Acute Renal Failure

Pathogenesis and
Treatment
Lestariningsih
Subbag Nefrologi/Hipertensi
Bagian Penyakit Dalam
FK UNDIP/RS Dr. Kariadi Semarang

Definition

Abrupt sustained decline in GFR

Rising serum urea and creatinine
Loss of water and salt homeostasis
Life threatening metabolic sequelae
Occurs over hours or days
Incidence approximately 140 p.m.p. per
year
5% of all surgical and medical admissions

Subtypes

Acute or acute on chronic

Single organ or multi-organ failure
Oliguric or polyuric
Mild or severe

Aetiology
Pre-renal ARF
Intrinsic ARF
Post-renal ARF

Pre-renal ARF
Reversible fall in GFR due to renal hypoperfusion
Hypovolaemia
Haemorrhage, burns, GI fluid loss, renal fluid
loss
Hypotension
Cardiogenic shock, sepsis
Renal hypoperfusion
renal vasoconstriction, drugs, liver disease, renal
vascular disease

Renal ARF
Disease of the renal parenchyma
ATN
Ischaemia, direct toxicity, myoglobin, sepsis

Vascular disease
Vasculitis, atheroemboli, infarction

Diseases of glomeruli/arterioles
RPGN, myeloma, HUS, vasculitis, SLE

Tubulo-interstitial nephritis
Drug related, paraneoplastic

Post-renal ARF
Renal failure secondary to urinary tract
obstruction
Ureteric
Calculi, carcinoma, retroperitoneal fibrosis,
stricture

Bladder neck
prostatic hypertrophy/malignancy, carcinoma,
neuropathy, blocked catheter

Prevention
Identify at risk patients
pre-existing CRF, diabetes, jaundice, myeloma,
elderly

Optimise renal perfusion

IV fluids, inotropes, central line

Maintain adequate diuresis

Mannitol, frusemide, NOT dopamine

Avoid nephrotoxic agents

ACE inhibitors, NSAIDS, radiological contrast,
aminoglycosides

Cockcroft Gault equation

(140-age in years) x weight in kg

serum creatinine (mol/L)
(corrected for males x 1.23, females x 1.04)

Principles of investigation

Acute or acute on chronic?

Exclude volume depletion
Exclude renal tract obstruction
Exclude major vascular occlusion
Exclude renal parenchymal disease other
than ATN

History
When did it start?
What was the baseline renal function?
Pre -existing medical conditions

What were the likely insults?

Episodes of hypotension
Nephrotoxic agents
Sepsis

Symptoms of other diseases

Examination
Current volume status
Skin turgor, oedema, lung bases, heart
sounds, central pressures, blood pressure

Bladder and kidneys

Signs of systemic disease
rashes, anaemia,

Investigations
Laboratory

U+Es, Bone, Glucose, Urate, Bicarbonate

Urine urea, sodium, creatinine, protein
FBC, Clotting, ESR
Urine microscopy, MSU, blood cultures
CRP, ANA, ANCA, anti GBM, myeloma
screen

Investigation
Radiology
Plain abdomen, renal U/S, IVU, CT
scanning, renal angiography, isotope
renography

Renal biopsy

Treatment
Correct renal perfusion
Optimise volume status
Inotropes ( dopamin 3 ug/kgBB/jam )

Remove nephrotoxins
Relieve obstruction
- Bladder catheter
Nephrostomies

Treatment
Make the patient safe
Hyperkalaemia
Volume overload
Uraemia
Acidosis

Specific treatments
Antibiotics, steroids

Methods of treatment
DRUG

DOSE

DURATION

Calcium Gluconate

10 ml of 10%

30 minutes

Glucose + Insulin

50 ml 50% + 8U

1 - 4 hours

IV Na Bicarbonate

1l of 1.4%

1 - 8 hours

Ventolin Nebuliser

5 ml

1 - 4 hours

Resonium

30 - 60 g (po/pr)

days

Bendrofluazide

5mg

days

and there is always dialysis!

Dialysis
Acute intermittent haemodialysis
Continuous dialysis treatments
Peritoneal dialysis

Outcome

Full recovery
Partial recovery
No recovery - progress to ESRF
Death