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Acute renal failure (ARF) is characterised by a rapid fall in glomerular filtration rate,
clinically manifest as an abrupt and sustained rise in urea and creatinine.1 Definitions of
acute renal failure range from severe (i.e. requiring dialysis) to slight increases in serum
creatinine concentration. In the absence of a universal definition, acute renal failure is
often defined as a significant deterioration in renal function occurring over hours or
days.2 There may be no symptoms or signs, but oliguria (urine volume less than 400
mL/24 hours) is common. There is an accumulation of fluid and nitrogenous waste
products demonstrated by a rise in blood urea and creatinine.
Causes of acute renal failure1
• Prerenal:
• Intrinsic ARF:
• Eclampsia
• Post-renal:
• Calculus
• Blood clot
• Πα π ι λ λ α ρ ψ νεχ ρ ο σ ι σ
• Υρ ε τ η ρ α λ στρ ι χ τ υ ρ ε
• Πρ ο σ τ α τ ι χ ηψ π ε ρ τ ρ ο π η ψ or malignancy
• Βλα δ δ ε ρ τυµ ο υ ρ
• Radiation fibrosis
• Pelvic malignancy
Ρε τ ρ ο π ε ρ ι τ ο ν ε α λ φιβρ ο σ ι σ
Epidemiology
• Recent studies have found an overall incidence of acute renal failure of almost
500 per million per year and the incidence of acute renal failure needing dialysis
being more than 200 per million per year.1
• Prerenal ARF and ischaemic acute tubular necrosis together account for 75% of
the cases of acute renal failure.3
Risk factors1
People with the following comorbid conditions are at a higher risk for developing ARF:
• Elderly
• Hypertension
• Vascular disease
• Χο ν γ ε σ τ ι ϖ ε χαρ δ ι α χ φα ι λ υ ρ ε
• ∆ιαβ ε τ ε σ
• Myeloma
• Chronic infection
Μψ ε λ ο π ρ ο λ ι φ ε ρ α τ ι ϖ ε δισο ρ δ ε ρ
Presentation
The presentation will depend on the underlying cause and severity of acute renal failure.
The first indication may be a raised urea and creatinine on a blood test in a patient with
non-specific symptoms and signs.
Symptoms
• Urine output:
• Nausea, vomiting
• Dehydration
Χο ν φ υ σ ι ο ν
Signs
• Hypertension
• Fluid overload with raised JVP, pulmonary oedema and peripheral oedema
• Pallor, rash, bruising: petechiae, purpura, and nose bleeds may suggest
inflammatory or vascular disease, emboli or disseminated intravascular
coagulation
• Pericardial rub
Assessment1
• Palpable bladder
• Consider hypovolaemia:
• Risk factors include use of ACE inhibitors and diuretics in patient with
renal artery stenosis, hypotension or instrumentation of the renal artery or
aorta.
• Chronic renal failure: factors that suggest chronic renal failure include:
• Nocturia
• Anaemia
• Reduced renal size and cortical thickness on renal ultrasound (but renal
size is typically preserved in patients with diabetes
• Urinalysis:
• Biochemistry:
• Serum creatinine has significant limitations. The level can remain within
the normal range despite the loss of over 50% of renal function.
• Haematology:
• Immunology:
• Virology:
• Radiology:
Ρενα λ βιο π σψ
Management
Principles of management of acute renal failure1
• Advice from a nephrologist should be sought for all cases of acute renal failure, as
early consultation can improve outcomes.
• No drug treatment has been shown to limit the progression of, or speed up
recovery from, acute renal failure.
• Review drugs: stop nephrotoxic agents; adjust doses and monitor concentrations
where appropriate.
• Identify and treat bleeding tendency: prophylaxis with proton pump inhibitor or
H2 antagonist, transfuse if required, avoid aspirin.
• Renal specialists are not necessary for provision of renal replacement therapy, as
this can be initiated promptly in most intensive care units by continuous
venovenous haemofiltration.
Accurate control of fluid balance (avoid volume overload or depletion)
• The situation may change rapidly and so daily clinical assessment, measurement
of body weight and CVP monitoring are required.
• In the slightly longer term, potassium-binding resins can be used if dialysis is not
immediately available.
• It is important to maintain adequate nutrition, preferably via the enteral route, but
using parenteral nutrition if necessary.
• Nitrogen balance can be complex, especially with a hyper catabolic state and
possible gastrointestinal bleeding, and diarrhoea.
• Sodium bicarbonate may be used cautiously to treat acidosis, but may worsen
sodium overload.
Hyperglycaemia adversely affects the prognosis for patients with acute renal failure;
there has been shown to be a reduction in mortality and morbidity of critically ill
patients with strict control of blood glucose concentration.3
Prevention of infection
• Blood transfusion
• Acute renal artery thrombosis (of a single functioning kidney) may be treated
surgically, or by angioplasty and stenting.
• Haemolytic uraemic syndrome may respond to plasma exchange with fresh frozen
plasma.
Dialysis or haemofiltration
• In oliguric or anuric patients, the fluid intake required for feeding generally means
that dialysis will be necessary.
• Refractory hyperkalaemia
• Acidaemia (pH<7.0)
• Hyperthermia
Complications
Life threatening complications include:
• Hyperkalaemia
• Metabolic acidosis
• When acute renal failure is severe enough to need dialysis, in-hospital mortality is
around 50%, and it may exceed 75% in the context of sepsis or in critically ill
patients.1
• If there is not a significant return of renal function within 6 to 8 weeks this usually
means that there is end stage renal failure but rarely late recovery can occur.
• Patients who need dialysis have a higher mortality but this is a reflection of the
condition rather than a result of the treatment.
• Within an intensive care setting, mortality varies from 7.5% to 40% and outside
of intensive care from zero to 17%.
• The Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring
system indicates prognosis. In those who have a score between 10 and 19 the
mortality rate is 60% but with a score above 40 it approaches 100%.9
• Another system to help indicate prognosis and to aid classification for research
purposes is called RIFLE and was developed by the Acute Dialysis Quality
Initiative Workgroup. The first 3 items are risk, injury and failure. The last two
are outcomes or loss and end-stage renal failure.10
• Indicators of poor prognosis include older age, multiple organ failure, oliguria,
hypotension, number of transfusions and acute on chronic renal failure.
Prevention