ACUTE RENAL

FAILURE
Vimar A. Luz, MD, FPCP, DPSN
OUTLINE
 Definition
 Incidence
 Causes/Pathophysiology
 Phases
 Evaluation
 Management
 Outcome
 RENAL FAILURE
 Acute  Chronic
 Rapid decline in  Kidney Damage for
GFR (Over Hours To > 3 months
Days)  Irreversible
 Usually Reversible
INCIDENCE
 5% to 7% of hospital admissions
 30% of ICU admissions
ACUTE RENAL FAILURE
CATEGORIES

55% to 60% 35% to 40% <5%

ACUTE RENAL FAILURE
Prerenal

Due to decreased
blood flow
in the kidneys
ACUTE RENAL FAILURE
ACUTE RENAL FAILURE
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
 Phases of Ischemic ARF

begins with renal insult

hypothetical period of time
S/S: Urine 400ml or less/24 hrs,
Increasing BUN
 Phases of Ischemic ARF

Period of ongoing renal failure

and lasts 7-14 days
S/S: Urine Output is Lowest
 Phases of Ischemic ARF

Gradual return of renal function

S/S: Can be complicated my marked
diuretic phase
NEPHROLOGICAL EVALUATION
 Risk factors for ARF
 Underlying CKD
 Exposure to potential nephrotoxins
 Recent disturbance of renal perfusion
RISK GROUPS/FACTORS
 Hemodynamic instability
 Nephrotoxins
 Sepsis
 Post surgical
 Cardiovascular
 Elderly, HPN, Diabetics
 Trauma, Burns
 Neoplasia
 Pulmonary
 Muskuloskeletal
 Injury/Poisoning
 Gastrointestinal

Chertow GM et al, Toward and evidence based definition of hospital-acquired acute renal
failure. J Am Soc Nephrol 2003; 8:1042A
MANAGEMENT PRIORITIES
(I)
 Search for and correct prerenal and
postrenal factors
 Review medications and stop nephrotoxins
 Optimize cardiac output and renal blood
flow
 Restore and/or increase urine flow
 Monitor fluid intake and output, daily
weight
MANAGEMENT PRIORITIES (II)
 Search for and treat acute complications
(hyperkalemia, hyponatremia, acidosis
hyperphosphatemia , pulmonary edema)
 Provide early nutritional support
 Search for and aggressively treat infections
 Initiate dialysis before uremic complications
emerge
 Dose drugs appropriate for their clearance
 Stop and repair ongoing intracellular injury
MANAGEMENT
 Preventive
 Resuscitative/Supportive
 Factors affecting choice of RRT
modality
 Patient factors:
- Hypercatabolism and abdominal surgery: no PD
a.The underlying disease process
isolated ARF: IHD
MODS and hemodynamically unstable: CRRT, IHF, SLED
Cerebral edema: continuous forms
ARF and respiratory failure: continuous forms, SLED

b. The indications for dialysis

Rapid removal of solutes (life-threatening
hyperkalemia):IHD
Fluid removal in unstable patient: continuous forms

c. Location of the patient and duration of treatment

Patient mobility: SLED
ICU: Continuous, SLED
Cardiac ICU: CRRT, SLED
 Factors affecting choice of RRT
modality
 Technique factors
a. Solute and water clearance
need for high urea clearance:IHD, SLED
drug overdoses: drugs with large DV and easy
dialysability: IHD, but rebound, thus: IHD
followed by CRRT

b. Ease of application and local possibilities

number of nurses, machines,
training of nurses
risk of bleeding: preferably IHD or SLED, PD?
ACUTE RENAL FAILURE
 Increase hospital length of stay
 Associated with more than doubling of the
cost of hospital care
 Increased morbidity and mortality

Chertow, et al. Toward and evidence-based definition of hospital acquired acute renal failure. J am Soc
Nephrol 2003; 8:1042 A
OUTCOME
 50% MORTALITY
 Irreversible in about 5% of cases
 About 5% suffer progressive deterioration
in renal function
 50% have subclinical functional defects

 *Dose of renal Replacement Therapy –

The higher dose the better the survival
Ronco C et al. Effects of different doses in continous veno-venous hemofiltration on outcomes of acute
renal failure: a prospective randomized trial. Lancet 2000;356:26-30
RECOVERY
 Severity of Creatinine Elevation
 Requirement for Dialysis
 Other organ system involvement

Morgera et al. Long-term outcomes in acute renal failure patients treated with continous renal
replacement therapies. Am J Kidney Dis 2002; 40:275-279
Bhandari S et al. Survivors of acute renal failure who do not recover renla function. Qjm 1996;89:415-
421
Salmanullah M et al. The effects of acute renal failure on long term renal function. Ren Fail 2003;
25:267-276
GOOD DAY!