Acute Renal Failure/ Acut kidney

injury
Pathogenesis and Treatment
dr. Lestariningsih SpPD KGH
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

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

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)

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

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

Hemodialysis

Outcome

Full recovery
Partial recovery
No recovery - progress to ESRF
Death

Conclusion
ARF is a life-threatening condition
Many cases can be avoided
Early diagnosis and expert treatment is
associated with a better outcome
ARF requiring specific treatment, especially
urinary tract obstruction and RPGN must not
be missed
Urgent treatment is needed for life-threatening
complications