1. ACUTE RENAL FAILURE SEMINAR ON BY UJJAL MOHANTA UNDER THE GUIDANCE OF TEACHERS OF DEPARTMENT OF PRACTICE OF MEDICINE D.N.DE. HOMOEOPATHIC MEDICAL COLLEGE & HOSPITAL 12, G.K. ROAD, KOLKATA-700046. 4 th B.H.M.S.

2. DEFINITION Acute renal failure (ARF) is defined as a potentially reversible rapid decline in the excretory function of the kidney which develops over hours to days leading to retention of nitrogenous waste products and the consequent clinical complications.

3. EPIDEMIOLOGY ARF complicates the clinical course of upto 5% of all hospital inpatients and nearly 30% of Intensive Care Unit (ICU) admissions. The annual incidence of adult ARF in the general population is 200/million.

4. CAUSES 1. PRERENAL 2. INTRINSIC/RENAL 3. POSTRENAL

5. A.R.F. PRE RENAL CAUSE DECREASED RENAL PERFUSION WITHOUT CELLULAR INJURY SYSTEMIC:- HEART FAILURE BLOOD AND FLUID LOSS LOCAL:- RENAL ARTERY OCCULSION/STENOSIS DISEASE EFFECTING ARTERIOLES

6. A.R.F. INTRINSIC / RENAL CAUSES Acute tubular necrosis (ATN) – Ischaemia – Toxin – Septic renal failure Acute interstitial Necrosis (AIN) – Inflammation – oedema Glomerulonephritis (GN) – Damage to filtering mechanisms

7. A.R.F. POST RENAL CAUSES Post renal obstruction Obstruction to the urinary outflow tract – Prostatic hypertrophy – Blocked catheter – Malignancy

8. Acute tubular necrosis showing focal loss of tubular epithelial cells (arrows) and partial occlusion of tubular lumens by cellular debris (D) (H&E stain).

9. Another example of ischemic ATN (PAS stain).

10. Cholesterol Embolization

11. This longitudinal ultrasound shows a kidney with moderate hydronephrosis

12. Abdominal CAT scan with contrast demonstrates right hydronephrosis and hydroureter as a consequence of ureteral obstruction

13. ARF SIGNS AND SYMPTOMS Urine Output Low Loss of Acid Base Equilibrium Hyperkalemia Nausea/Vomiting HTN Pulmonary edema Ascites Asterixis Encephalopathy

14. LAB FINDINGS Rising creatinine and urea Rising potassium Decreasing Hb Acidosis Hyponatraemia Hypocalcaemia

15. INVESTIGATIONS Blood tests (blood cell count,blood urea, serum creatinine level) Urialysis Imaging tests evaluate the kidney and surrounding structures. These may include: Kidney ultrasound CT scan MRI scan

16. DIFFERENTIAL DIAGNOSIS Hypovolemia – GI loss: Nausea, vomiting, diarrhea (hyponatraemia) – Renal loss: diuresis, hypo adrenalism, osmotic diuresis (DM) – Sequestration: pancreatitis, peritonitis,trauma, low albumin (third spacing). – Hemorrhage, burns, dehydration (intravascular loss).

17. DIFFERENTIAL DIAGNOSIS Renal vasoconstriction: hypercalcaemia, adrenaline/noradrenaline, cyclosporin, tacrolimus, amphotericin B. Systemic vasodilation: sepsis, medications, anesthesia, anaphylaxis. Cirrhosis with ascites Hepato-renal syndrome Impairment of autoregulation: NSAIDs, ACE, ARBs. Hyperviscosity syndromes: Multiple Myeloma, Polycyaemia rubra vera

18. It should be referred to the nearest hospital and in case hospitalization no possible the following management should be administered. Immediate Fluid Management should be done Intra venous glucose and insulin – this reduces serum concentration Hemofiltration/ hemodialysis Nutrition –If acute renal failure is severe appropriate protein diet may be required to obtain a positive nitrogenous balance. MANAGEMENT OF ESTABLISHED ARF

19. Monitoring – daily monitoring of body weight, fluid balance, urea, electrolytes, and creatinine has to be done. Management of complications – like persistent infection and fungal super infection muscle compartment syndromes antibiotic colitis, metabolic complications has to be managed Renal replacement therapy – is urgently required if there is hyperkalaemia, oliguria, metabolic acidosis, and rapidly increasing serum creatinine. Homoeopathic Management

20. There are following remedies which are helpful in the management of ARF:- Apis Mel, Cantharis, Aconite, Belladonna, Merc Cor, Dulcamara, Rhus Tox, Opium, Berberis vulgaris, Terebinthina, veratrum v, Benzoic Acid, Helonias, Bryonia Alba, and many other medicines. HOMOEOPATHIC THERAPEUTICS

21. Five major components: such as exercise training, diet & fluid management, medication & medical surveillance, education, psychological & vocational counseling. Present and future perspectives of RR is addressed in this chapter. REHABILITATION

22. BIBLIOGRAPHY Smith JD, Hayslett JP. Reversible renal failure in the nephrotic syndrome. Harrison's Principles of Internal Medicine, 19th Edition Textbook Textbook Of Medicine by Pc Das,Pk Das Davidson's principles and practice of medicine Internet Class Notes