Acut Renal Failure

Renal failure : Classifications

 Acute versus chronic
 Pre-renal, renal, post-renal
 Anuric, oliguric, polyuric
 Acute Versus Chronic
 Acute
 sudden onset
 rapid reduction in urine output
 Usually reversible
 Tubular cell death and regeneration
 Chronic
 Progressive
 Not reversible
 Nephron loss
 75% of function can be lost before its noticeable
 Acute Renal Failure

 Pre-renal = 55%

 Renal parenchymal (intrinsic)= 40%

 Post-renal = 5-15%
 Causes of ARF
 Pre-renal =
 vomiting, diarrhea, poor fluid intake, fever, use of
diuretics, and heart failure
 cardiac failure, liver dysfunction, or septic shock
 Intrinsic
 Interstitial nephritis, acute glomerulonephritis, tubular
necrosis, ischemia, toxins
 Post-renal =
 prostatic hypertrophy, cancer of the prostate or cervix, or
retroperitoneal disorders
 neurogenic bladder
 bilateral renal calculi, papillary necrosis, coagulated
blood, bladder carcinoma, and fungus
 Symptoms of ARF
 Decrease urine output (70%)
 Edema, esp. lower extremity
 Mental changes
 Heart failure
 Nausea, vomiting
 Pruritus
 Anemia
 Tachypenic
 Cool, pale, moist skin
 Symptoms of ARF
 Decrease urine output (70%)
 Edema, esp. lower extremity
 Mental changes
 Heart failure
 Nausea, vomiting
 Pruritus
 Anemia
 Tachypenic
 Cool, pale, moist skin
 Assessing the patient with acute renal
failure – Physical exam
 Vital Signs:
 Elevated BP: Concern for malignant hypertension
 Low BP: Concern for hypotension/hypoperfusion (acute tubular necrosis)
 Neuro:
 Confusion: hypercalcemia, uremia, malignant hypertension, infection,
malignancy
 HEENT:
 Dry mucus membranes: Concern for dehydration (pre-renal)
 Abd:
 Ascites: Concern for liver disease (hepatorenal syndrome), or nephrotic
syndrome
 Ext:
 Edema: Concern for nephrotic syndrome
 Skin:
 Tight skin, sclerodactyly – Sclerodermal renal crisis
 Malar rash - Lupus
Diagnosis of Renal Failure
 Pre renal acute renal failure is diagnosed by :
 1-BUN/Cr ratio ≥ 20
 2-Ucr/Pcr ratio ≥ 40
 3-urine specific gravity ≥ 1020
 4- all of above.
Acute Renal Failure Management
 Make/think about the diagnosis
 Treat life threatening conditions
 Identify the cause if possible
 Hypovolemia
 Toxic agents (drugs, myoglobin)
 Obstruction
 Treat reversible elements
 Hydrate
 Remove drug
 Relieve obstruction
Treatment of Acute Renal Failure
 Treat underlying cause
 Blood pressure
 Infections
 Stop inciting medications
 Nephrostomy tubes/ureteral stents if obstruction
 Treat scleroderma renal crisis with ACE inhibitor
 Hydration
 Diuresis (Lasix)
 Dialysis
 Renal Transplant
Acute Renal Failure
 An abrupt decrease in renal function
sufficient to cause retention of metabolic
waste such as urea and creatinine.
 Frequently have:
 Metabolic acidosis
 Hyperkalemia
 Disturbance in body fluid homeostasis
 Secondary effects on other organ systems
Risk factor for acute renal failure
 Advanced age
 Preexisting renal parenchymal disease
 Diabetes mellitus
 Underlying cardiac or liver disease
Urine Output in Acute Renal failure
 Oliguria
 = daily urine output < 400 mL
 When present in acute renal failure, associated with a
mortality rate of 75% (versus 25% mortality rate in non-
oliguric patients)
 Most deaths are associated with the underlying disease
process and infectious complications
 Anuria
 No urine production
 Uh-oh, probably time for dialysis