Acute Renal Failure

Introduction
Glomerular Filtration Rate (GFR) Decrease
Rapidly (all kinds of causes)
Broad Sense: Pre-renal; Intrinsic Renal Disease;
Post-renal
Narrow Sense: Acute Tubular Necrosis
Involve All Specialized Subject
 Acute Renal Failure
Causes
Ischemia: Shock 、 Hypovolemia
Renal Toxicant :Medicine （ Aminoglycoside
Antibiotic, Mannitol etc ）
Contrast Medium
Chemical Poison — Arsenism
Biological Poison
 Acute Renal Failure
Cause—Medicine
There is no medicine without effect.
There is effect we can’t see.
There is no medicine without side-
effect.
There is side-effect we can’t see.
Drug-induced ARF
Others
37%
NSAIDs
16%

Antibiotic
34%

R.C.M
13%
 Acute Renal Failure
Mechanism
（ 1 ） Hemodynamic Changes ： Sympathetic N
、
RAS 、 PG-K 、 NO-ET
（ 2 ） Tubular Epithelium Cell Dysfunction
（ 3 ） Tubular Epithelium Cell Exfoliate 、 Cast
Form
（ 4 ） Urine Reflux
 Acute Renal Failure
Pathology
• Ischemia: Parts of Tubule unequally
Degenerate and Necrosis 、 GBM Break
• Toxication: Proximal tubule equally
Degenerate and Necrosis 、 GBM is Intac
t.
 Acute Renal Failure
Clinical Manifestation
Oliguric stage 5-14d ; 3-4w(few)
Oliguria,Edema:<400ml/d ; without Oliguria (minority)
Multi-systematic Symptom ： Nausea and Vomiting 、
Heart Failure 、 Pulmonary Edema 、
Hemorrhagic Tendency 、 Nervous-
mental symptom
Urine ： Specific Gravity 、 Proteinuria 、 Hematuria 、 Cast U
ne
Cr 、 BUN 、 Acidosis 、 Hyperpotassaemia
Polyuric Stage 1-3 W
Urine Volume Increase >500ml/d approach
3000-5000ml
Body Weight 、 even Dehydration
Urine Recover
Cr 、 BUN probably Electrolyte Disturbance
Convalescent Stage 3-6M
All Indexes Recover Specific Gravity is normal
completely Recover
 Acute Renal Failure
Diagnosis
（ 1 ） History:Hypovolemia+Renal Toxic Drugs
（ 2 ） usually without Anemia and Hypoproteinemi
a
（ 3 ） Nephrauxe
（ 4 ） Test of Nail Cr
（ 5 ） Renal Biopsy
 Acute Renal Failure
Differential Diagnosis
Differential Diagnosis of Oliguria
——Oliguria is not only the first symptom of
ARF,but also the definite sign of pre-ren
al hypoperfusion ， the treatment is diffe
rent.
Putting Zhang’s hat on Li’s hat
may break out at any moment,
putting Li’s hat on Zhang’s hat
may snow plus frost.
 Acute Renal Failure
Differential Diagnosis
Pre-renal Oliguria ATN
Specific gravity >1.020 <1.
015
Urinary Precipitate Normal Protein 、 Ca
st
Urinary 0smotic pressure >550mOsm/L <350mOsm/L
Urine/Blood 0smotic pressure >2:1 <1.1:1
Urinary sodium concentration <20 >40
UCr/SCr >40:1 <
10:1
BUN/SCr >20:1 <1
0:1
NaKF <1
>1
RFI <1
>2
Experimental treat Good reaction No reaction
 Oliguria 、 Anuria

5-10%GS 500ml or + Dopamine 40mg

Urine Volume Urine Volume(-)

20% Mannitol 100-200 m

l iv

Urine volume  Urine volume(-)

Lasix 60-100mg iv

Good Reaction  No Reaction

Hypovolemia ARF

Method and Approach of experimental fluid

infusion and diuresis provocative test
 Acute Renal Failure
Treatment
“Waiting”is the best way
——“go to bed”
“Waiting”the coming of polyuria
—— the light of life.
Attitude should be active
—— but Action should be slow.
 Acute Renal Failure
Treatment
 Limit water:
 It’s TOTAL FLUID INTAKE that counts,
not water the patient drinks
 Limit salt:
 It’s TOTAL SODIUM INTAKE that counts,
not salt the patient takes in
 Acute Renal Failure
Treatment
Emergency Treatment of Hyperpotassemia
Dialysis （ HD+PD ）
5% NaHCO3 100ml iv
5%GS 50ml+RI 10u iv
10% Calcium Gluconate 10ml iv
Ion-exchange Resin Po
 Acute Renal Failure
Treatment
Index of Acidosis
Index: Deep Breath 、 Central Inhibition 、 Blood Ga
s
Analysis
Begin from 5%NaHCO3 100ml
Dialysis
Acute Left Heart Failure 、 Pulmonary Edema
Hyperpotassemia >6.5ml/L
Acidosis PH<7.25 CO2CP <13mmol/L
High Catabolism Cr>176.8μmol/L/d BUN>8.9mmol/L/d
 Acute Renal Failure
Severe ARF
Effective Treatment CRRT
Continuous Renal Replacement Therapy

Advantage ：
Mild Effect on Hemodynamics.
Liquid Balance ， no Disturbance Syndrome.
Internal Environment is more stable.
 Acute Renal Failure
Famous Saying
 NO drug make the tubular cells to
regenerate
 MANY drugs may be hazardous to
kidney
 STOP unnecessary drugs is
crucial
 NECESSARY drug using should be
monitored
 Acute Renal Failure
Famous Saying
 Allsubstances are poisons;
 There is none which is not a poison.

 The right dose differentiates a poison and a remedy

 ---- Paracetsus 1493- 1541