Marcela Ramirez, MD
Abrupt ( hours or days) deterioration of
renal
function with decrease in GFR or tubular
injury compromising the kidney ability to
maintain fluid or electrolyte homeostasis
ARF Definition
1. An increase in serum creatinine of 0.5mg/dl or
greater
2. 50% increase in P Cr
3. A 50% reduction in calculated Cr Clearance
4. A decrease in renal function that warrants
dilaysis
The Acute Dialysis Quality Initiative Group
proposed the RIFLE system classification :
- Three severity categories:
Risk
Injury
Failure
- 2 clinical outcomes categories:
Loss
ESRD
An increase in BUN and creatinine >/50%
over baseline in 24h
Acute Azotemia
Intrinsic RF
Pre-renal Post renal
Reversible
Oliguria U/O < 400ml/ 24h
Asociated with ATN
Rarely Progresses to anuria unless it is
associated with sepsis
Anuria U/O <50ml/24h
Abrupt development suggest other
conditions:
-Renal vascular occlusion
- obstructive uropathy
- Severe cortical necrosis
Risk Factors ARF
Severity and duration of renal hypoperfusion
Exposure to nephortoxins
Pre-existing renal insufficiency
Age
Injury Severity score >17
Comorbidities (DM, PVD)
Bone Fractures
GCS <10
ALI requiring mechanical ventilation
Renal ischemia
central contributor in at least half of the
cases of ARF.
Causes: - Absolute loss of IV volume ( hemorrhage)
- Decreased effective IV volume
(sepsis)
- Diminished CO
- Meds ( NSAIDS, ACE-I, contrast)
Renal
perfusion
pressure
circulating volume MAP
renal blood flow GFR
Aldosterone and ADH (retain Na & H2O)
Concentrated urine with low Na ( u/o)
BUN reabsorbed tubules
Azotemia
Blockage of both urethers or urethra
Obstruction of urine flow
renal basal vascular tone renal blood flow
Reversible atrophy
CRF
Can be categorized according to the primary site of
injury within the renal parenchyma:
Glomerular disease (drugs & infections)
Interstitial nephritis (drugs, allergies, vascular injury)
Vasculopathy
ATN
Sudden drop U/O (< 0.5ml/Kg/h in 4h) or
daily Cr level (≥0.25mg/dl from
baseline)
Cr 1.5mg/dl (represent a 50% in GFR
R/O obstruction (foley, US)
R/O prerenal dysfunction
Surgical patients Renal perfusion (mcc
of oliguria)
Renal work + Renal perfusion
( O2 Consumption) ( O2 delivery)
ATN
Hypovolemia is the most common cause
Indications of PA catether
•Dependence of inotropes
•Poor baseline CO
•Evidence of large volume shifts
Decrease filtration : creatinine
BUN
Because Cr is not reabsorbed, Cr level rises more
slowly during low tubular flow rates.
Serum BUN increases more quickly than Cr.
A ratio BUN: Cr ≥ 15 Renal hypoperfusion
BUN is influenced by the patients metabolic
state.
BUN can also be : - Excesive protein intake
(nl renal Function) - Steroids
Prerenal Renal
azotemia Dysfunction
Plasma BUN:Cr >20 <10
Urine Osmolality >500 or >100 <350 or < plasma
over plasma
U specific gravity >1.020 <1.010
U Na <20meq/L >30meq/L
FENa <1% 2%
U Cr/ P Cr >40 <20
FENa: U Na x P Cr
P Na x U Cr
Accuracy decreases:
o Pre-existing renal insufficiency
o Recent diuretic use
o Eldderly patients
Diagnosis of Renal Parenchyma injury
GFR •the best measure of proportion of functional
nephron
•Can be estimated by Cr Clearance
•Maybe overstimated by CCr in early stages
Creatinine good marker for filtration through the glomerulus
Cr Clearance (140-Age) x Kg/ PCr x 72
Female 95 ±20 ml/min
Male 120 ±25 ml/min
Oliguria Increased Cr Cr > 0.25g/dl
in 24h
R/O Insert Foley
Obstruction Flush foley
US
BUN Cr >20
Prerenal? TC, Low filling preasure
No yes
Fluid
Challenge
No response
Intrarenal Injury/ Dysfunction
U Na >20
Intrarenal Injury/ Dysfunction U osm <300-400
FENa >1
Cast in urine
Transfuse Increased
Optimize preload DO2I
MAP >80
Diuretic
trial
Requires renal Nonoliguric
replacement renal injury
Hemodymically
stable
yes no
IHD Continues renal
replacement
Indications of Dialysis
Fluid overload
Severe uremia
Critical electrolyte abnormailties
Metabolic acidosis (pH 7.2)
Some toxins
Management of ARF
Prevention ( most important)
Maintenance of IV volume
Avoidance of hypotensive episodes
Minimization of toxic exposure
Aggressive treatment of infections
Early intervention
Nutrition (protein 2.5g/kg/day)
