Acute Renal Failure Fall Medical/ Surgical Conference Lubbock-Crosby-Garza County Medical Society

1. Acute Renal FailureFall Medical/ Surgical ConferenceLubbock-Crosby-GarzaCounty Medical Society Sandra Sabatini PhD, MD Neil A Kurtzman MD

2. Acute Kidney Injury now the preferred term • It's imprecise • Some forms of ARF are not associated with tissue injury • We'll stick with ARF

3. An elevated serum creatinine during hospitalisation is an independent risk factor for mortality, progression to CKD, end-stage renal disease, and reduced long-term survival. Patients with chronically elevated serum creatinine (i.e., impaired baseline renal function) have a higher risk for acute kidney injury during hospital stays and are more often dialysis-dependent at hospital discharge than those without. http://bestpractice.bmj.com/best-practice/monograph/935.html

4. ARF is an acute decline in the glomerular filtration rate (GFR) from baseline, with or without oliguria/anuria. It may be due to various insults such as impaired renal perfusion, exposure to nephrotoxins, outflow obstruction, or intrinsic renal disease.

5. Three General Mechanisms • Pre-renal • Renal • Post-Renal

6. ARF vs CRFadaptation • BP • Edema - fluid overload • Acid-Base • RBC • Ca • PO4 • K

7. Pre-Renal • Decreased renal perfusion • Contracted EABV • CHF • Blood loss • Vomiting • Diarrhea • Sweating • Decreased fluid intake • Cirrhosis • Pre-glomerular vascular disease

8. Evaluation • History • PE - Pulse and BP- Edema - Signs of other diseases • Urine NaCl • BUN/Cr • Uric Acid

9. Treatment and Implications • Depends on cause • Fluid loss different from CHF different from Cirrhosis • Vol contraction predisposes to ATN - more soon

10. Post Renal • Prostatism • Advanced Cervical Cancer • Retroperitoneal Fibrosis • Retroperitoneal Lymphoma • Bilateral Renal Calculi

11. Features • Anuria if complete • Collecting duct dysfunction

13. Polyuria - NDI • Metabolic acidosis • Hyperkalemia • NaCl loss

14. Treatment • Relieve obstruction if possible • Dialysis and supportive care if obstruction is irreversible

15. Renal • Acute glomerulonephritis • Acute vasculitides • Acute interstitial nephritis • Toxins • Acute tubular necrosis (ATN) • Acute papilary necrosis

16. Toxins -Ethylene Glycol

17. Ethylene Glycol - Anti-Freeze

18. Dog kidney - polarized light

19. Manifestations • CNS • Metabolic Acidosis • Renal failure

20. Diagnosis • History • CNS - "drunk", seizures • Anion gap metabolic acidosis • Oxaluria • Acute renal failure

21. Treatment • Ethanol • Fomepizole (inhibits alcohol dehydrogenase) • Hemodialysis • Prognosis - good early treatment • Prognosis - bad late treatment

22. Acute Interstitial Nephritis • Can be infectious • Usually non-infectious inflammatory • Commonly drug induced

23. Allergic reaction to a drug (acute interstitial allergic nephritis) • Autoimmune disorders such as anti-tubular basement membrane disease, Kawasaki’s disease, Sjogren syndrome, systemic lupus erythematosus, or Wegener’s granulomatosis • Acetaminophen, aspirin,NSAIDS

24. Penicillin, ampicillin, methicillin, sulfonamide • Furosemide, thiazide diuretics, omeprazole, triamterene, and allopurinol • Hypokalemia • Hypercalcemia, hyperuricemia

25. Kidney International (2001) 60, 804–817

26. Kidney International (2001) 60, 804–817

27. Kidney International (2001) 60, 804–817

28. Treatment • Stop offending drug • Treat underlying disease • Steroids may hasten recovery

29. Acute Papillary Necrosis • Chronic more common • Diabetes • Infection • Often a catastrophic illness

30. ATN • Requires an underperfused kidney • Nephrotoxins (Hg, Pt) • Major surgery (due to multiple factors) • Third-degree burns covering > 15% of BSA • The heme pigments myoglobin and hemoglobin • Tumor lysis or multiple myeloma • Herbal and folk remedies, such as ingestion of fish gallbladder in Southeast Asia (uncommon)

31. Am J Med Sci. 2007, 334(2):115-24. Cisplatin nephrotoxicity: a review. Yao X1, Panichpisal K, Kurtzman N, Nugent K.

32. Common nephrotoxins include the following: • Aminoglycosides • Amphotericin B • Cisplatin and other chemotherapy drugs • Radiocontrast agents • NSAIDs • Colistimethate • Calcineurin inhibitors (cyclosporine, tacrolimus)

33. ATN

34. ATN is more likely to develop in patients with the following: • Preexisting hypovolemia or poor renal perfusion • Preexisting chronic kidney disease • Diabetes mellitus • Older age

35. Crush Syndrome

36. J Am Soc Nephrol 11: 1553–1561, 2000

37. J Am Soc Nephrol 11: 1553–1561, 2000

38. Contrast Induced ARF • Systolic blood pressure <80 mm Hg • Intraarterial balloon pump • Congestive heart failure • Age >75 y • Hematocrit level <39% for men and <35% for women

39. Diabetes especially with ↑Cr • Contrast media volume • Renal insufficiency • Serum creatinine level >1.5 g/dL • Estimated Glomerular filtration rate < 60 ml/min • Gadolinium enhance MRI risks NSF and CRI

40. Prevention • Avoid use in high risk patients • Isotonic saline • Saline and furosemide if CHF present • HCO3 of uncertain utility • N-acetylcysteine probably ineffective • Prophylactic hemodialysis not proven effective

41. Prostaglandins and the Kidney

42. NSAIDS and Renal Disease • AIN • Pre renal azotemia • ATN • Nephrotic Syndrome • Hyperkalemia • Hyponatremia

43. NSAIDS and ARF • Relatively uncommon • Incidence increases with age • ACE inhibitors and ARBs increase incidence • Volume contraction • Diuretics • Pre-existing renal disease

44. Prognosis • 65% recover to baseline in 7-10 days • Dialysis needed <1% of patients • 18% who need HD remain on it • Maioli M, Toso A, Leoncini M, Gallopin M, Musilli N, Bellandi F. Persistent renal damage after contrast-induced acute kidney injury: incidence, evolution, risk factors, and prognosis. Circulation. Jun 26 2012;125(25):3099-107

45. The Centre for Adverse Reactions Monitoring, NZ 2000

46. Antibiotic induced ARF Aminoglycosides Martínez-Salgado et al. / Toxicology and Applied Pharmacology 223 (2007), 86–98

47. Renal Under perfusion always present

48. Amphotericin Nephrotoxicity • Renal Underperfusion • Hypokalemia • Renal tubular acidosis • Liposomal formulation likely lower incidence • Acute renal failure

50. Fractional Excretion FEx= Cx/Ccr X 100 Cx= UxV/Px FENa (<0.5%) FEurea (<35%)