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ACUTE RENAL FAILURE

ACUTE RENAL FAILURE . Background . Common in Hospitalized patients Associated with high Morbidity and Mortality Often Multifactorial Identifiable risk factors. Renal biopsy. Renal biopsy on hospital day 2 demonstrating massive oxalosis. Acute dialysis. Acute Renal Failure .

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ACUTE RENAL FAILURE

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  1. ACUTE RENAL FAILURE

  2. Background • Common in Hospitalized patients • Associated with high Morbidity and Mortality • Often Multifactorial • Identifiable risk factors.

  3. Renal biopsy

  4. Renal biopsy on hospital day 2 demonstrating massive oxalosis

  5. Acute dialysis

  6. Acute Renal Failure • Sudden decrease in function (hours-days) • Often multifactorial • Pre-renal and intrinsic renal causes 70% • oliguric UOP < 400 ml • Non-oliguric (up to 65%) • Associated with high mortality and morbidity

  7. Acute Renal FailureDiagnosis • Laboratory Evaluation: • Scr, More reliable marker of GFR • Falsely elevated with Septra, Cimetidine • small change reflects large change in GFR • BUN, generally follows Scr increase • Elevation may be independent of GFR • Steroids, GIB, Catabolic state, hypovolemia • BUN/Cr helpful in classifying cause of ARF • ratio> 20:1 suggests prerenal cause • ratio 10-15:1 suggests intrinsic renal cause

  8. Acute Renal Failure Diagnosis (cont’d) • Urinalysis • Unremarkable in pre and post renal causes • Differentiates ATN vs. AIN. vs. AGN • Muddy brown casts in ATN • WBC casts in AIN • Hansel stain for Eosinophils

  9. Acute Renal Failure Diagnosis (cont’d) • Urinary Indices; • FE Na = (U/P) Na X (P/U)CrX 100 • FENa < 1% C/W Pre-renal state • May be low in selected intrinsic cause • Contrast nephropathy • Acute GN • Myoglobin induced ATN • FENa> 1% C/W intrinsic cause of ARF

  10. Prerenal Azotemia • Nearly as common as ATN (think of as early part of the disease spectrum) • Diagnose by history and physical exam • N/V, Diarrhea, Diuretic use,... • low FENa (<1%) • high BUN/creat ratio, normal urinary sediment • Treat by correction of predisposing factors

  11. Acute Renal Failure Etiologies • Acute Tubular Necrosis • Most common cause of intrinsic cause of ARF • Often multifactorial • Non-oliguria carries better prognosis • Ischemic ATN: • Hypotension, sepsis, prolonged pre-renal state • Nephrotoxic ATN: • Contrast, Antibiotics, Heme proteins

  12. Acute Tubular Necrosis (ATN) -- 2 • Diagnose by history,  FENa (>2%) • sediment with coarse granular casts, RTE cells • Treatment is supportive care. • Maintenance of euvolemia (with judicious use of diuretics, IVF, as necessary) • Avoidance of hypotension • Avoidance of nephrotoxic medications (including NSAIDs and ACE-I) when possible • Dialysis, if necessary • 80% will recover, if initial insult can be reversed.

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