RENAL FAILURE

Dr Uzma Bano
FCPS Medicine
• ACUTE RENAL FAILURE

vs.

• CHRNIC RENAL FAILURE

 Acute renal failure.
Loss of renal function in hours
or days.

•Is the kidney functioning?

•What caused it to fail?
•Can we restore renal function?
When does renal failure occur?
• Always in the setting of an acute illness
not of renal origin.
• In patients with multi organ failure.
• In the setting of shock from bleeding:
accidents, surgery, obstetrical
emergencies.
• Hypovolemia: gastroenteritis, sweating,
loss of fluid into body compartments like
paralyzed gut.
 How do we know the kidney is
functioning? .
A. Quantity of urine.
1. Normal. 500-> 1.5 litres.
2. OLIGURIA: less than normal. <400ml in
24 hours, <20 ml/hour. Less than
100ml/24 hours is ANURIA.
3. POLYURIA: more than normal >4-6 litres
in the absence of intake or signs of
dehydration if fluid is restricted.
 Is the kidney functioning? .
Quality of urine.
• Concentrating power. Specific gravity or
osmolality. Fixed at <1010 or failure to rise in the
presence of dehydration and low serum sodium.
• Abnormal sediment.
• Na concentrating power.
• Ratio of urinary creatinine to plasma creatinine.
• pH of urine vis a vis pH of blood.
 Biochemical parameters of renal
function.
• Blood or serum urea.
• Serum creatinine level.
• Serum Na, K levels.
• pH, HCO³ of blood.
• Glomerular filtration rate.
1. Creatinine clearance:
2. Cr EDTA GFR.
• Plasma osmolality.
2xNa+2xK+urea+sugar in mmols.
Rationale of biochemistry of blood.
• Excretion of waste products of
metabolism: urea, creatinine, uric acid.
• Regulation of electrolytes: sodium,
potassium, magnesium.
• Excretion of [H]: pH of blood.
• Conservation of HCO3: acidosis.
• Excretion solutes: plasma osmolarity.
What has caused renal failure?
• Low renal blood flow: hypovolemia caused
by loss of fluid from the vascular
compartment or loss of blood. PRERENAL
FAILURE.
• Disease of renal tissue: acute
glomerulonephritis, acute pyelonephritis.
INTRINSIC RENAL FAILURE.
• Obstruction to urine flow: both ureters
obstructed or POST-RENAL FAILURE.
 Clinical features of Acute Renal
Failure
• Anorexia, Nausea & vomiting.
• Drowsiness, apathy and confusion.
• Muscle twitching, hiccoughs
• Fits and Coma
• All these are late features. The ARF
should be detected early by looking for:
• Reduced urinary output < 20 ml/hour.
• High BUN or doubling of baseline serum
creatinine.
 Clinical setting of acute renal
failure.1
Case A. A 40 year old man had a road traffic accident. He fractured his right femur,
had a deep cut on the upper arm and injuries to his abdomen. Reached a hospital 6
hours later. He was conscious but disoriented, BP was 80/40, extremities were cold
and clammy. X ray confirmed # femur, broken ribs, a hemothorax. On ultra-sound of
abdomen the spleen was ruptured. His Hb was 6 gm/dl. He was given IV saline, 3
units of blood, and rushed to surgery. Splenectomy was done, a litre of blood-stained
fluid was removed from his abdomen, a chest tube was put in the chest and 600ml of
blood was aspirated, his femur was splinted and arm wound was stitched.4 hours
post-op he had passed only 20 ml of urine. Initial S creatinine was 1.1 mg/dl & 12
hours later the creatinine was 2.2 mg/dl.
Diagnosis : 1. Multiple injuries, blood loss: thigh, abdomen, thorax, arm.
2. Hypovolemic Shock causing low renal perfusion.
3. Acute renal shut down: low urine output, doubling of creatinine.
 Clinical setting of acute renal
failure. 2
Case 2. A 6 year old girl developed diarrhea and vomiting and was brought to the
hospital after 2 days. The mother had stopped giving her water and liquids
because of the vomiting. Profuse diarrhea persisted. On arrival her eyes were
sunken, tongue dry, eyeballs flaccid and she was crying without tears. Her hands
and feet were cold and clammy and breathing was deep and sighing. Her BP was
not recordable. The mother had not noticed if she had passed urine as there was
watery stool. The bladder was empty. She produce no urine out put after IV fluids
given to bring her CVP to 6cm of water.
Biochemistry. Hb was 12 gm/dl. Ph of blood was 7.1, HCO³ was 16 mmol/l, Serum
Na was 129 meq/l, serum K 2.6 meq/l, blood urea was 32 mmol/l, serum creatinine
was 4.5 mg/dl.
• acute gastro-enteritis.
• dehydration and hypovolemia and shock.
• acute renal failure with anuria and acidosis.
 Clinical setting of acute renal
failure.3
A 60 year old woman with diabetes was found
unconscious at home. She was not taking her
medication, had passed large amounts of urine, and had
become drowsy. In the hospital she was grossly
dehydrated, had an empty bladder and a BP of 90/60
though she was known to be hypertensive. Her blood
sugar was 408 mg/dl and ketone bodies were present in
her blood and bladder urine. Her urine output after IV
fluids was 10 ml/hour. Her blood urea was 120mg/dl, and
s. creatinine was 3.4mg/dl.
Diagnosis: diabetic keto-acidosis, dehydration, shock and
acute renal failure.
 Clinical setting of Hypovolemia.
• Acute gastro-enteritis. • Septicemic shock
• Profuse sweating. • Cardiogenic shock,
• Uncontrolled diabetes from MI, heart block,
• Tachyarrhythmia
Intestinal obstruction
• • Anaphylactic shock
Paralytic ileus
• • Acute drug reactions
Fluid loss from gastric
aspiration. • Transfusion reactions
• Burns. • Low serum sodium
• Acute pancreatitis. • Low or high serum K
 Blood loss and low volume.
• External injury • DIC. Disseminated
• Peri-operative intravascular
• Postoperative. coagulation,
• Ruptured hollow viscus. • Acute hemolysis.
• Ruptured solid organ. • Myoglobinuria.
• Antepartum hge. • Complement
• Postpartum hge. activation as in
• Hge into a body hemodialysis, bypass
compartment. surgery
• Crush injuries.
 Evidence of fluid retention.
• Breathlessness.
• Frothy sputum with cough.
• Falling O² saturation.
• Crackles at the lung base, bronchospasm.
• Peripheral edema.
• Enlarging liver.
• Batwing edema on the X ray chest.
 Management of early renal
shutdown.
• Replace volume: normal saline, plasma,
blood, plasma expanders.
• Renal dose of dopamine: 2mcg/ml/hour.
• Frusamide in large boluses or IV infusion.
• Monitor biochemistry.
• Monitor urine output.
• Check ABGs, pH, HCO³.
• Consider dialysis.
 Management of imbalances.
• ACIDOSIS: Patient’s HCO³ × .3 × base
deficit= required HCO³. Give 2/3 amount
of IV HCO3. Body will correct the rest.
• OSMOLARITY. 2Na×2K×urea × glucose.
• HYPERKALEMIA: Monitor ECG: tall T
waves, absent P, wide QRS complexes,
Ventricular fibrillation.
• Measure serum SODIUM.
 Indications for emergency
hemodialysis or peritoneal dialysis..
• Failure to improve renal functions with
conservative management.
• 10 mmol rise in urea/day.
• Serum creatinine >6mg/dl.
• HCO³ < 10mmol/l.
• Serum K >6meq/l.
• Pulmonary edema.
• Pericarditis, encephalopathy, uremic GI
hemorrhage.
 Prognosis in ARF.
• With early fluid replacement 80% will
recover.
• In severe bilateral cortical necrosis of
kidneys and multi organ failure no
recovery is possible.
• In burns, extensive injury, sepsis, DIC
mortality is > 40%.
Chronic Renal
Failure
The National Kidney Foundation - Kidney
Disease Outcomes Quality Initiative
(NKF-K/DOQI) workgroup has defined
CKD as
• The presence of markers of kidney damage for > or =3
months, as defined by structural or functional
abnormalities of the kidney with or without decreased
glomerular filtration rate (GFR), manifest by either
pathological abnormalities or other markers of kidney
damage, including abnormalities in the composition of
blood or urine, or abnormalities in imaging tests

OR

• The presence of GFR <60 mL/min/1.73 m2 for > or =3

months, with or without other signs of kidney damage
as described above.
 CKD Stages
• Stage 1 disease is defined by a normal GFR (greater than
90 mL/min per 1.73 m2) and persistent albuminuria

• Stage 2 disease is a GFR between 60 to 89 mL/min per

1.73 m2 and persistent albuminuria

• Stage 3 disease is a GFR between 30 and 59 mL/min per

1.73 m2

• Stage 4 disease is a GFR between 15 and 29 mL/min per

1.73 m2

• Stage 5 disease is a GFR of less than 15 mL/min per 1.73

m2 or end-stage renal disease
 Relative frequency
• • DM
• HTN
• Glomerulonephritis
• Acute tubular necrosis – 45 percent
• • Prerenal – 21 percent
• • Acute on chronic renal failure – 13 percent
• • Urinary tract obstruction – 10 percent
• • Glomerulonephritis or vasculitis – 4 percent
• • Acute interstitial nephritis – 2 percent
• • Atheroemboli – 1 percent
 Clinical Features
• Anorexia, nausea, vomiting, pericarditis,
peripheral neuropathy, and central nervous
system abnormalities ( lethargy, seizures, coma,
and death).
• Decreased or no urine output, flank pain,
edema, hypertension, or discolored urine.
• Asymptomatic elevations in urea, abnormalities
on urinalysis.
• Systemic symptoms and findings, such as fever,
arthralgias, and pulmonary lesions.
• Incidental findings (e.g., renal cyst or mass) on
radiographic testing performed for some other
reason.
 GFR Estimation
Cockcroft-Gault equation
Creatinine Clearance= (140-age)×weight in kg
72 ×S Creatinine in mg/dL

For example 68 yr old diabetic weighing 50 kg with

a plasma creatinine of 5 mg/dL
(140-68) × 50 = 10 ml/min
72 × 5
 Blood tests
• Blood CP- anemia of normochromic
normocytic type
• Electrolytes- Hypo/hypernatremia,
hyperkalemia, low bicarbonate, low
calcium, high phosphate, metabolic
acidosis
• Autoantibody screening
• Urine analysis
RADIOLOGIC STUDIES
• Plain film of the abdomen
• Ultrasonography
• Intravenous pyelogram
• CT scan
• Magnetic resonance imaging
• Renal arteriography
• Renal venography
• Radionuclide scans
• Voiding cystourethrogram
• Retrograde or anterograde pyelography
Indications for renal replacement
therapy
• Pericarditis
• Fluid overload or pulmonary edema refractory to
diuretics
• Accelerated hypertension
• Acidosis pH <7.1
• Hyperkalemia K> 6.0
• Progressive uremic encephalopathy or neuropathy,
• Bleeding diathesis attributable to uremia
• Persistent nausea and vomiting
• Plasma creatinine concentration above 12 mg/dL
(1060 µmol/L, urea of 200 mg/dl or GFR of 15 ml/min