Acute Renal Failure/Acute Kidney Injury

Acute Renal Failure/Acute Kidney Injury. Dr. Sudarshan Singh. Introduction. Acute renal failure (ARF), or acute kidney injury (AKI) , [as it is now referred to in the literature], is defined as An abrupt or rapid decline in renal filtration function

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imaging studies procedures tests
residual scarring
septicemia
renal blood flow
renal failure onset phase
metabolic acidosis

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Acute Renal Failure/Acute Kidney Injury

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Acute Renal Failure/Acute Kidney Injury Dr. Sudarshan Singh
Introduction • Acute renal failure (ARF), or acute kidney injury (AKI), [as it is now referred to in the literature], is defined as • An abrupt or rapid decline in renal filtration function • Condition is usually marked by a rise in serum creatinine concentration or by azotemia (a rise in blood urea nitrogen [BUN] concentration)
Causes • Acute kidney failure appears most frequently as a complication of serious illness, like • Heart and/or liver failure, serious infection, dehydration, severe burns, and excessive bleeding (hemorrhage) • May also be caused by an obstruction to the urinary tract or as a direct result of kidney disease, injury, or an adverse reaction to medicine • These conditions divide AKF into 3 main categories: • Prerenal • Postrenal, and • Intrinsic (inside) conditions
Causes • PrerenalAKF • Does not damage the kidney, but can cause diminished kidney function and significantly decreased renal (kidney) blood flow • Most common type of acute renal failure, and is often the result of: • Dehydration • Extracellular fluid (ECF) volume depletion (or other acute fluid loss from the gastrointestinal tract, kidneys, or skin) • Drugs (NSAIDS, cyclosporine, radiopaque contrast materials, or any substance toxic to the kidneys) • Hemorrhage • Septicemia, or sepsis • Congestive heart failure (CHF) • Liver failure • Burns • Decreased intravascular volume (referred to as third spacing, also found in the presence of pancreatitis, post surgical patients, and patients with a nephrotic syndrome)
Causes • Postrenal AKF • Result of an obstruction of some kind somewhere in the urinary tract, often in the bladder or ureters (the tubes leading from the kidney to the bladder) • The kidneys compensate to such a degree that one kidney can be completely obstructed and the other will maintain nearly normal kidney function for the body • The conditions that often cause postrenal AKF are: • Inflammation of the prostate gland in men (prostatitis) • Enlargement of the prostate gland (benign prostatic hyperplasia - BPH) • Bladder or pelvic tumors • Kidney stones (calculi)
Causes • Intrinsic AKF • Involves a type of kidney disease or direct injury to the kidneys. • Accounts for 20-30% of AKF reported among hospitalized patients • Intrinsic AKF can result from: • Lack of blood supply to the kidneys (ischemia) • Use of radiocontrast agents in patients with kidney problems • Drug abuse or overdose • Long-term use of nephrotoxic medications, like certain pain medicines • Acute inflammation of the glomeruli, or filters, of the kidney (glomerulonephritis) • Kidney infections (pyelitis or pyelonephritis) • Infiltration by lymphoma, leukemia, or sarcoid carcinomas
The Four Phases of Acute Renal Failure • Onset Phase– this period represents the time from the onset of injury through the cell death period. This phase can last from hours to days and is characterized by: • Renal flow at 25% of normal • Oxygenation to the tissue at 25% of normal • Urine output at 30 ml (or less) per hour • Urine sodium excretion greater than 40 mEq/L. • In this phase only 50% of the patients are noted to be oliguric. With prompt treatment, irreversible damage can be achieved during this pre renal failure onset phase.
The Four Phases of Acute Renal Failure • Oliguric/Anuric Phase– this phase usually lasts between 8-14 days and is characterized by further damage to the renal tubular wall and membranes. Other characteristics in the oliguric-anuric phase include: • Great reduction in the glomerular filtration rate (GFR) • Increased BUN/Creatinine • Electrolyte abnormalities (hyperkalemia, hyperphosphatemia and hypocalcemia) • Metabolic acidosis
The Four Phases of Acute Renal Failure • Diuretic Phase– this phase occurs when the source of obstruction has been removed but the residual scarring and edema of the renal tubules remains. This phase usually lasts and additional 7-14 days and is characterized by: • Increase in glomerular filtration rate (GFR) • Urine output as high as 2-4 L/day • Urine that flows through renal tubules • Renal cells that cannot concentrate urine • Increased GFR in this phase contributes to the passive loss of electrolytes which requires the administration of IV crystalloids to maintain hydration.
The Four Phases of Acute Renal Failure • Recovery Period Phase– The recovery phase can last from several months to over a year. During this phase, edema decreases, the renal tubules begin to function adequately and fluid and electrolyte balance are restored (if damage was significant, BUN and Creatinine may never return to normal levels). At this point the GFR has usually returned to 70% to 80% of normal.
Symptoms and Signs • The signs and symptom that may be experienced with ARF depend on • Phase, degree of azotemia (abnormal levels of urea and creatinine) and degree of metabolic acidosis • The following signs and symptoms are consistent with ARF: • Decreased urine output (urine may be pink or reddish in color) • Edema (face, arms, legs, feet eyes) • Flank pain/Pelvic pain • Poor appetite (nausea, vomiting) • Bitter or metallic taste in mouth
Symptoms and Signs • Symptoms and signs (Contd) • Dry itchy skin • Easy bruising • Fatigue • Seizures/LOC • Shortness of breath • Arrhythmias • Sudden weight gain

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