1. Acute Renal Failure
Dr.Nariman Fahmi

2. Clinical Scenario
History: A five years old male presents to emergency with a 5 day history of diarrhoea and vomiting. he has been unable to keep anything down including water and now lethargic and the mother noticed no urine output for the last 12 hours .
O/E: he has dyspnea and has reduced skin turgor. BP is 70/50 and HR 95. Examination is otherwise unremarkable
Ix: normal FBC, Na 149meq/l, K 6.7meq/l, Urea 17.0 mmol/l and Creatinine 258mmol/l

3. Acute kidney injury By the end of the lecture the student can
-Describe the etiology &categories of AKI
-Understand principles of management of AKI
-Identification of appropriate investigations
- Knowledge of indications for dialysis
-Awareness of complications and management of hyperkalemia (common complication)

4. Renal system
2 Kidneys
2 Ureters
Bladder
Urethra

5. What do
the kidneys do??

6. Kidney Function Detoxify blood
Regulate blood pressure , electrolyte and fluid balance
Increase calcium absorption
calcitriol
Stimulate RBC production
erythropoietin

10. To function properly kidneys require:
Normal renal blood flow
Functioning glomeruli and tubules
Clear urinary outflow tract
for drainage and elimination of formed urine from the body.

11. Acute renal failure Acute sudden onset rapid reduction in urine output
Usually reversible

12. Classifications
Pre-renal (55%)
renal(40%)
post-renal(5-15%)

13. Causes of ARF Pre-renal = Intrinsic Post-renal
vomiting, diarrhea, cardiac failure, septic shock ,others
Intrinsic
Interstitial nephritis, acute glomerulonephritis, tubular necrosis, toxins
Post-renal
-prostatic hypertrophy, bilateral renal calculi, bladder carcinoma

14. PRE-RENAL (Hemodynamic) AKI
Generalized or localized
reduction in RBF
Hypovolaemia
Haemorrhage
Volume depletion
( vomiting,
diarrhoea,
burns)
Hypotension
Cardiogenicshock
(sepsis, anaphylaxis)
Oedema states
Cardiac failure
Hepatic cirrhosis
Nephrotic syndrome
Renal Hypoperfusion
NSAIDs
ACEI / ARBs
RAS /occlusion
Hepatorenal
syndrome
Reduced GFR
PRERENAL AKI

15. Symptoms of ARF Decrease urine output (70%)
Edema, esp. lower extremity
Mental changes
Nausea, vomiting
Tachypenia

17. Management Think about the diagnosis Maintenance of
-volume homeostasis (Assess fluid status, Fluid resuscitation)
-Stop Nephrotoxic drugs
-correction of biochemical abnormalities
Treat reversible elements
Hydrate
-Relieve obstruction

18. Management Treat the Treat reversible causes
Infection – give antibiotics, renal doses
Intrinsic renal disease – R/v medication
Obstruction
Example (calculus obstruction either surgical removal or nephrectomy)

21. Hyperkalemia Symptoms
Weakness
Lethargy
Dysrhythmias
EKG?

22. Hyperkalaemia Potassium range is 3.5 – 5mmol/L
Rise in serum K+ >5mmol/l
Signs/symptoms: muscle weakness
ECG changes:
Flattened P waves
Broad QRS complex
Slurring of ST segment
Tall tented T waves

23. Hyperkalemia Potassium >6.0 mmol/L Potassium >6.5 mmol/L
Calcium resonium 15g QDS PO
If septic or rising quickly treat as though K+ 6.5
Potassium >6.5 mmol/L
Dextrose-insulin (50ml 50% Dextrose with 10units Actrapid insulin, IV over 5mins) –
Dextrose-insulin wears off approx 4hours, so repeat if necessary
Recheck k+ after 4hours 23

24. Hyperkalemia Potassium >7 mmol/L
Calcium gluconate (10ml of 10% solution into central vein or diluted into 40ml 0.9% saline into peripheral vein over 10mins, with cardiac monitor)
Dextrose insulin
Nebulised salbutamol 5mg
IV sodium bicarbonate (50ml 8.4% over 5mins centrally or 500mls 1.26% over 30mins peripherally
Calcium resonium 24

25. Dialysis

26. Dialysis Diffuse harmful waste out of body Control BP
Keep safe level of electrolytes and acid base level in body
2 types
Hemodialysis
Peritoneal dialysis

27. Peritoneal Dialysis
Abdominal lining filters blood

28. INDICATIONS FOR DIALYSIS IN ACUTE RENAL FAILURE
PERICARDITIS
MENTAL STATUS CHANGE
SEIZURES
Uncontrollable hypertension , hyperkalemia or acidosis
Toxins

29. summary
Acute renal failure is defined as an abrupt or rapid decline in renal filtration function.
It is the clinical manifestation of several disorders that affect the kidney acutely
treatment is supportive

30. References http://www.umm.edu/ency/article/000471.htm

31. Questions?

32. Davidson's Principles and Practice of Medicine
Edited by Brian R. Walker, BSc MD FRCPE FRSE, Nicki R Colledge, BSc (Hons) FRCPE, Stuart H. Ralston, MD FRCP FMedSci FRSE and Ian Penman, BSc MD FRCPE
Harrisons Principles of Internal Medicine,

33. Thank you