Management of Management of Acute Renal Failure Acute Renal Failure Dr. Sachin Verma MD, FICM, FCCS, ICFC Dr. Sachin Verma MD, FICM, FCCS, ICFC Fellowship in Intensive Care Medicine Fellowship in Intensive Care Medicine Infection Control Fellows Course Infection Control Fellows Course Consultant Internal Medicine and Critical Consultant Internal Medicine and Critical Care Care Web:- Web:- http://www.medicinedoctorinchandigarh.com Mob:- +91-7508677495 Mob:- +91-7508677495 References References Brenner & Rector’s The Kidney, 7 Brenner & Rector’s The Kidney, 7 th th ed. ed. Harrison’s Principles of Internal Medicine, Harrison’s Principles of Internal Medicine, 16 16 th th ed. ed.
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
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Management of Management of Acute Renal FailureAcute Renal Failure
ReferencesReferences Brenner & Rector’s The Kidney, 7Brenner & Rector’s The Kidney, 7thth ed. ed. Harrison’s Principles of Internal Medicine, 16Harrison’s Principles of Internal Medicine, 16thth ed. ed.
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DefinitionDefinition
Acute renal failure is a syndrome Acute renal failure is a syndrome characterized by a rapid (hours to week) characterized by a rapid (hours to week) decline in GFR and retention of decline in GFR and retention of nitrogenous waste products such a BUN nitrogenous waste products such a BUN and creatinineand creatinine
Etiology & Classification of ARFEtiology & Classification of ARF
A. Pre renal azotemia (55-60%)A. Pre renal azotemia (55-60%) Intravascular volume depletionIntravascular volume depletion Decreased cardiac output Decreased cardiac output Renal vasoconstrictionRenal vasoconstriction
B. Acute intrinsic renal azoteniaB. Acute intrinsic renal azotenia Disease involving large renal vesselsDisease involving large renal vessels Diseases of glomeruli and renal microvasculature Diseases of glomeruli and renal microvasculature Injury to renal tubules. Exogenous toxins and Injury to renal tubules. Exogenous toxins and
endogenous toxins endogenous toxins Acute disease of tubulo interstitium. Acute disease of tubulo interstitium.
C. Post renal azotemiaC. Post renal azotemia Ureteric obstruction (Intraluminal, intramural, Ureteric obstruction (Intraluminal, intramural,
Flow chart of serial BP, Wt, BUN, S. Cr. Flow chart of serial BP, Wt, BUN, S. Cr. Major clinical events interventionsMajor clinical events interventions
Pre renalPre renal Fluid loss in any formFluid loss in any form Symptoms of thirstSymptoms of thirst Orthostatic dizziness and hypotension Orthostatic dizziness and hypotension TachycardiaTachycardia Decreased skin turgor dry mucus membrane Decreased skin turgor dry mucus membrane Decreased axillary sweatingDecreased axillary sweating
Definitive diagnosisDefinitive diagnosis Resolution of ARF after restoration of renal Resolution of ARF after restoration of renal
perfusionperfusion
IntrinsicIntrinsic Increased muscular activity (Rhabdomyolysis)Increased muscular activity (Rhabdomyolysis) Recent transfusion (Hemolysis) Recent transfusion (Hemolysis) Flank pain Flank pain Hyperreflexia and asterixisHyperreflexia and asterixisPost renalPost renal Suprapubic pain (Acute distension of bladder)Suprapubic pain (Acute distension of bladder) Colicky flank pain radiating to groin Colicky flank pain radiating to groin Definitive diagnosisDefinitive diagnosis Radiologic investigation and rapid improvement Radiologic investigation and rapid improvement
in renal function after relief of obstruction in renal function after relief of obstruction
– 160 mg orally or IV twice daily) to effect – 160 mg orally or IV twice daily) to effect adequate diuresis and convert oliguric to non-adequate diuresis and convert oliguric to non-oliguric RF. oliguric RF.
ARF with cirrhosis (fluid challenge) paracentesis ARF with cirrhosis (fluid challenge) paracentesis with albumin administrationwith albumin administration
hour before and after procedure) hour before and after procedure) Use of less nephrotoxic contrast agent Use of less nephrotoxic contrast agent
(Gadolinium and CO(Gadolinium and CO22)) Cautious use of diuretics, NSAIDs, ACE inhibitorsCautious use of diuretics, NSAIDs, ACE inhibitors Lipid encapsulated formulation of amphotericin B Lipid encapsulated formulation of amphotericin B Allopurinol (Acute urate nephropathy)Allopurinol (Acute urate nephropathy) Amifostine an organic thiophosphate (Cisplatin) Amifostine an organic thiophosphate (Cisplatin)
Forced diuresis and alkanization of urine Forced diuresis and alkanization of urine (Rhabdomyolysis)(Rhabdomyolysis)
N Acetylcysteine within 24 hour N Acetylcysteine within 24 hour (Acetaminophen)(Acetaminophen)
htpertensive nephrosclerosis)htpertensive nephrosclerosis) Acute GN (pulse glucocorticoid therapy)Acute GN (pulse glucocorticoid therapy)
ANPANP 28 amino acid polypeptide. Synthesized in cardiac 28 amino acid polypeptide. Synthesized in cardiac
atrial muscle. Increased GFR by triggering afferent atrial muscle. Increased GFR by triggering afferent arteriolar vasodilatation and increasing ultrafiltration. arteriolar vasodilatation and increasing ultrafiltration. Inhibits Na transport and lower oxygen requirement. Inhibits Na transport and lower oxygen requirement.
Post renal ARFPost renal ARF Transuretheral or suprapubic placement of bladder Transuretheral or suprapubic placement of bladder
catheter (obstruction of urethra or bladder neck) catheter (obstruction of urethra or bladder neck) Percutaneous catheterization of dilated renal pelvis or Percutaneous catheterization of dilated renal pelvis or
ureter (ureteric obstruction) ureter (ureteric obstruction) Removal of obstructing lesion percutaneously or Removal of obstructing lesion percutaneously or
bypassed by insertion of ureteric stentbypassed by insertion of ureteric stent
Management of complicationManagement of complication
Intravascular volume overloadIntravascular volume overload Salt (1-2 gm/day) and water (<1 lt/day) restrictionSalt (1-2 gm/day) and water (<1 lt/day) restriction Diuretics, usually loop Diuretics, usually loop ++ thiazide thiazide Ultrafiltration or dialysis Ultrafiltration or dialysis
HyponatremiaHyponatremia Restriction of enteral free water intake (<1lt/day)Restriction of enteral free water intake (<1lt/day) Avoid hypotonic intravenous solution (including Avoid hypotonic intravenous solution (including
dextrose)dextrose)
HyperkalemiaHyperkalemia Restriction of dietary KRestriction of dietary K++ intake (<40 mmol/day) intake (<40 mmol/day) Eliminate KEliminate K++ supplement and K supplement and K++ sparing diuretic, sparing diuretic, Potassium binding ion-exchange resin (Na Potassium binding ion-exchange resin (Na
polystyrene sulphonate)polystyrene sulphonate) Glucose (50 ml of 50% Dextrose) and insulin (10 Glucose (50 ml of 50% Dextrose) and insulin (10
U regular) U regular) NaCONaCO33 (50-100 mmol) (50-100 mmol) Calcium gluconate (10 ml of 10% solution) over 5 Calcium gluconate (10 ml of 10% solution) over 5
HyperuricemiaHyperuricemia Treatment usually not necessary (<15 mg/dl)Treatment usually not necessary (<15 mg/dl)
NutritionNutrition Restriction of dietary protein (0.6 g/kg/day)Restriction of dietary protein (0.6 g/kg/day) Carbohydrate (100 g/day)Carbohydrate (100 g/day) Enteral / Parenteral nutritionEnteral / Parenteral nutrition
Indication for DialysisIndication for Dialysis
Clinical evidence (signs & symptoms) of uremia Clinical evidence (signs & symptoms) of uremia Intractable intravascular volume over loadIntractable intravascular volume over load Hyperkalemia Hyperkalemia Severe acidosis (resistant to conservative Severe acidosis (resistant to conservative
measures)measures) Prophylactic dialysis when urea >100-150 mg/dl Prophylactic dialysis when urea >100-150 mg/dl
or creatinine >8-10 mg/dlor creatinine >8-10 mg/dl
OutcomeOutcome
Mortality rate approximately 50%Mortality rate approximately 50% Poor prognosis – Oliguria (<400 mg) or serum Poor prognosis – Oliguria (<400 mg) or serum
creatinine (>3 mg/dl), older debilitated patient creatinine (>3 mg/dl), older debilitated patient and multiple organ failure at the time of and multiple organ failure at the time of presentation presentation
50% subclinical impairment of renal function 50% subclinical impairment of renal function 5% never recover (require dialysis or 5% never recover (require dialysis or
transplantation)transplantation) 5% progressive decline in GFR5% progressive decline in GFR