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ACUTE RENAL FAILURE
JAKUB ZÁVADA
KLINIKA NEFROLOGIE 1.LF UK
ACUTE RENAL FAILURE (ARF)
• ARF IS A CLINICAL SYNDROME CHARACTERIZED BY A RAPID DECLINE IN GLOMERULAR FILTRATION RATE (OVER HOURS TO WEEKS)
• ARF IS ACCOMPANIED BY – DISTRUBANCES OF
• EXTRACELLULAR FLUID VOLUME• ELECTROLYTE HOMEOSTASIS• ACID-BASE BALANCE
– ACCUMULATION OF NITROGENOUS WASTE PRODUCTS
• ARF IS OFTEN REVERSIBLE• ARF INCREASES MORBIDITY AND MORTALITY
ACUTE RENAL FAILURE
• PRERENAL – PHYSIOLOGICAL RESPONSE TO RENAL HYPOPERFUSION IN WHICH INTEGRITY OF RENAL PARENCHYMA IS PRESERVED
• INTRINSIC RENAL – CAUSED BY DISEASES OF RENAL PARENCHYMA
• POSTRENAL – ACUTE OBSTRUCTION OF URINARY TRACT
CAUSES OF PRERENAL ARF
• INTRAVASCULAR VOLUME DEPLETION– HEMORRHAGE, GASTROINTESTINAL, RENAL, SKIN AND
MUCOUS MEMBRANE, THIRD SPACE LOSSES
• DECREASED CARDIAC OUTPUT– DISEASES OF MYOCARDIUM, PERICARDIUM, VALVES ETC.
• SYSTEMIC VASODILATION– DRUGS, SEPSIS, LIVER FAILURE, ANAPHYLAXIS
• IMPAIRED RENAL AUTOREGULATION– ACEI, ATRA, NSAID
CAUSES OF INTRINSIC RENAL ARF
• SEVERE RENAL HYPOPERFUSION (+SIRS)• TOXINS
– EXOGENOUS (RADIOCONTRAST, NEFROTOXIC ANTIBIOTICS, ANTICANCER AGENTS )
– ENDOGENOUS (RHABDOMYOLYSIS, HEMOLYSIS, TUMORLYSIS, HYPERCALCEMIA, LIGHT Ig CHAINS)
• DISEASES OF LARGE RENAL VESSELS:– ATHEROEMBOLISM, THROMBOSIS OF RENAL ARTERY AND
VEIN• DISEASES OF SMALL VESSELS AND GLOMERULI
– GLOMERULONEPHRITIS AND VASCULITIS, TTP-HUS, MALIGNANT HYPERTENSION
• ACUTE DISEASES OF THE TUBULOINTERSTITIUM– ALLERGIC INTERSTICIAL NEPHRITIS, ACUTE BILATERAL
PYELONEPHRITIS
CAUSES OF POSTRENAL ARF
• BILATERAL OBSTRUCTION OF URETHERS
• OBSTRUCTION OF BLADDER NECK
• DISEASES OF PROSTATE GLAND
• OBSTRUCTION OF URETHRA
DIFFERENTIAL DIAGNOSIS OF ARF
• IS THE RENAL FAILURE ACUTE, ACUTE ON CHRONIC OR CHRONIC?
• IS THERE RENAL TRACT OBSTRUCTION?• IS THERE EVIDENCE OF TRUE
HYPOVOLEMIA OR REDUCED EFFECTIVE ARTERIAL BLOOD VOLUME?
• HAS THERE BEEN A MAJOR VASCULAR OCCLUSION?
• IS THERE EVIDENCE OF PARENCHYMAL RENAL DISEASE OTHER THAN ATN?
DIFFERENTIAL DIAGNOSIS OF ARF
IS THE RENAL FAILURE ACUTE, ACUTE ON CHRONIC OR CHRONIC?
• ARF:– RECENT INCREASE OF BUN AND SERUM CREATININ– CLINICAL AND HISTORY DATA CONSISTENT WITH ARF
• CRF:– PREVIOUSLY RECORDED ALTERED RENAL
PARAMETRES– HISTORY CONSISTENT WITH POSSIBLE CHRONIC
KIDNEY DISEASE (DM, HT, AMYLOIDOSIS, NSAID)– SEVERE ANEMIA, HYPERPHOSPHATEMIA,
HYPOCALCEMIA– ULTRASONOGRAPHY: SMALL, SHRUNKEN OR
POLYCYSTIC KIDNEYS
DIFFERENTIAL DIAGNOSIS OF ARF
IS THERE URINARY TRACT OBSTRUCTION?
• CLINICAL POINTS: – SUPRAPUBIC PAIN, PALPABLE BLADDER DISTENTION– HISTORY OF PROSTATIC DISEASE (NOCTURIA,
FREQUENY, HESITANCY)– COLICKY PAIN WITH IRADIATION TO THE GROIN– HISTORY OF MALIGNANCY IN PELVIS– HISTORY OF NEUROGENIC BLADDER
• IMAGING– ULTRASOUND, CT, MRI, IVU
DIFFERENTIAL DIAGNOSIS OF ARFIS THERE EVIDENCE OF TRUE HYPOVOLEMIA OR REDUCED EFFECTIVE ARTERIAL BLOOD VOLUME?
• HISTORY– BLEEDING, LOSS OF SOLUTES, LOW FLUID INTAKE – HEART OR LIVER FAILURE– NSAID, ACEI, ATRA
• SIGNS– ORTOSTATIC HYPOTENSION, TACHYCARDIA, DRY
MUCOUS MEMBRANES, LOW JUGULAR VENOUS PRESSURE, OLIGURIA, SEPSIS/SIRS
• LABORATORY AND URINARY FINDINGS– HEMOCONCENTRATION, UREA/KREATININ, SPEC.
GRAVITY OF URINE, U-Na
• INVASIVE MONITORING– CENTRAL VENOUS PRESSURE, SWAN-GANZ CATHETR
DIFFERENTIAL DIAGNOSIS OF ARF
HAS THERE BEEN A MAJOR VASCULAR OCCLUSION?
• ATHEROEMBOLISM– RECENT INSTRUMENTATION IN AORTA, AGE OVER 50,
SEVERE ATHEROSCLEROSIS, WARFARIN– PURPURA, LIVEDO RETIKULARIS– EOSINOPHILIA, HYPOCOMPLEMENTEMIA– RENAL BIOPSY
• TROMBOSIS OF RENAL ARTERY– HISTORY OF ATRIAL FIBRILLATION, RECENT MI– NAUSEA, ABDOMINAL PAIN, FLANK PAIN– ANGIOGRAPHY, AG-CT, MRI
• TROMBOSIS OF RENAL VEIN– NEPHROTIC SYNDROME, PULMONARY EMBOLISM– AG, AG-CT, MRI, DOPPLER US
DIFFERENTIAL DIAGNOSIS OF ARF
IS THERE EVIDENCE OF PARENCHYMAL RENAL DISEASE OTHER THAN ATN?
• HISTORY AND PHYSICAL EXAM– ARTHRALGIAS– SKIN CHANGES– PULMONARY AND ETN DISORDER– MALIGNANT HYPERTENSION
• URINANALYSIS– ACTIVE URINE SEDIMENT (PRU>1g/d, ERY-U)
• LAB – SIGNS OF MICROANGIOPATIC HEMOLYSIS– IMUNOLOGY (ANCA, ANA, C3, C4, ANTI-GBM, APLA)
• RENAL BIOPSY
ACUTE TUBULAR NECROSIS (ATN)
• ETIOLOGY– ISCHEMIA– TOXINS– SIRS/SEPSIS
• PATOPHYSIOLOGY– VACUOLATION, LOSS OF BRUSH BORDER,
APOPTOSIS/NECROSIS OF TUBULÁR CELLS– INTRARENAL VASOCONSTRICTION, IMPAIRED RENAL
AUTOREGULATION– INTRATUBULAR OBSTRUCTION – INFILTRATION BY NEUTROPHILS AND MACROPHAGES
• PROGNOSIS– UNCOMPLICATED ATN REVERSES IN 2-3 WEEKS– CORTICAL NECROSIS IS IRREVERSIBLE
ACUTE TUBULAR NECROSIS (ATN)
DIFF.DG. OF PRERENAL AZOTEMIA AND ATN:
• PRERENAL AZOTEMIA:– ADEQUATE KIDNEY RESPONSE TO VOLUME DEPLETION:
• ↑ URINE OSMOLALITY (U-OSM>500 mOsm/kg)• ↑ SPECIFIC GRAVITY (>1,018)• LOW URINARY SODIUM (U-Na<10 mmol/l, FeNa <1%)
– RAPID RESTORATION AFTER VOLUMEXPANSION
• ATN:– DISTURBED CONCENTRATING AND
VOLUMEREGULATORY KIDNEY FUNCTION:• ↓ URINE OSMOLALITY (U-OSM<250 mOsm/kg)• ↓ SPECIFIC GRAVITY (< 1,012)• HIGH URINARY SODIUM (U-Na > 20 mmol/l, FeNa > 2%)
NEFROTOXIC AGENTS• HEME PIGMENTS
– MYOGLOBIN – RHABDOMYOLYSIS• MUSCLE TRAUMA, ETHANOL, SEIZURES, LIMB ISCHEMIA,
STATINS, FIBRÁTES• ↑ CK, MYOGLOBIN IN PLASMA
– HEMOGLOBIN – HEMOLYSIS• INKOMPATIBILE TRANSFUSION, AIHA, SNAKE VENOM,
MALÁRIA, G6PDH DEFICIENCY, PNH
• RADIOCONTRAST• NEPHROTOXIC DRUGS
– NSAID, ACEI, ATRA– AMINOGLYKOSIDS, AMFOTERICIN B, PENTAMIDIN,
ACYCLOVIR– CYCLOSPORINE, TAKROLIMUS– CISPLATINE, IFOSFAMIDE
• ETHYLENGLYKOL, HEAVY METALS, HERBAL REMEDIES
ACUTE RENAL FAILURE – COMPLICATIONS
• HYPERVOLEMIA• HYPERKALEMIA• METABOLIC ACIDOSIS• UREMIA• HYPERURICEMIA• HYPOCALCEMIA, HYPERPHOSFATEMIA• RECOVERY PHASE OF ARF
– POLYURUIA– HYPERNATREMIA, HYPOKALEMIA, HYPOMAGNESEMIA,
HYPOPHOSFATEMIA
ACUTE RENAL FAILURE– MANAGEMENT
• PRERENAL ARF → RESTORATION OF RENAL PERFUSION– REPLACEMENT OF FLUID LOSSES (CRYSTALOIDS,
COLLOIDS)– MANAGEMENT OF CIRCULATORY FAILURE (INVASIVE
HEMODYNAMIC MONITORING, TREATMENT OF HEART FAILURE, IONOTROPES, VASOACTIVE DRUGS)
• POSTRENAL ARF → RELIEVE OBSTRUCTION – MULTIDISCIPLINARY APPROACH (RADIOLOGIST,
UROLOGIST, NEPROLOGIST)– URINARY BLADDER CATHETER– NEPHROSTOMY
ACUTE RENAL FAILURE– MANAGEMENT
INTRARENAL ARF • PREVENTION
– OPTIMAL HYDRATION OF PATIENTS AT RISK – MONITORING OF LEVELS OF AMINOGLYCOSIDES AND
CYKLOSPORINE – N-ACETYLCYSTEINE? – CAVE ACEI, NSAID, DIURETICS
• SUPPORTIVE TREATMENT– ADRESSING COMPLICATIONS (ACIDOSIS, ELECTROLYTE
ABNORMALITIES, HYPERVOLEMIA)– DIALYSIS (OR HEMOFILTRATION)
• TREATMENT OF SPECIFIC CAUSES OF ARF– TTP-HUS, RPGN, ATIN
ACUTE RENAL FAILURE – INDICATIONS OF DIALYSIS
• UREMIA
• HYPERKALEMIA
• HYPERVOLEMIA
• SEVERE ACIDOSIS