ACUTE RENAL FAILURE

ARF SUDDEN DECREASE IN RENAL FUNCTION TO REGULATE HOMEOSTASIS CLINICAL DISTURBANCE : WATER AND ELECTROLITE BALANCE ACID - BASE BALANCE WASTE PRODUCT ELIMINATION

CHRONIC RENAL FAILURE

DEFINITION
THE STAGE OF IRREVERSIBLE RENAL DYSFUNCTION RESULT IN RENAL DAMAGE AND INABILITY OF THE KIDNEY TO REGULATE HOMEOSTASIS SEVERITY OF RENAL FUNCTION IMPAIRMENT VARIOUS

ARF
OLIGURIA : REDUCTION IN URINE OUTPUT < 240 cc/m2/24 hr, or < 400 cc/m2/24 hr, or < 300 cc/m2/24 hr.

CLASSIFICATION OF CRF

ANURIA : -

NO URINE /24 hr. - EXCRETION < 75 cc/24 hr - < 1cc/m2/24 hr

1. 2. 3. 4.

EARLY RENAL FAILURE CHRONIC RENAL INSUFFICIENCY CHRONIC RENAL FAILURE END STAGE RENAL FAILURE

AZOTEMIA : HIGH ACULUMULATION OF NITROGENOUS PRODUCT IN BLOOD

ETIOLOGY ARF PRE RENAL

- HYPOVOLAEMIA, HAEMORRHAGE, GASTROINTESTINAL DRAINAGE - EFFECTIVE VASCULAR VOLUME - CARDIAC OUT PUT RENAL - INTRA RENAL VASCULAR DISTURBANCE - GLOME RULONEPHRITIS - TUBULUS DISTURBANCE - CONGENITAL POST RENAL - ARF - CONGENITAL - CALCULI , CLOTTING ,ASAM JENGKOL CRYSTAL - TUMOR

ETIOLOGY CRF

- CONGENITAL : RENAL HYPOPLASIA, RENAL DYSPLASIA OBSTRUCTIVE UROPATHY - HEREDITARY : JUVENILE NEPHRONOPHTHISIS, HEREDITARY NEPHRITIS,

ALPORTS SYNDROME
- ACQUIRED : FSGS, MEMBRANOUS GLOMERULOPATHY METABOLIC DISORDER

PATHOGENESIS

PATHOPHYSIOLOGY
Definite Mechanism ?

PRE - RENAL CIRCULATORY VOLUME RBF TO THE CORTEX & GFR

FACTORS

RENAL VASCULAR DISTURBANCE, GLOMERULUS, INTERSTITIAL TUBULUS, CONGENITAL ANOMALY DISTURBANCE : ISCHAEMIA OR NEPHROTOXIC DRUG POST RENAL CONGENITAL / ACQUIRED IN URINE FLOW OBSTRUCTION PARENCHYMAL DAMAGE

IMMUNE PROCESS HEMODYNAMIC HYPERFILTRATION DIETARY PHOSPHORUS PROTEIN PERSISTENT PROTEINURIA SYSTEMIC HYPERTENSION

CLINICAL MANIFESTATION ARF

- COMMONLY SUPER IMPOSED WITH PRIMARY DISEASE - ANEMIA, OLIGURIA, PULMONARY EDEMA, HYPERKALEMIA, GASTROINTESTINAL BLEEDING, CONVULSION, CONSCIOUSNESS - NON OLIGURIC ARF : DETECTION IS DIFICULT

CLINICAL MANIFESTATIONS CRF ARE FROM :

1.INABILITY OF THE KIDNEY TO REGULATE FLUID
AND ELECTROLYTE HOMEOSTASIS 2.TOXIC METABOLITE ACCUMULATION 3.RENAL HORMONE (ERYTHROPOIETIN AND ACTIVE FORM OF VIT. D) 4.ABNORMAL RESPONSE ORGAN TO ANDROGEN

CLINICAL EPISOD OF ARF

OLIGURIA PHASE POLYURIA PHASE

HORMONE

SYMPTOMS MAY BE NON SPECIFIC :

HEADACHE, FATIGUE, LETHARGY, ANOREXIA, VOMITING, POLYDIPSI, POLYURIA

RESOLUTION PHASE

+ELECTROLYTE IMBALANCE
- SODIUM - POTASIUM : EXCRETIE AND RETENSION : HYPER OR HYPOKALEMIA - METABOLIC ACIDOSIS - FLUID IMBALANCE - URINE CONCENTRATE IMPAIRMENT

METABOLIC IMPAIRMENT
- CARBOHIDRATE GLUCOSE INTOLERANCE - FAT HYPERLIPIDERMIA

ANEMIA
HEMORRHAGE IMPAIRMENT IMPAIRED CARDIOVASCULAR FUNCTION HYPERTENSION

HEART IMPAIRMENT
- PERICARDITIS, ESPECIALLY SEVERE UREMIA - UREMIC CARDIOMYOPATHY

NEUROLOGIC IMPAIRMENT
- PERIPHERAL NEUROPATHY - HYPERTENSIVE ENCEPHALOPATHY

RENAL OSTEODYSTROPHY GROWTH RETARDATION SEXUAL DEVELOPMENT

DIAGNOSIS
A. ANAMNESIS B. PHYSICAL EXAMINATION C. LABORATORY - ANEMIA

DIAGNOSIS
- CLINICAL MANIFESTATION - SUPPORTIVE EXAMINATION LABORATORY BLOOD ROUTINE, URINE ROUTINE, RENAL FUNCTION : UREUM, CREATININE

- URINE ANALYSIS - SERUM CREATININ & UREUM HYPO NATREMIA, HYPER KALEMIA BLOOD GAS ANALYSIS D. RADIOLOGIC RADIOLOGIC

BLOOD GAS ANALYSIS

: X-RAY, BONE AGE, GFR, RENOGRAM

MANAGEMENT

MANAGEMENT CRF
- CONSERVATIVE :

A. PRE - RENAL ARF ~ ETIOLOGY B. POST - RENAL ARF TREATMENT FOR OBSTRUCTION C. RENAL ARF 1. CONSERVATIVE - PREVENTIVE FOR PROGRESSIVE FLUID - FLUID OVER LOAD 2. DIALYSIS - UREUM > 200 mg % - PERSISTETN HYPERKALEMIA

ADEQUATE FLUID INTAKE CONTROL HYPERTENSION, ANEMIA, FLUID AND ELECTROLYTE

IMBALANCE ACIDOSIS, RENAL

OSTEODYSTROPHY, HEART FAILURE, HEMOLOGIC AND MUSCLE IMPAIRMENT, HYPERURICEMIA, TOXIC SUBSTANCE. - REPLACEMENT THERAPY : DIALYSIS BEFORE GFR 5 ML/M/1,73 M2 TRANSPLANTATION

DIET CRF:
CALORI 100 KKAL/KG BW/DAY PROTEIN RESTRICTION 1,4 G/KG BW/DAY (INFANT) 0,8 - 1,1 G/KGBW/DAY (CHILD)

SODIUM, IF EDEMA (-) / HYPERTENSION (-)

2 MEQ/KG BW/DAY WITH EDEMA 1 MEQ/KG BW/DAY OLIGURIA / ANURIA 0,2 MEQ/KG BW/DAY FLUID : 400 ML/M2/DAY + WATER LOSSES

(VOMITING/ DIURESIS)

POTASSIUM
- > 6 MEQ/KG CLINICAL SYMPTONS (-) FOOD CORRECTION OR KAYEKSALAT 1 G /KG BW UNTIL < 6 MEQ/L - > 7 MEQ/L CA GLUCONATE OR NA BICARBONATE

RENAL OSTEODYSTROPHY
- CALCIUM 100 300 MG /M2/DAY - ROCATROL 0,25 MG/DAY, ROXANE 0,125 MG/DAY

ACIDOSIS :
NaHCO 1-5 mEq/kg BW/day

HYPERTENSION DIETARY SALT RESTRICTION,

FAIL ? PRORANOLOL/ETANOLOL,HYDRALAZONE, OR CAPTOPIL ANEMIA ELEMENTAL IRON 2-3 MG/KG BW/DOSE FOLIC ACID 1-5/DAY FOR 3-4 WEEK HB < 6G/DL PRC TRANFUSION 10 20 ML/KG BW HEART IMPAIRMENT FUROSEMIDE

PROGNOSIS
MORTALITY DEPEND ON ETIOLOGY, AGE AND PARENCHYMAL DAMAGE OF THE KIDNEY

BYE - BYE BYE - BYE BYE - BYE