acute renal failure arf
TRANSCRIPT
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Acute renal failureARF
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Definition
ARF is a clinical syndrome characterized byan abrupt decline in GFR and theaccumulation of nitrogenous waste (BUN & creatinine). The decrease in GFR occursrelatively rapidly, over the course of days toweeks. (By contrast, CRF develops overmonths or years.)
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Epidemiology of acute renal failure
• Common clinical syndrome• broad aetiological profile• 5 % of hospital admissions, 30 % of
admissions to ICU.
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Etiology
• prerenal (about 75 %),• intrinsic or parenchymal renal disease (25
%),• postrenal (5 %)
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Clinical approach to the diagnosis
• Is it ARF or acute-on-chronic renal failure?• Is there renal tract obstruction?• Is there reduction in effective ECF volume?• Has there been a major vascular occlusion?• Is there parenchymal renal disease other
than ATN?
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Is the renal failure really acute?Differential diagnosis
Acute renal failure• normal or enlarged
kidneys• no/mild anemia (BUT
HUS)• Ca & P normal
Chronic renal failure• smaller kidneys• severe anemia without
serious symptomes• nocturia, pruritus, long
lasting HT, neuropathy
• Ca⇓, P⇑, • abnormal biochemical
values / patient withoutserious symptomes
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• Urine volume– oliguria < 400 ml/day– anuria < 50 ml/day
• Serum chemistry– BUN (back-diffusion
depends on urine flowrate)
– creatinine
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Treatment of ARF
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Prerenal ARF
• Glomerular perfusion ⇓• GFR ⇓
• absence of any structural abnormality of the renal parenchyma
• rapidly and completely reversed• RBF sufficient to sustain the viability of
renal tubular cells (⇔ ATN)
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Acute tubular necrosis (ATN)
• Renal parenchymal injury caused by ischemia or exposure to nephrotoxins, which particularly injure the tubular epithelium.– Ischemic– nephrotoxins
• endogenous (e.g. myoglobin, light chains)• exogenous (e.g. drugs, heavy metals)
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Causes of acute interstitialnephritis (AIN)
1. Drug-related AIN2. Infection-related AIN3. Systemic diseases
lupus erythematosusSarcoidosisSjögren’s syndrome
4. Malignancy5. Idiopathic AIN
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CHRONIC RENAL FAILURE
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Diabetes: The Most Common Cause of ESRD
Primary Diagnosis for Patients Who Start Dialysis
United States Renal Data System. USRDS 2000 Annual Data Report. June 2000.
Diabetes50%
Hypertension27%
Glomerulonephritis
13%
Other10%
Patients (n)Projection95% CI
1984 1988 1992 1996 2000 2004 20080
100
200
300
400
500
600
700
r2 = 99.8%243,524
281,355520,240
No. of Dialysis Patients
(thousands)
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CHRONIC RENAL FAILURE
• The progression of chronickidney disease
• Uremia – clinical abnormalities• Renal anemia and renalosteodystrophy
• Renal replacement therapy
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Risk Factors for Renal Disease Progression
Proteinuria > 1.5 g/24 hrHypertensionType of underlying renal diseaseAfrican-American raceMale sexObesityDiabetes mellitusHyperlipidemiaSmokingHigh protein dietPhosphate retentionMetabolic acidosis
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The epidemiology of CKD
USA: 11 % of the population, around 20 million people haveCKD
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Treatment of Renal DiseaseProgression
• Goals:– stop or slow the rate of GFR
decline– prevent additional kidney damage
cused by superimposed events– maintain nutritional status and
prevent complications of the uremicsyndrome.
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Slowing the progresion of chronic kidneydisease
Tight blood pressure control (BP≤ 130/80 mm Hg) using:low sodium dietACE inhibitorsangiotensin receptor antagonistsdiureticscalcium channel blockers +…
Dietary protein restriction (0.8-1 g/kg bodyweight)
Glycemic controlDecreasing proteinuria
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CHRONIC RENAL FAILURE
• The progression of chronickidney disease
• Uremia – clinical abnormalities• Renal anemia and renalosteodystrophy
• Renal replacement therapy
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Uremic toxins
• Low molecular mass solutes: 10-3000 Da– urea, creatinine
• Middle molecules: 3000-15000 Da– PTH, ß2-microglobulin
• Large solutes: more than 15000 Da– myoglobin
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Major Clinical Abnormalities in Uremia I.
Water and electrolyte abnormalities:volume expansionhyperkalaemiametabolic acidosishyperphosphatemia and hypercalaemia
Cardiovascular abnormalities:hypertensioncongestive heart failurecardiomiopathypericarditisaccelerated atherosclerosisarrhythmias
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Major Clinical Abnormalities in Uremia II.
Gastrointestinal abnormalities:anorexia, nausea, and vomitinguremic fetorstomatitis, gastritispeptic ulcergastrointinal bleeding
Hematologic and immunologic abnormalities:anemiableedingphagocyte inhibitionlymphocytopeniaincreased susceptibily to infection andneoplasia
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Major Clinical Abnormalities in Uremia III.
Neurological abnormalities:malaiseheadacheirritability and sleep disordersmuscle crampstremorseizuresstupor and comaperipheral neuropathyrestless legsmotor weakness
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Major Clinical Abnormalities in Uremia IV.Endocrine and metabolic abnormalities:
hypertriglyceridemiaprotein malnutritionimpaired growthinfertility, sexual dysfunction, andamenorrhearenal osteodystrophysecondary hyperparathyreoidism
Dermatologic abnormalities:pallorhyperpigmentationpruritus
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CHRONIC RENAL FAILURE
• The progression of chronickidney disease
• Uremia – clinical abnormalities• Renal anemia and renalosteodystrophy
• Renal replacement therapy
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Renal Anemia• Anemia develops early during renal failure
and is one of the major causes of malaiseand fatigue.
• It is normocytic and normochromic but maybe complicated by– iron deficiency due to gastrointestinal bleeding
(microcytic)– folate deficiency due to dietary restriction
(macrocytic)– fibrosis of the bone marrow due to
hyperparathyroidism.
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Correction of Anemia
• Improves cardiac function, centralnervous system symptoms, appetiteand sexual function.
• Erythropoietin administration shouldbe started in the predialysis period.
• Target hemoglobin: 110-120 g/l.• Sufficient iron and folate stores
should be maintained!
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Renal Osteodystrophy
• Includes all sceletal disorders ofpatients with renal failure:– osteitis fibrosa– osteomalacia– mixed and adynamic bone lesions– dialysis related amyloidosis
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CHRONIC RENAL FAILURE
• The progression of chronickidney disease
• Uremia – clinical abnormalities• Renal anemia and renalosteodystrophy
• Renal replacement therapy
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Renal Replacement Therapy
• Hemodialysis• Peritoneal dialysis• Kidney transplantation
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Absolute Indications for Initiation of Dialysis
Ø PericarditisØ Advanced or progressive uraemic encephalopathy
or neuropathyØ Pulmonary edema and fluid overload unresponsive
to diuretic measuresØ Hypertension poorly responsive to treatmentØ Hyperkalaemia attributed to ESRD unresponsive to
conservative treatmentØ Bleeding diathesis with clinical bleeding attributed to
uraemiaØ Persistent nausea
Hakim, Advances Nephrol 23: 295-309, 1994
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Relative Relative Indications for Indications for Initiation of DialysisInitiation of Dialysis
Ø General
Anorexia, fatigue, weaknessGFR < 20 ml/min in diabetics or
GFR = 10-15 ml/min (other etiologies)
Hakim, Advances Nephrol 1994; 23: 295-309
Ø Neurological
Peripheral neuropathy (often burning dysesthesia)Restless leg syndrome
Ø Cardiovascular
Peripheral edema unresponsive to diuretics
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Ø Gastrointestinal
Anorexia progressing to nausea and vomitingGastritis, duodenitis, constipationAscites without liver disease
RelativeRelative Indications for Indications for Initiation of Dialysis (continued)Initiation of Dialysis (continued)
Hakim, Advances Nephrol 1994; 23: 295-309
Ø Hematological
Anaemia with poor response to erythropoeitinInfectionsIncreased bleeding tendency due to platelet dysfunction
Ø Dermatological
Persistent and severe itching
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BloodInflow
DialysateOutflow
DialysateInflow
BloodOutflow
Countercurrent flow of blood (within capillaries) and dialysate(outside of capillaries).
Solute Transferacross the Capillary Walls
Principles of dialysers
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Blood PumpAnticoagulation
Blood tothe Patient
Blood fromthe Patient
Dialyser
Fresh Dialysate
UsedDialysate
Flow Scheme Hemodialysis
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Standard Arteriovenous (AV) Fistulaat the Wrist
modified from Man, Zingraff, Jungers, Long-Term Hemodialysis, 1995
Patient access
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Twin Catheters Placed in the Internal Jugular Vein
modified from Man, Zingraff, Jungers, Long-Term Hemodialysis, 1995
Patient access
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Haemodialysis
Standard Standard TherapyTherapy::IntermittentIntermittent HDHD
ca. 3x4ca. 3x4--5 h / 5 h / weekweek
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Peritoneal Dialysis
„„NaturalNatural““Semipermeable Semipermeable
Membrane :Membrane :
PeritoneumPeritoneumThe transport of substances
via Peritoneum occurs in both directions: i.e. Wastesubstances from the bloodinto the solution and buffer
substances in the otherdirection.
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Principles of Peritoneal Dialysis
• Small solute movement occurs by diffusionbased on the concentration gradient (urea, creatinine, potasssium).
• Large solute removal occurs by convection: the solute movement is related to fluid removal.
• The volume of ultrafiltration depends onthe concentration of glucose solution (thelength of dwell and the peritonealmembrane characteristics).
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C C ontinuousontinuous
A A mbulatorymbulatory
P P eritonealeritoneal
D D ialysisialysis
the patient can walk aroundwhile it's happening
constant dialysis24 hours a day
peritoneal membraneworks as a filter
What is CAPD ? What is CAPD ?
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Summary –Renal Replacement Therapies
Peritoneal dialysis• Most frequent home dialysis modality, lower
efficiency but continuous treatment• Risk of infectious complications
Kidney Transplantation• Best outcome• Risk for infections, tumours, bone fractures• Not all patients are eligible for transplantation
Hemodialysis• Most frequent modality, highly efficient but
intermittent• Risk of intradialytic complications• Mainly centre treatment