INTRODUCTION

Acute kidney injury (AKI) has now replaced the term acute renal failure and a universal definition and staging system has been proposed to allow earlier detection and management of AKI. The new terminology enables healthcare professionals to consider the disease as a spectrum of injury. This spectrum extends from less severe forms of injury to more advanced injury when acute kidney failure may require renal replacement therapy (RRT). Clinically AKI is characterised by a rapid reduction in kidney function resulting in a failure to maintain fluid, electrolyte and acid-base homoeostasis. There have previously been many different definitions of AKI used in the literature which has made it difficult to determine the epidemiology and outcomes of AKI. Over recent years there has been increasing recognition that relatively small rises in serum creatinine in a variety of clinical settings are associated with worse outcomes. To address the lack of an universal definition for AKI a collaborative network of international experts representing nephrology and intensive care societies established the Acute Dialysis Quality Initiative (ADQI) and devised the RIFLE definition and staging system for AKI. Shortly after this many of the original members of the ADQI group collaborated to form the Acute Kidney Injury Network (AKIN). The AKIN group modified the RIFLE staging system to reflect the clinical significance of relatively small rises in serum creatinine. Most recently the international guideline group, Kidney Disease: Improving Global Outcomes (KDIGO) has brought together international experts from many different specialties to produce a definition and staging system that harmonises the previous definitions and staging systems proposed by both ADQI and AKIN. It is anticipated that this definition and staging system will be adopted globally. This will enable future comparisons of the incidence, outcomes and efficacy of therapeutic interventions for AKI. Acute kidney injury is common in hospitalised patients and also has a poor prognosis with the mortality ranging from 10%-80% dependent upon the patient population studied. Patients who present with uncomplicated AKI, have a mortality rate of up to 10. In contrast, patients presenting with AKI and multiorgan failure have been reported to have mortality rates of over 50%. If renal replacement therapy is required the mortality rate rises further to as high as 80% Acute kidney injury is no longer considered to be an innocent bystander merely reflecting coexistent pathologies. It has been demonstrated to be an independent risk factor for mortality . The cause of this is unclear but is possibly associated with an increased risk of non-renal complications such as bleeding and sepsis. An alternative explanation may lie in experimental work that has demonstrated the "distant effects" of ischaemic AKI on the other organs. In these experimental models isolated ischaemic AKI upregulates inflammatory mediators in other organs including the brain, lungs and heart. The UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD) adding insult to injury acute kidney injury report was published last year. This report examined the care of patients who died with a diagnosis of AKI. It identified many deficiencies in the care of patients who developed AKI and reported that only 50% of patients received good care. There was poor attention to detail, inadequate assessment of risk factors for AKI and an unacceptable

delay in recognising post admission AKI. The report made a number of recommendations which included the following

all emergency admissions should have a risk assessment for AKI all emergency admissions should have electrolytes checked on admission and appropriately thereafter predictable avoidable AKI should not occur all acute admission should receive adequate senior reviews (consultant review within 12 hours) there should be sufficient critical care and renal beds to allow rapid step up care undergraduate medical training should include the recognition of the acutely ill patient and the prevention, diagnosis and management of AKI postgraduate training in all specialties should include training in the detection, prevention and management of AKI.

The NCEPOD report was used to support a successful proposal made to the National Institute for Health and Clinical Excellence (NICE) for an AKI guideline. It is hoped that the guideline will be available in the near future. Once a patient has developed AKI the therapeutic options are limited with the mainstay of treatment being renal replacement therapy (RRT). However there are many important aspects surrounding the care of a patient with AKI that must be considered which include timely referral and transfer to renal services if appropriate. There is a paucity of evidence to guide the optimal time to initiate RRT and the decision remains the choice of the individual physician. If a patient commences RRT then there are number of practical issues to be considered including the modality, the choice of filter membrane, the optimal site of vascular access, anticoagulation and the intensity of the treatment. The purpose of these clinical practice guidelines is to review the available evidence and provide a pragmatic approach to the patient with AKI. There is a pressing need for renal physicians to engage in undergraduate and postgraduate educational programmes to improve the current management of AKI.

EPIDEMIOLOGY Distribution Local National

In the year 2009, end Stage Renal Disease is already the 7th leading cause of death among Filipinos. It is said that a Filipino is having the disease hourly or 120 Filipinos per million population per year. This shows that about 10, 000 Filipinos need to replace their kidney function. Unfortunately though only 73% or about 7, 267 patients recieved treatment. An estimate of about a quarter of the whole population probably just died without recieving any treatment.
International

The reported prevalence of AKI from US data ranges from 1% (community acquired) up to 7.1% (hospital-acquired) of all hospital admissions. The population incidence of AKI from UK data ranges from 172 per million population (pmp) per year from early data up to 486-630 pmp/year from more recent series, again depending on definition. The incidence of AKI requiring renal replacement therapy (RRT) ranges from 22 pmp/year7 to 203 pmp/year. An estimated 520% of critically ill patients experience an episode of AKI during the course of their illness and AKI receiving RRT has been reported in 49% of all admissions to intensive-care units (ICU). In the united states, 5,181people dies of acute renal failure. Japan has a mortality of 3, 963 deaths; Brazil: 2,029 deaths; Egypt: 2,014 deaths and Mexico: 1,220 deaths in the year 2011 was reported.
Determinants Modifiable

Diabetes Almost 40% of new dialysis patients have diabetes, making it the fastest growing risk factor for kidney disease. Type 2 diabetes is the number one cause of kidney failure, responsible for more than one of every three new cases. High Blood Pressure (Hypertension) High blood pressure puts more stress on blood vessels throughout the body, including the kidney filters (nephrons). Hypertension is the number two cause of kidney failure. Normal blood pressure is less than 130/85and this is the target for people who have diabetes, heart disease, or CKD. Weight control,

exercise, and medications can control blood pressureand perhaps prevent or slow the progress from kidney disease to kidney failure. Blockages Scarring from infections or a malformed lower urinary tract system (birth defect) can force urine to back up into the kidney and damage it. Blood clots or plaques of cholesterol that block the kidney's blood vessels can reduce blood flow to the kidney and cause damage. Repeated kidney stones can block the flow of urine from the kidney and are another kind of obstruction that can damage the kidneys. Overuse of Painkillers and Allergic Reactions to Antibiotics Heavy use of painkillers containing ibuprofen (Advil, Motrin), naproxen (Aleve), or acetaminophen (Tylenol) have been linked to interstitial nephritis, a kidney inflammation that can lead to kidney failure. A new study suggests that ordinary use of painkillers (e.g., one pill per day) is not harmful in men who are not at risk for kidney disease. Allergic reactions toor side effects ofantibiotics like penicillin and vancomycin may also cause nephritis and kidney damage. Drug Abuse Use of certain nonprescription drugs, such as heroin or cocaine, can damage the kidneys, and may lead to kidney failure and the need for dialysis. Inflammation Certain illnesses, like glomerulonephritis (inflammation of the filtering units of the kidneys), can damage the kidneys, sometimes enough to cause CKD. Some glomerulonephritis is inherited, and some may be an immune response to infections like strep throat. Smoking Smoking causes intense sympathetic excitation paralleled by an increase in blood pressure (up to 21mmHg systolic), tachycardia and increased concentrations of catecholamines in the circulation. Vasoconstriction is noted in many vascular beds, i.e. the coronary circulation or the forearm. It comes as no surprise that in healthy volunteers acute smoking (compared to sham smoking) causes an increase in renovascular resistance of 11% as well. This is accompanied by a decrease in glomerular filtration rate (GFR) (15%) and filtration fraction (18%)

Obesity Researchers at the University of California, San Francisco have determined that there is a strong relationship between being obese and developing endstage renal disease, or kidney failure. The long-range study found that the obese have up to a seven times greater risk of kidney failure than normal weight people, suggesting that obesity should be considered a risk factor for the condition, and that kidney failure is yet another consequence of obesity. Alcohol Intake Drinking alcohol can hurt your kidneys in many ways and can increase the chance of needing dialysis.4, 5, 6 It may damage the kidney cells. It increases your chance of developing HBP, a leading cause of kidney disease. Drinking alcohol can interfere with your medicines and make it harder to control your pressure.
Non-modifiable

Family History of Kidney Disease If you have one or more family members who have CKD, are on dialysis, or have a kidney transplant, you may be at higher risk. One inherited disease, polycystic kidney disease, causes large, fluid-filled cysts that eventually crowd out normal kidney tissue. Diabetes and high blood pressure can also run in families. Be aware of your family history and share it with your doctor. This can ensure that you are screened for risk factors regularly and get the care you need. Premature Birth About one in five very premature infants (less than 32 weeks gestation) may have calcium deposits in parts of the kidney called nephrons. This is termed nephrocalcinosis. Sometimes, individuals with this condition may go on to develop kidney problems later in life. Age Since kidney function is reduced in older people, the older you are, the greater your risk. Trauma or Accident Accidents, injuries, some surgeries, and certain radiocontrast dyes that doctors use to monitor blood flow to your heart and other organs can damage the kidneys or reduce blood flow to the kidneys, causing acute (sudden) kidney failure. Sometimes acute kidney failure will get better, but it may lead to CKD.

Certain Diseases Having certain diseases puts people at higher risk of kidney disease. These diseases include systemic lupus erythematosus (a connective tissue disease), sickle cell anemia, cancer, AIDS, hepatitis C, and congestive heart failure.

Prevention Local National

Renal Disease Control Program (REDCOP)

The Renal Disease Control Program (REDCOP) is the office in-charge of implementing the NKTI's public health projects on the prevention and control of renal and other related diseases. It plans, implements and monitors projects for research, advocacy, training, service and quality assurance. REDCOP's activities are done mostly on a national scale through its network of Regional Coordinators throughout the country.

International

CKD Health Evaluation and Risk Information Sharing (CHERISH)

The Chronic Kidney Disease (CKD) Initiative is designed to provide comprehensive public health strategies for promoting kidney health. These strategies seek to prevent and control risk factors for CKD, to raise awareness, to promote early diagnosis, and to improve outcomes and quality of life for those living with CKD.

PATHOGENESIS

PATHOGENESIS OF ACUTE RENAL FAILURE

PATHOPHYSIOLOGY OF ARF DUE TO ISCHEMIA

Pathophysiology of acute renal failure in TLS. (Tumor Lysis Syndrome)

DUE TO SEPSIS.

SIGNS AND SYMPTOMS: Acute renal failure often does not cause symptoms that you notice. If you are already in the hospital, tests done for other problems may also detect your kidney failure. When symptoms do appear, they may include:

Swelling, especially of the legs and feet. Little or no urine output. Thirst and a dry mouth. Rapid heart rate. Feeling dizzy when you stand up. Loss of appetite, nausea, and vomiting. Feeling confused, anxious and restless, or sleepy. Pain on one side of the back, just below the rib cage and above the waist (flank pain). Severe dehydration, a common cause of prerenal acute renal failure, may cause extreme thirst, lightheadedness or faintness, and a weak, rapid pulse. A blockage in the urinary tract, which causes postrenal acute renal failure, may cause pain in the side or lower back, blood in the urine (hematuria), or reduced urine output (oliguria).

TREATMENT: Treatment is focused on removing the cause of the kidney failure. Medications and other products the patient ingests will be reviewed. Any that might harm the kidneys will be eliminated or the dose reduced. Other treatments will be offered, with the following goals:

Correct dehydration - Intravenous fluids, with electrolyte replacement if needed Fluid restriction - For those types of kidney failure in which excess fluid is not appropriately eliminated by the kidneys Increase blood flow to the kidney - Usually related to improving heart function or increasing blood pressure Correct chemical (electrolyte) abnormalities - Keeps other body systems working properly

If the patient's kidneys do not respond to treatment, and adequate kidney function does not return, they will need to undergo dialysis. Dialysis is done by accessing the blood vessels through the skin (hemodialysis) or by accessing the abdominal cavity through the lining that encases the abdominal organs (peritoneal dialysis). With hemodialysis, the patient is connected to a machine by a tube running from a conduit created surgically between a large artery and vein. Blood is circulated through the

RECIPE (COOKING LESSON) Ingredients: clove garlic, minced 1 medium oinion, finely chopped 1 tbsp oil 1 1/2 lbs. ground beef 1 pack tomato sauce 1 can tomato paste 2 cups cooked spaghetti Instructions: Combine garlic and onion in oil over low heat until tender. Add meat; cook and stir until brown; drain fat. Stir in remaining ingredients; break up tomatoes. Simmer uncovered over low heat about 30 minutes.