ACUTE RENAL FAILURE
Background:
Acute renal failure (ARF) is defined as an abrupt or rapid
decline in renal function. A rise in serum blood urea
nitrogen (BUN) or serum creatinine concentrations, with
or without a decrement in urine output, is usually
evidence of ARF. The condition is often transient and
completely reversible.
Pathophysiology
Causes: The causes of ARF traditionally are divided into
3 main categories: prerenal, intrarenal, and postrenal.
In prerenal ARF
Perfusion of the kidneys is compromised by the
following:
a)Hypotension
b) CHF.
c) Hypovolemia -Renal loss (e.g due to Addison disease
or diabetic ketoacidosis) or extrarenal loss (e.g. Due to
vomiting, diarrhea, pancreatitis, burns, or sweating) may
be present.
d)Intense vasoconstriction due to
 Hypercalcemia
 Prostaglandin inhibition [NSAIDs])
 Cyclosporine
 ACE inhibition
 Amphotericin B
 Cocaine use
 Hepatorenal syndrome also results in intense
vasoconstriction leading to functional failure
 Renal artery stenosis
-Depressed perfusion eventually leads to ischemia and
cell death.
-This initial ischemic insult triggers production of oxygen
free radicals and enzymes that continue to cause cell
injury even after restoration of perfusion.
-Tubular cellular damage results in disruption of tight
junctions between cells, allowing back leak of glomerular
filtrate and further depressing effective GFR. In addition,
dying cells slough off into the tubules, forming
obstructing casts, which further decrease GFR and lead to
oliguria.
Intrarenal ARF
Can be grouped into vascular, interstitial, and glomerular
factors, as follows:
a)Vascular causes
 Vasculitis involving the small vessels
 Scleroderma
 Atheroembolic renal disease
 Malignant hypertension
 Thrombotic angiopathy.
Although many of these causes can also be grouped
under prerenal ARF, more frequently they cause ischemic
tubular necrosis.
b)Interstitial nephritis
 Drugs commonly implicated include penicillins
and other antibiotics, NSAIDs, diuretics,
cimetidine, and allopurinol ,aminoglycosides,
or radiologic contrast agents
c)Glomerular
 Crescentic glomerulonephritis
 Post infective glomerulonephritis
 Lupus nephritis,
 Vasculitis-associated glomerulonephritides.
Postrenal ARF
-The most common cause of postrenal failure is
secondary to bladder outlet obstruction due to prostatic
hypertrophy.
- Physical:
Adults
History-below
Clinical presentation
ARF has such a long differential diagnosis, obtain a
The obstruction must be distal to the bladder or bilateral
to cause ARF unless only a single kidney is functioning
properly.
-Renal ultrasound is a quick and noninvasive study that
can help detect obstruction
In prerenal failure, restoration of circulating blood
volume is usually sufficient.
Rapid relief of urinary obstruction in postrenal failure
results in a prompt decrease of vasoconstriction.
With intrinsic renal failure, removal of tubular toxins and
initiation of therapy for glomerular diseases decreases
renal afferent vasoconstriction. Mortality
Mortality/Morbidity
-Most cases of community-acquired ARF are secondary
to volume depletion, as many as 90% of cases are
estimated to have a potentially reversible cause.
-Hospital-acquired ARF often is commonly the end result
of multiorgan failure or due to drugs.
-The most common causes of death associated with ARF
are sepsis, cardiac failure, and pulmonary failure.
-Mortality rates are generally lower for nonoliguric ARF
(>400 mL/day) than for oliguric (<400 mL/day) ARF,
reflecting the fact that nonoliguric ARF is usually caused
by drug-induced nephrotoxicity and interstitial nephritis,
which have few other systemic complications.
Sex: Males and females are affected equally.
Age: The patient's age has significant implications for the
differential diagnosis of ARF.
Newborns and Infants
The most common cause of ARF is prerenal etiologies.
 Perinatal hemorrhage - Twin-twin transfusion,
complications of amniocentesis, abruptio
placenta, birth trauma
 Neonatal hemorrhage - Severe intraventricular
hemorrhage, adrenal hemorrhage
 Perinatal asphyxia and hyaline membrane
disease (newborn respiratory distress
syndrome) both may result in preferential blood
shunting away from kidneys (ie, prerenal) to
central circulation.
Intrinsic ARF
 Acute tubular necrosis (ATN) can occur in the
setting of perinatal asphyxia. (aminoglycosides,
NSAIDs) given to the mother perinatally.
 ACE inhibitors can traverse placenta, resulting
in a hemodynamically mediated form of ARF.
 Acute GN is result of maternal-fetal transfer of
antibodies against the neonate's glomeruli or
transfer of chronic infections (syphilis,
cytomegalovirus)
Postrenal ARF: Congenital malformations of urinary
collecting systems should be suspected.
Children
The most common cause of ARF is prerenal etiologies.
Prerenal ARF
 hypovolemia in children is gastroenteritis.
 Congenital and acquired heart diseases
Intrinsic ARF
 HUS common cause of ARF in children.
Commonly associated with a diarrheal
prodrome caused by Escherichia coli.Present
microangiopathic anemia, thrombocytopenia,
colitis, mental status changes, and renal failure.
 Acute poststreptococcal GN considered in any
child who presents with HTN, edema,
hematuria, and renal failure.
-Facial puffiness, respiratory distress
-BP-Hypotension and tachycardia are obvious clues to
decreased renal perfusion.
Evaluation for hypovolemia should include evaluations
for orthostatic hypotension, mucosal membrane moisture,