Acute Renal Failure

Definition
Sudden rise in blood urea and creatanine
Fall in glomerular filtration rate

Presentation
Incidental finding on blood tests Commonly oliguric on anuric, can be polyuric or have normal urine volume Symptoms of metabolic acidosis Symptoms of salt and water overload Haematuria Drug overdose


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Renal function is based on 4 sequential steps: Blood flows from the renal arteries to the glomeruli Glomeruli form an ultrafiltrate which flows to the renal tubules Tubules reabsorb and secrete solute and/or water from the ultrafiltrate Urine leaves the kidney draining into the renal pelvis, ureter and bladder, its then excreted through the urethra

Classification
Pre-renal Renal Post-renal
Identifying pre and post renal causes are particularly important as they may be readily reversible

Pre-renal
Severe diarrhoea Severe burns Massive haemorrhage Dehydration post operatively Sepsis Severe liver disease(hepato-renal syndrome) Renal artery stenosis with ACEI

Renal
Acute Hb deposition in the tubules secondary to intravascular haemolysis Drugs and toxins causing acute interstitial nephritis Infection Thromboembolic disease Haemolytic uraemic syndrome Thrombotic thrombocytopaeniapurpura Malignant hypertension Scleroderma Vasculidities Immune mediated

Post-renal
Bilateral renal calculi Involvement of both ureters with bladder carcinoma Advanced cervical carcinoma Prostatic enlargement

Poor prognostic features

Age >50 Septicaemia Burns >70% surface area Rising urea >16mmol/24hours Oliguric >2 weeks Multi-organ failure >3 Jaundice

Urgent investigations
U&E FBC and film Coagulation Blood cultures Urine MC&S ECG CXR USS kidneys Consider:CK, Immunology, LDH, LFT, HIV,HBsAg, HCVAb

Management
1. Assess state hydration-?CVP line 2. Correct hypovolaemia 3. Arterial pH & plasma HCO3- correct with 50-100ml 8.4% NaHCO3 slowly, centrally 4. Treat hyperkalaemia (K>6.5) If ECG abnormal-20ml 10% Ca Gluconate Dextrose insulin infusion- 50ml 50% with 10U insulin over 30mins, thereafter 10ml/hr. BMs hourly Ca resonium 15g QDS orally

5. Catheterise- does not need to remain in situ if anuric/oliguric 6. If systolic BP<100mmHg despite optimal intravascular volume start ionotropes 7. If no diuresis give hourly fluid on basis of measuring losses plus insensible losses (aprox 30ml/hour), appropriate to clinical state. N.B. primary goal is to achieve optimal blood volume, urine flow is of secondary importance. Early mortality is often due to fluid overload and pulmonary oedema.

8. Look for sepsis 9. Stop all nephrotoxic drugs 10. Give H2 blocker or PPI 11. Early USS 12. Consider renal biopsy if features suggestive of multisystem disease

Indications for dialysis

1. Life-threatening, intractable pulmonary oedema 2. Uncontrollably rising K 3. Severe or worsening acidosis, pH<7.2 4. Uraemia

 N.B: ARF can often be prevented

Avoid dehydration in high risk patients e.g. :diabetics, myeloma, CRF NBM Surgery IV contrast Caution with NSAIDs and aminoglycosides

13 year old female Co: acute abdominal pain BP 100/60 U&E: Na 131 K 7.2 Ur 13 Cr 121 HCO3 8 Cl 96 AXR: NAD Urinalysis: glucose +++

1. What is the most likely cause for here clinical state?

2. How would you manage here?

 5 year old male CO: 2/52 bloody diarrhoea, 3/7 nausea and malaise OE: Periorbital oedema, BP 150/95 FBC: Hb 8 WCC 13 PLT 36 Film: anaemia, red cell fragments, thrombocytopaenia, reticulocytosis Clotting: PT 13s (control 13) APTT 34s( control 36)

U&E: Na 138 K 5.9 Ur 11 Cr 130

1. What is the diagnosis?

2. What would you look for to confirm it?

 40 year old Ugandan male, found in a ditch having fallen off his boda-boda. Previous history of hypertension on bendrofluazide 2.5mg od, diet controlled diabetic OE: Drowsy, HR 41bpm, BP 140/90, Temp 36.8C, BM 9 Cardiovascular, respiratory, abdominal examinations normal Left lower limb externally rotated and painful. Bruising ++++ buttock and left thigh FBC: Hb 9.8
WCC 14 PLT 350 MCV 84

Urinalysis: blood++++ Prot + CXR: NAD Xray left hip: fracture dislocation NOF ECG: minor lateral T wave changes

1. What is the diagnosis?

2. Give 2 investigations to confirm the diagnosis?

 30 year old female teacher from UK, returned home after visiting Uganda for 4 weeks. CO: Fevers, rigors, abdominal pain, headache OE: Temp 40C, Pulse 100bpm, BP116/80, GCS 15 Cardiovascular and respiratory system NAD Abdomen soft, 6cm tender splenomegaly FBC: Hb 9.2 WCC 3.2 Plt 84

 LFT: bili 56 Alp 97 ALT 29 Alb 30 U&E: Na 131 K 5.6 Ur 16 Cr 175 Urinalysis: blood +++ prot ++ gluc -

1. What is the most likely cause of her illness? 2. How would you confirm the diagnosis? 3. How would you manage the patient?

Haemolytic uraemic syndrome

Caused by E.coli 0157:H7 Most commonly from undercooked beef Toxin causes GI effects, colicky pain, blody diarrhoea, absent or mild fever HUS in 6% patients with E.coli0157:H7 Characterised by MAHA, result of endothelial damage by the toxin, causing adherence of fibrin strands, which trap fragment RBC and platlets Small vessel fibrin deposition and thrombosis result from MAHA causing renal damage and oliguric renal failure

Bruising and bleeding are common Clotting is usually normal Treatment is supportive 50% need dialysis 3-5% mortality

Rhabdomyolysis
Causes: muscle trauma/infarction Electrocution Hypothermia Status epilepticus Neuroleptic malignant syndrome Exstacy/amphetamine abuse Burns Septicaemia Statins Very strenuous exercise (eg marathon )

 Myoglobin is toxic to the renal tubules causing renal failure Serum Ca2+ drops as it is bound by the myoglobin K+ and PO4 increase as they are released from damaged muscle cells Management Hydration and alkanisation of urine Avoid loop diuretics as they acidify the urine

Falciparum Malaria
Renal failure results from a combination of pyrexia, volume depletion and haemolysis Falciparum does not appear to cause CRF Poor prognostic signs Neurological features; deep coma, seizures, decerebrate posturing Retinal haemorrhage Hypoglycaemia Paracitaemia>5% Pulmonary oedema WCC>12 Hb<7

 DIC Cr>250 Lactic acidosis

 U&E: Na 135 K 6.8 Ur 16 Cr 670 HCO3 15 Ca 2.0 PO4 2.8 LFT: Bili 14 AST 26 ALP 100 ALB 40