Acute Renal Failure Or The Kidney Is Your Friend

Katie Murphy MD September 2007

Katies Approach to Medical Topics

For any topic, I ask the following
questions:
What Is It? (Definitions, Classifications) Why Do I Care? (Prevalence, Morbidity, Mortality) What Do I Need to Do? (Workup)

What Is Acute Renal Failure ?

There is no universally accepted definition
of acute renal failure (ARF).

What Is Acute Renal Failure ?

There is no universally accepted definition
of acute renal failure (ARF). Commonly used definition is > or = to 0.5mg/dl increase in serum creatinine in 2 weeks or less if the baseline creatinine is less than 2.5mg/dl. If baseline creatinine is greater than 2.5mg/dl, ARF is defined as a greater than 20% increase.

What Is Acute Renal Failure?

Oliguric Renal Failure

What Is Acute Renal Failure?

Oliguric Renal Failure
Less than 500 ml urine output/day in adults

What Is Acute Renal Failure?

Oliguric Renal Failure
Less than 500 ml urine output/day in adults
Derived from the fact that a healthy kidney, if maximally concentrating the urine, will have to excrete 500 ml urine per day to get rid of the daily osmotic load from dietary intake and metabolic byproducts.

What Is Acute Renal Failure?

Oliguric Renal Failure
Less than 500 ml urine output/day in adults
Derived from the fact that a healthy kidney, if maximally concentrating the urine, will have to excrete 500 ml urine per day to get rid of the daily osmotic load from dietary intake and metabolic byproducts.

Anuric Renal Failure

What Is Acute Renal Failure?

Oliguric Renal Failure
Less than 500 ml urine output/day in adults
Derived from the fact that a healthy kidney, if maximally concentrating the urine, will have to excrete 500 ml urine per day to get rid of the daily osmotic load from dietary intake and metabolic byproducts.

Anuric Renal Failure

Less than 100 ml/day urine output

What Is Acute Renal Failure?

Oliguric Renal Failure
Less than 500 ml urine output/day in adults
Derived from the fact that a healthy kidney, if maximally concentrating the urine, will have to excrete 500 ml urine per day to get rid of the daily osmotic load from dietary

Anuric Renal Failure

intake and metabolic byproducts.

Less than 100 ml/day urine output Non-Oliguric Renal Failure

Chronic Kidney Disease

The new nomenclature for renal disease:
Stage 1 CKD: kidney damage but normal GFR (>90ml/min) Stage 2 CKD: mild kidney damage (GFR 60-89ml/min) Stage 3 CKD: moderate kidney damage (GFR 3059ml/min) Stage 4 CKD: severe kidney damage (GFR 1529ml/min) Stage 5 CKD: kidney failure (GFR < 15ml/min or ESRD on renal replacement therapy)

Why Do We Care ?
ARF occurs in 5% of hospitalized patients. ARF has been found to be related to a
20% mortality rate (often infectious or cardiorespiratory) When serum creatinine increases by >3.0mg/dl, mortality approaches 40-50% and thus prompt diagnosis and institution of appropriate treatment is crucial.

Etiologies of Acute Renal Failure

Pre-Renal Post-Renal Intrinsic or Intra-Renal

Pre-Renal Acute Renal Failure

Accounts for 60-70% of ARF. Etiologies:
True Volume Depletion (blood loss, dehydration) Effective Circulating Volume Depletion (CHF, sepsis) Hypotension (sepsis, meds, cardiogenic shock) ACE-Inhibitors NSAIDS Hepatorenal Syndrome

Post-Renal Acute Renal Failure

Accounts for 5-10% of ARF. Remember anatomy and have a
systematic approach. Etiologies include:
Ureteral: Tumors, stones, clot and lymphadenopathy Bladder: Tumors, stones, neurogenic, drugs Prostate: Hypertrophy, tumors Urethral: Strictures, tumors

Intrinsic Renal ARF

Accounts for 25-40% of
ARF. Again, remember the component anatomy
of the kidney.

Intrinsic Renal ARF

Accounts for 25-40% of ARF. Again, remember the component anatomy of
the kidney. Vessels: Vasculitis, Emboli Glomerulus: Nephrotic syndromes, Nephritic
Syndromes Tubules: Acute Tubular Necrosis, Rhabdomyolysis, Contrast Nephropathy

Interstitium(peri-tubular and peri-arteriolar

tissue) : Acute Interstitial Nephritis, Severe
Pyelonephritis.

What Do We Need to Do ?
First, you need to suspect acute renal
failure. Presentation of ARF:
include Malaise Hematuria Flank Pain Dyspnea

Most patients are asymptomatic, but symptoms

Hypertension Encephalopathy Pruritis Bleeding from platelet dysfunction Oliguria/Anuria

Edema

What Do We Need to Do Part 2

Now, we need to look for risk factors,
symptoms and signs History:
Drugs: Anticholinergics, IV Contrast, Aminoglycosides, Amphotericin. Classic AIN Medications:
Penicillins Cephalosporins Sulfa drugs NSAIDS Rifampin

History Continued
Causes of Volume Depletion Autoimmune Disease Previous History of ARF

Physical Exam
Volume Status:
Tachycardia Mucous membranes Orthostatics Vital signs

Physical Exam Continued

Dermatologic: Rashes, petechia, purpura
Abdomen: CVAT, enlarged bladder. Mental Status: Altered Mental Status CV: Pericardial friction rub

What Do We Need to Do ? Part 3

We need to act quickly to initiate workup Labs and Studies: Stat:
BMP UA with micro Una Ucr Uosm: >400 in pre-renal <350 in post-renal <350 in intrinsic renal

UA Interpretation
Hyaline Casts: Not indicative of renal disease
Concentrated urine, febrile disease, poststrenuous exercise, diuretic therapy Granular Casts: Degenerating cellular casts, non-specific RBC Casts: Glomerulonephritis, vasculitis WBC Casts: Pyelonephritis, Interstitial nephritis Renal Tubular Cell Casts: Nonspecific, degenerating cellular casts Waxy casts: Chronic renal failure

Labs and Studies Continued

In oliguric ARF, calculate FeNa: <1% (pre-renal, acute GN, contrast,
hepatorenal), >1% Intrinsic renal failure (Damaged kidney can not concentrate urine, loses Na) Una/Pna x 100 Ucr/PCr FeNa has a 96% sensitivity and a 95% specificity for distinguishing pre-renal from ATN. Not accurate with diuretics.

Studies and Labs Continued

Renal Ultrasound
r/o hydronephrosis Bilateral Small Kidneys: Chronic Renal Disease Unilateral Small Kidney: Renal Artery Stenosis Enlarged Kidneys: HIV, amyloid, PCKD, early DM

Treatment
Place Foley or flush Foley if already present. As a large percentage of ARF is pre-renal, IVF
challenge appropriate in many cases. Evaluate for life-threatening complications:
A: E: (I): O: U:

 Place Foley or flush Foley if already present. As a large percentage of ARF is pre-renal, IVF
challenge appropriate in most cases. Evaluate for life-threatening complications:
A: Acidemia E: Electrolyte Abnormalities (Hyperkalemia) (I: Ingestion) O: Overload (CHF) U: Uremic Encephalopathy or pericarditis ALL OF THE ABOVE ARE INDICATIONS FOR EMERGENT HEMODIALYSIS

Treatment

Treatment Continued
D/C all meds with kidney damaging potential
and adjust dosing of renally cleared meds. Monitor strict Is/Os, follow CBC to evaluate for anemia and bleeding disorders. Control hyperkalemia No longer recommended to give furosemide to convert anuric to oliguric renal failure. Consult renal for intra-renal or rapidly progressive renal failure.

An Ounce of Prevention...
Check troughs after third dose of
aminoglycosides. Use oral N-acetylcysteine or bicarbonate for contrast loads in patients with risk factors for ARF. Avoid diagnostic studies involving contrast unless absolutely necessary. Monitor Is/Os in patients with ESLD, febrile states, prolonged NPO.

Where Can I Learn More About Acute Renal Failure?

Acute Renal Failure Core Curriculum
Handout Thadhani, et. Al., Acute Renal Failure,NEJM, May 30, 1996 Review Article Agrawal,N., et. Al., Acute Renal Failure, APF 2000;61:2077-2088. Your local public library