ACUTE RENAL FAILURE

Syakib Bakri, Hasyim Kasim, Haerani Rasyid

*Division of Nephrology, Department of Internal Medicine Faculty of Medicine, Hasanuddin University

Acute Renal Failure

An abrupt and sustained decrease (days to weeks/within 48 hours) in renal function resulting in retention of nitrogenous (urea and creatinine) and non-nitrogenous waste products.

Depending on severity and duration of the renal dysfunction, this accumulation is accompanied by metabolic dysturbance, such as metabolic acidosis and hyperkalaemia, changes in body fluid balance, and effects on many other organ systems.

Acute Renal Failure/Acute kidney injury

An acute and sustained increase in serum creatinine concentration of 0.5 mg% if the baseline is < 2.5 mg%, or an increase in serum creatinine concentration of > 20% if the baseline is > 2.5 mg%/. An Increase % more than or equal 50%/1.5 fold from base line Reduction in urine out put(documented oliguria of less then 0.5 ml/kg perhour for more than six hours)

TABEL 2 : RIFLE criteria ADQI Bellomo et al, Curr Opin Crit Care 2002;6:505-8

RIFLE Criteria for Acute Renal Dysfunction

Category GFR Criteria Risk Increased creatinin x1.5 or GFR decrease > 25% Increased creatinine x2 or GFR decrease > 50% Increase creatinine x3 or GFR decrease > 75%

UO Criteria UO < 0.5 ml/kg/h x 6 hr High Sensitivity

Injury

UO < 0.5 ml/kg/h x 12 hr

Failure

UO < 0.3 ml/kg/h x 24 hr or Anuria x 12 hrs

High Specivity

Loss ESKD

Persistent ARF = complete loss of kidney function > 4 weeks End Stage Kidney Disease (> 3 months)

GFR=Glomerular Filtration Rate ARF; Acute Renal Failure UO = Urine Output ESKD; End Stage Kidney Disease References : Bellomo R, Kellum JA, Mehta R, Palevsky PM, Ronco C. Curr Opin Crit Care. 2002 Dec; 8(6):505-8.

Acute Renal Failure

Oligouric
Non-oligouric

EPIDEMIOLOGY
1% of hospitalized patients
20% of patients treated in ICU 4-15% of patients after cardiovascular surgery Cause of mortality 1. (75%) : Sepsis/multy organ dysfuntion syndrome 2. Cardiopulomonal( 50%)

Acute Renal Failure

Dialysis Treatments
Creatinine M/l Urine l/day

Zllner, Innere Medizin, modified

Time / days

1. Damage Damage to Renal Tissue (minutes to days)

2. Oliguria / Anuria Complete Loss of Renal Function (up to 6 weeks)

3. Polyuria Uncontrolled Urine Quantities (1 - 2 weeks)

4. Recovery slow Recovery of Renal Function (several months)

Prerenal

35 %

CLASSIFICATION OF ACUTE RENAL FAILURE

Renal

50 %

Postrenal

10 %

ACUTE RENAL FAILURE

PRERENAL

Absolute decrease in effective blood volume Haemorrhage Volume depletion

Relative decrease in blood volume (ineffective arterial volume) Congestive heart failure Decompensated liver cirrhosis
Arterial occlusion or stenosis of renal artery

Haemodynamic form NSAIDs ACE-inhibitors or angiotensin-II receptor antagonists in renal-artery stenosis or congestive heart failure

Hypovolemia

Baroreceptor activation

Reduced affective circulation volume

Respons neurohormonal

Axis renin-angiotensin aldosterone

Vasopressin

Sympathetic nervous system

Vasoconstriction contraction of mesangial cells Reabsorpsi natrium and water

Reduced renal blood flow and glomerular filtration rate

Acute renal failure pre-renal

ACUTE RENAL FAILURE

INTRINSIC RENAL

Vascular Vasculitis, Malignant HT

Glomerulonephritis

Acute interstitial nephritis Drugs Allergy

Acute tubular necrosis

Ischaemic (50%)

Nephrotoxic (35%)

Exogenous Antibiotics (gentamicin) Radiocontrast agents Cisplatin

Endogenous Intratubular pigments (haemoglobinuria, myoglobinuria) Intratubular proteins (myeloma) Intratubular crystals (uric acid, oxalate)

ACUTE RENAL FAILURE

POSTRENAL

Obstruction of collecting system or extrarenal drainage

Bladder-outlet obstruction Bilateral ureteral obstruction or unilateral in one functioning kidney

Causes for Kidney Failure Location of the Cause?

Upstream of the Kidney - prerenal Heavy Blood Loss Stenosis of the Renal Artery ...

Within the Kidney - intrarenal Drugs Diabetes Inflammatory Diseases ...

Downstream of the Kidney - postrenal Prostatic Hypertrophy Renal Calculus ...

RENAL ANAEMIA

Assessment of a Patient with Acute Renal Failure (1)

Procedure
Clinical history and examination

Information Sought
Clues to the cause of acute renal failure Indicators of severity of metabolis disturbance Estimate of volume status (hydration) Markers of glomerular or tubulointerstitial inflammation, urinary tract infection or crystal uropathy To assess extent of GFR reduction and metabolic consequences To differentiate prerenal from established renal failure To determine presence of anemia, leucocytosis, and platelet consumption

Urinalysis and urine microscopy

Plasma biochemistry

Urine biochemistry

Full blood count

Findings that suggest prerenal causes Volume depletion Congestive heart failure Severe liver disease or other edematous state Findings that suggest postrenal causes Palpable bladder or hydronephrotic kidneys Enlarge prostat Abnormal pelvic examination Large residual bladder urine volume History of renal calculi (perform USG to screen obstruction) Findings that suggest intrinsic renal disease Hypotension, exposure to nephrotoxic drugs Recent radiographic procedure with contrast

Finding in the urine sediment

If no abnormalities: suspect prerenal or postrenal azotemia
If eosinophils: suspect acute interstitial nephritis If red blood cell casts: suspect glomerulonephritis or vasculitis If renal tubular ephitelial cells and muddy brown casts: suspect acute tubular necrosis

Assessment of a Patient with Acute Renal Failure (2)

Procedure
Renal ultrasound Plus, where appropriate : Abdominal CT-Scan To define structural abnormalities of the kidneys or urinary tract To assess abnormal renal perfusion To evaluate / relieve urinary tract obstruction

Information Sought
To determine kidney size, presence of obstruction, abnormal renal parenchymal texture

Radionuclide scan Cystoscopy +/- retragrade pyelograms Renal biopsy

To define pathology of renal parenchymal disease

WHEN ?

Reverse An-/Oliguria to Normouria -volume replacement -osmotic diuresis (mannitol 12.5-25 g in 30m) -forceed diuresis (furosemide 40-300mg/4-6h) -correct acidosis & hyperkalemia) -reverse hypercatabolism)

Maintain homeostasis -electrolite imbalance -Nutrition -Normohydration -Acid-base balance

Avoid hypovolemi Caused by polyuria

Increase metabolism
Avoid persistent Causative of decrease RF

-RENAL -REPLACEMENT -& SUPPORT

Management priorities in patients with acute renal failure

Search for and correct prerenal and postrenal factors.

Review medications and stop administration of nephrotoxins.

Optimise cardiac output and renal blood flow. Monitor fluid intake and output; measure bodyweight daily. Search for and treat acute complications (hyperkalaemia, hyponatraemia, acidosis, hyperphospataemia, pulmonary oedema). Provide early nutritional support. Search for and aggressively treat infections.

Expert nursing care (management catheter care and skin in general; physicological support).
Initiate dialysis before uraemic complication emerge. Give drugs in doses appropriate for their clearance.

Indications for dialysis in acute renal failure

Indications
Uremia

Characteristics
Asterixis, seizures, nausea & vomiting, pericarditis

Hyperkalemia

K+ >6.5 mmol/L; K+ 5.5-6.5 mmol/L if ECG changes Fluid overload resistant to diuretics, especially pulmonary edema

Fluid overload

Metabolic acidosis

pH < 7.2 despite sodium bicarbonate therapy; sodium bicarbonate not tolerated because of fluid overload

Proposed criteria for the initiation of renal replacement therapy in adult critically ill patients

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Oliguria (urine output < 200 ml/12 hr) Anuria/extreme oliguria (urine output < 50 ml/12 hr) Hyperkalemia ([K+] > 6.5 mmol/liter) Severe acidemia (pH < 7.1) Azotemia ([urea] > 30 mmol/liter) Clinically significant organ (especially lung) edema Uremic enchepalopathy Uremic pericarditis Uremic neuropathy/myopathy Severe dysnatremia ([Na] > 160 or < 15 mmol/liter) Hyperthermia/Hypothermia Drug overdose with dialysable toxin

WHEN ?

The presence of : - one of the above criteria is sufficient to initiate renal replacement therapy in a critically ill patients - two of these criteria makes renal replacement urgent and mandatory. - combined derangements suggest initiation of renal replacement therapy even before the above mentioned limits have been reached.

CAVH
Willem KOLF 1943-1944 Dialysis in 15 pts (1 survived)l

KRAMER 1977

CAVHD CVVHD CAVHF CVVHF CAVHDF CVVHDF

IHD

HD
Renal Replacement
Belding SCRIBNER 1960, begin chronic dialysis

HYBRID DIALYSIS

EDD CAPD Fred BOEN 1961 SLED

George Haas 1914-1915 Dialysis in Animal

PD
SELLIGMENT & FINE 1945

APD

Dialysis modalities for acute renal failure

Intermittent therapies (up to 12 hours)

Hemodialysis intermittent daily Hemodiafiltration Slow Continous Ultra-Filtration Extended Daily Dialysis Sustained Low Efficient Dialysis

Continuous therapies (24 hours)

Peritoneal dialysis Ultrafiltration (SCUF) Hemofiltration (CAVH, CVVH) Hemodialysis (CAVHD, CVVHD) Hemodiafiltration (CAVHDF, CVVHDF)

Adapted from Mehta RL. Supportive therapies; intermittent hemodialysis, continuous renal replacement therapies and peritoneal dialysis. In : Schrier RW, editor. Atlas of diseases of the kidney, Current Medicine, Philadelphia: Blackwell Science; 1998: with permission.

WHICH ?

# Proses difusi ( Perpindahan molekul melalui membran semi permeable Dengan cara difusi) # Dipengaruhi oleh : - berat molekul - perbedaan konsentrasi - Resistensi/ jenis membran # Proses Filtrasi (Perpindahan cairan dengan cara convective) # Dipengaruhi oleh : - Perbedaan tekanan (transmembrane) - Koefisien ultrafiltrasi

Proses difusi dan ultrafiltrasi

Dengan dialisis darah dibersihkan dengan proses difusi dan filtrasi Melalui membran semi-permeable dalam Ginjal Buatan Darah kotor masuk dialisat

Darah bersih

Proses yang terjadi

dialisat masuk

Proses difusi

Proses Filtrasi ultrafiltrat keluar UltraFiltrat Darah bersih keluar Darah

GINJAL BUATAN

Membran semi-permeable Didalam ginjal buatan

a. Modifikasi proses dialysis, dengan - Qb = 150 cc/menit - Qd = 300 cc/menit - tD = 6 12 jam / hari b. Dimulai Juli, 1998 di University of Arkansas, Amerika
c. Indikasi untuk ARF dengen hemodinamik tidak stabil d. Merupakan alternatif terapi dari CAVHD atau CVVHD e. Biasanya menggunakan Mesin Fresenius 4008, dengan ginjal BUKAN Cellulosa Acetate

THANK YOU