULAR VOLUME </li></ul><ul><li>INTRINSIC  IMPROVE RENAL PL...

When the insult cross the limits…. <ul><li>Compensatory mechanisms overwhelmed  renal perfusion decrease  GFR fall </l...

Hepatorenal syndrome <ul><li>Unique form of prerenal ARF </li></ul><ul><li>Structurally normal </li></ul><ul><li>Profound ...

INTRINSIC ARF CAUSES RENOVASCULAR >ATHEROEMBOLISM >MALIGNANT HTN > >HUS > DIC >PREECLAMPSIA GLOMERULAR >AGN TUBULES -ATN I...

Ischemic ATN 4 PHASES INITIATION:GFR DECREASE , OBSTRUCTION BY DEBRIS , BACKLEAK EXTENSION : CONTINUED…. MAINTENANCE : GFR...

The so called diuretic phase… <ul><li>Recovery phase </li></ul><ul><li>Filtration recovers early </li></ul><ul><li>Recover...

Nephrotoxic ATN <ul><li>RISK FACTORS </li></ul><ul><li>Advanced age </li></ul><ul><li>Preexisting kidney disease </li></ul...

Toxins….

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

Atheroembolic ATN <ul><li>After manipulation of aorta or renal arteries during surgery / angiography / trauma </li></ul><u...

POSTRENAL ARF <ul><li>Obstruction is always the most likely cause when there is anuria </li></ul><ul><li>B/L ureteric </li...

Perioperative oliguria - pathophysiology <ul><li>Anesthetic agents: no renal vasodilation per se ; effects by reducing CO ...

Raised intra abdominal pressure <ul><li>Normal 0-17mm of Hg </li></ul><ul><li>>20 mm of Hg  compression of pelvis  an...

Clinical features

Pre renal <ul><li>vomiting , diarrhoea </li></ul><ul><li>Intestinal obstruction…. </li></ul><ul><li>Carry over cases..NPO...

Intrinsic renal <ul><li>oliguria,edema,hypertension  AGN </li></ul><ul><li>Intake of nephrotoxic drugs </li></ul><ul><li...

Post renal <ul><li>Anuria </li></ul><ul><li>Flank pain </li></ul><ul><li>h/o prostatic disease </li></ul>

INVESTIGATIONS

URINE MICROSCOPY CONDITION FINDINGS PRERENAL TRANSPARENT HYALINE CAST POSTRENAL HYALINE CAST/PUS CELLS/HEMATURIA ATN MUDDY...

Assessment of GFR

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 bette...

Serum creatinine <ul><li>Normal: <1.5 mg/dL </li></ul><ul><li>Overestimate GFR </li></ul><ul><li>Lags behind renal injury ...

Creatinine clearance <ul><li>Volume of plasma cleared off creatinine per unit time </li></ul><ul><li>Earlier warnings, 2hr...

Assessment of tubular function <ul><li>Renal Failure Indices </li></ul>PRERENAL INTRINSIC FENa <1 >1 URINARY Na <20 >40 UR...

Assessment of tubular function <ul><li>Differentiate pre renal from intrinsic renal failure </li></ul><ul><li>FeNa is the ...

Radiology <ul><li>Abdominal USG </li></ul><ul><li>Small  Htve Nephrosclerosis , CRF </li></ul><ul><li>Normal / large ...

Others <ul><li>renal biopsy </li></ul><ul><li>Increased potassium ,phosphorus , CK-MM, Uric Acid, decreased Calcium  ...

Complications <ul><li>. </li></ul>

Complications <ul><li>. </li></ul>

Complications <ul><li>. </li></ul>

Also… <ul><li>hyperphosphatemia </li></ul><ul><li>Infection </li></ul><ul><li>Uremic syndrome </li></ul><ul><li>Hypovolemi...

Prevention of ARF- in perioperative period

Identify patients at risk PATIENT FACTORS TYPE OF SURGERY CKD CARDIOPULMONARY BYPASS ELDERLY AORTIC ANEURYSM SURGERY NEPHR...

Adequate pre-intra & post op hydration <ul><li>Large bore cannula </li></ul><ul><li>Calculate for deficit correction ,main...

Maintain renal perfusion pressure <ul><li>Maintain MAP at 70-100 mm of Hg </li></ul><ul><li>Catecholamines may help if the...

Hemodynamic &urinary output monitoring <ul><li>Blood pressure </li></ul><ul><li>CVP </li></ul><ul><li>PAWP </li></ul><ul><...

Avoid nephrotoxins <ul><li>ACE-I & ARB </li></ul><ul><li>NSAIDs </li></ul><ul><li>AMINOGLYCOSIDES </li></ul><ul><li>AMPHOT...

Aggressive fluid loading <ul><li>Trauma </li></ul><ul><li>Compartment syndrome </li></ul><ul><li>Limb revascularization </...

Adequate oxygenation

Pharmacologic strategies

Mannitol <ul><li>Improve urinary flow </li></ul><ul><li>Plasma expansion </li></ul><ul><li>Osmotic hemodilution </li></ul...

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 cumula...

Frusemide <ul><li>Inhibit Na-K ATPase in mTAL </li></ul><ul><li>Renal vasodilation </li></ul><ul><li>Clear debris </li><...

Frusemide <ul><li>Pigment nephropathy[ 2-3 times the normal dose with aggressive hydration] </li></ul><ul><li>Contrast ne...

Dopamine <ul><li>Non specific DA1+DA2 agonist </li></ul><ul><li>“ subpressor dopamine has proved ineffective in clinical ...

Others <ul><li>Fenoldapam </li></ul><ul><li>Nor adrenaline </li></ul><ul><li>Dopexamine </li></ul><ul><li>CCBs </li></ul>...

ALSO NOTE… <ul><li>FORCED ALKALINE DIURESIS IN RHABDOMYOLYSIS </li></ul><ul><li>N-ACETYL CYSTINE IN ACETAMINOPHEN INDUCED ...

Treatment of complications of ARF

Hyperkalemia <ul><li>regular insulin 10 u + glucose [50 mL 50% dextrose </li></ul><ul><li>Ca gluconate 105 10 mliv </li></...

others <ul><li>Metabolic acidosis: NaHCO3 to keep its level >15mmol/L or pH >7.2 </li></ul><ul><li>Hyperphosphatemia :Ca ...

Renal replacement therapy

Criteria for initiation of RRT <ul><li>Anuria </li></ul><ul><li>Oliguria </li></ul><ul><li>Pulmonary edema </li></ul><ul...

Dialysis <ul><li>dialyser,dialysate,blood delivery system </li></ul><ul><li>Vascular access </li></ul><ul><li>Diffusion t...

hemodialysis <ul><li>ADVANTAGES </li></ul><ul><li>Efficient solute removal in short period of time </li></ul><ul><li>Lower...

hemodialysis <ul><li>DISADVANTAGES </li></ul><ul><li>Need for large bore venous access </li></ul><ul><li>Need for anticoag...

Complications <ul><li>Hypotension: poor tolerance to fluid removal or due to acetate component. Treatment  decrease blo...

hemodialysis <ul><li>Intermittent HD: 3-4hrs per day,3-4 times per week </li></ul><ul><li>Slow Low Efficiency Dialysis ^-1...

Continuous RRT <ul><li>When intermittent HD fails </li></ul><ul><li>When patient is not tolerating intermittent HD due to ...

Types <ul><li>Arteriovenous </li></ul><ul><li>Venovenous </li></ul>

Venovenous <ul><li>Continuous venovenous hemodialysis </li></ul><ul><li>Continuous venovenous hemofiltration </li></ul><u...

Advantages <ul><li>.better hemodynamic stability </li></ul><ul><li>Less arryhthmias </li></ul><ul><li>Improved nutritiona...

Disadvantages <ul><li>High risk of bleeding </li></ul><ul><li>Immobilization prolonged </li></ul><ul><li>Costly </li></ul...

peritoneal dialysis <ul><li>Less effective than HD </li></ul><ul><li>Useful if </li></ul><ul><li>HD not available </li><...

disadvantages <ul><li>Impaired drainage </li></ul><ul><li>Peritonitis </li></ul><ul><li>Protein loss </li></ul><ul><li>Com...

Peritoneal dialysis <ul><li>Access via a peritoneal catheter </li></ul><ul><li>1.5-3L of a dextrose containing solution in...

. <ul><li>“ Recent evidence suggest that more intensive hemodialysis [e.g. daily rather than alternative day intermittent ...

References <ul><li>Harrisons principles of internal medicine,17 th e </li></ul><ul><li>Acute kidney injury network , aki...

THANK YOU

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