1. ACUTE RENAL FAILURE
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2. DEFINITIONS
Acute renal failure is a sudden reduction in kidney function that results in nitrogenous wastes accumulating in the blood.
 Is a reversible clinical syndrome where there is a sudden and almost complete loss of kidney function (decreased GFR) over a period of hours to days with failure to excrete nitrogenous waste products and to maintain fluid and electrolyte homeostasis.
ARF manifests as an increase in serum creatinine (M= umol/L; F=44-97umol/L) and BUN (7-20mg/dl). Urine volume may be normal, or changes may occur. Possible changes include oliguria (<400ml/day), non-oliguria (>400ml/day), or anuria (<50 ml/day)
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3. Renal insufficiency
Renal insufficiency where kidney function is deranged but can still support life

4. Epidemiology It occurs in 5%of all hospitalized patients and
35% of those in intensive care units
Mortality is high:
up to 75–90% in patients with sepsis
35–45% in those without
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5. Categories of Acute Renal Failure
Prerenal-
occurs in 60%-70% of cases, is the result of impaired blood flow to kidney that leads to hypoperfusion of the kidney and a decrease in the GFR.
Common clinical conditions are volume-depletion states (hemorrhage or GI losses), impaired cardiac performance (MI, HF, or cardiogenic shock), and vasodilation (sepsis or anaphylaxis)
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6. Intrarenal-
is the result of actual parenchymal damage to glomeruli or kidney tubules. Nephrotoxic agents such as aminoglycosides and radiocontrast agents account for 30% of cases of acute tubular necrosis (ATN), and ischemia due to decreased renal perfusion accounts for more than 50% of cases
Characteristics of ATN are intratubular back leak (abnormal absorption of filtrate and decreased urine flow through the tubule), vasoconstriction, and changes in glomerular permeability. These processes result in a decrease of GFR, progressive azotemia, and impaired fluid and electrolyte balance.
Conditions such as burns, infections, crush injuries, and severe blood transfusion reactions can lead to intrarenal ARF and ultimately ATN
With burns and crush injuries, myoglobin (a CHON released from muscle when injury occurs) and hemoglobin are liberated, causing obstruction, renal toxicity, and ischemia
Medications such as NSAIDs and ACE inhibitors interfere with the normal auto regulatory mechanisms of the kidneys and may cause hypoperfusion and eventual ischemia.
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7. Postrenal – is usually the result of an obstruction somewhere distal to the kidneys. Pressure rises in the kidney tubules and eventually, the GFR decreases

8. Characteristics
Categories
Prerenal
Intrarenal
Postrenal
Etiology
Hypoperfusion
Parenchymal damage
Obstruction
BUN value
Increased
increased
Creatinine
Urine output
Decreased
Varies, often decreased
Varies, may be decreased, or sudden anuria
Urine sodium
Decreased to < 20 mEq/L
Increased to >40mEq/L
Varies, often decreased to 20mEq/L or less
Urinary sediment
Normal, few hyaline casts
Abnormal casts and debris
Usually normal
Urine osmolality
Increased to 500mOsm
About 350 mOsm similar to serum
Varies, increased or equal to serum
Urine specific gravity
Low normal
Varies

9. RISK FACTORS Advanced age
Blockages in the blood vessels in your arms or legs
Diabetes
High blood pressure
Heart failure
Kidney diseases
Liver disease
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10. Causes of Acute Renal Failure
A. Prerenal
1. Volume depletion resulting from:
a. hemorrhage
b. renal losses (diuretics)
c. GI losses (vomiting, diarrhea, NG suctioning)
2. Impaired cardiac efficiency resulting from:
a. MI
b. Heart failure
c. Dysrhythmias
d. Cardiogenic shock
3. Vasodilation resulting from:
a. sepsis
b. anaphylaxis
c. antihypertensive medications or other medications that cause vasodilation

11. Causes of Acute Renal Failure
B. Intrarenal
1. Prolonged renal ischemia resulting from:
a. pigment nephropathy (associated with the breakdown of blood cells containing pigments that in turn occlude kidney structures)
b. Myoglobinuria (trauma, crush injury, burns)
c. Hemoglobinuria (transfusion reaction, hemolytic anemia)
2. Nephrotoxic agents such as:
a. Aminoglycosides antibiotics (gentamicin, tobramycin)
b. Radiopaque contrast media
c. Heavy metals (lead, mercury)
d. Solvents and chemicals (carbon tetrachloride, arsenic)
e. NSAIDs, ACE inhibitors
3. Infectious processes such as:
a. acute pyelonephritis
b. acute GN
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12. Causes of Acute Renal Failure
C. Postrenal
1. Urinary tract obstruction, including:
a. calculi (stones)
b. tumors
c. BPH
d. Strictures
e. Blood clots
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13. Renal damage

14. Phases of ARF
Initiation – begins with the initial insult and ends when oliguria develops
2. The oliguric period is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys (uric acid, urea, creatinine, organic acids). In this phase uremic symptoms first appear and life-threatening conditions such as hyperkalemia develop.
3. The diuric period is marked by a gradual increase in urine output, which signals that glomerular filtration has started to recover.
4. The recovery period signals the improvement of renal function and may take 3-12 months. Lab values return to normal level. Although a permanent 1%-3% reduction in the GFR is common.

15. Difference between acute and chronic renal failure
History
Short (days-week)
Long (month-years)
Haemoglobin concentration
Normal
Low
Renal size
Reduced
Renal osteodystrophy
Absent
Present
Peripheral neuropathy
Serum Creatinine concentration
Acute reversible increase
Chronic irreversible
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16. CLINICAL FEATURES Symptoms and/or signs of renal failure:
weakness and
easy fatiguability (from anemia),
anorexia,
vomiting, mental status changes or
Seizures
edema
Systemic symptoms and findings:
fever
arthralgias,
pulmonary lesions
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17. Symptoms Vomiting and/or diarrhea, which may lead to dehydration.
Nausea. 
Weight loss. 
Nocturnal urination.
pale urine. 
Less frequent urination, or in smaller amounts than usual, with dark coloured urine
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18. Swelling of the legs, ankles, feet, face and/or hands.
Shortness of breath due to extra fluid on the lungs
Pain in the back or side
Feeling tired and/or weak.
Memory problems. 
Difficulty concentrating.
Dizziness.
Low blood pressure. 
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19. Other symptoms include
Anorexia
Pruritus
Seizures (if blood urea nitrogen level is very high)
Shortness of breath (if volume overload is present).
Decrease osmolality(A measurement of urine concentration that depends on the number of particles dissolved in it).
Increase urinary sodium.
Pericarditis.
Pericardial effusion.
Pleural effusion.
Decrease calcium and bicarbonate.
Defect in platelet functions
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20. Diagnosis History collection. Physical examination.
1 Asterixis and myoclonus
2 Peripheral edema (if volume overload is present)
3 Pulmonary rales (if volume overload is present)
4 Elevated right atrial pressure (if volume overload is present)
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21. INVESTIGATIONS Renal /bladder ultra sound. Renal scan.
Blood urea nitrogen and serum creatinine
CBC, peripheral smear, and serology
Urinalysis
Urine electrolytes
Serology: ANA,ANCA, Anti DNA, HBV, HCV, Anti GBM, cryoglobulin, CK, urinary Myoglobulin
Renal /bladder ultra sound.
Renal scan.
CT scans and MRI scan (to identify lesion and masses)
The urine will be examined under a microscope. 
biopsy
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22. Urinalysis Unremarkable in pre and post renal causes
Differentiates ATN vs. AIN. vs. AGN
Muddy brown casts in ATN
WBC casts in AIN
RBC casts in AGN
Hansel stain for Eosinophils
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23. MANAGEMENT AIM Optimization of hemodynamic and volume status
Avoidance of further renal insults
Optimization of nutrition
If necessary, institution of renal replacement therapy
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24. MANAGEMENT NUTRITIONAL THERAPY Provide protein diet.
Calorie requirements are met with high carbo-hydrate meals (carbo-hydrates have a protein-sparing effect. 
Foods and fluid containing potassium or phosphorous (banana, coffee) are restricted.
Patient may require parenteral nutrition.
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25. Medical and Pharmacological Treatment
correcting fluid and electrolyte balance.
Correct dehydration.
Keeps other body systems working properly
Furosemide, Torsemide, ethacrynic acid
calcium gluconate
Sodium bicarbonate
dialysis
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26. Pharmacologic Therapy
calcium carbonate (Os-cal) or calcium acetate (Phoslo) are prescribed to treat hyperphosphatemia and hypocalcemia
b. Antiseizure agents – diazepam (Valium) or phenytoin (Dilantin)
c. Antihypertensive and CV drugs - digoxin (Lanoxin) and dobutamine (Dobutrex)
d. Erythropoietin (Epogen) to treat anemia. It is initiated to reach a hematocrit of 33% and a target hemoglobin of 12g/dl.
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27. DIALYSIS
Is used to substitute some kidney functions during renal failure.
It is used to remove fluid and uremic waste products from the body when the kidneys are unable to do so.
It may be indicated to treat patients with edema that do not respond to treatment.
Acute dialysis is indicated when there is a high and increasing level of serum potassium, fluid overload, or impending pulmonary edema, increasing acidosis, pericarditis and severe confusion. It may also be used to certain medications or other toxins in the blood.
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28. Nursing Management
1. Assessing fluid status and identifying potential sources of imbalance. 2. implementing a dietary program to ensure proper nutritional intake 3. promoting positive feelings by encouraging increased self-care and greater independence. 4. Provide explanations and information to the patient and family concerning ESRD, treatment options and potential complications. 5. Provide emotional support to the patient and family.
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29. Indication for renal transplantation
Symptoms of uremia ( encephalopathy,…)
Uremic pericarditis
Refractory volume over load
Refractory hyperkalemia
Refractory metabolic acidosis
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30. Prevention
A careful history(nephrotoxic antibiotic agent aminoglycosides, gentamicin, tobramicine, etc.)
blood tests and urinalysis
Drink enough fluids
Difficulties urinating or blood in the urine should prompt a visit
Treat hypotension promptly.
Prevent and treat infections promptly.
Pay special attention to wound, burns and other precursors of sepsis.
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31. COMPLICATIONS Reduced level of consciousness. Immune deficiency.
ARF can affect the entire body
Infection
Hyperkalaemia,
Hyperphosphatemia
hyponatremia
 water overload
Pericarditis
Pulmonary edema.
Reduced level of consciousness.
Immune deficiency.
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32. Complications
Hyperkalemia due to decreased excretion, metabolic acidosis, catabolism and excessive intake (diet, meds and fluids)
2. Pericarditis, pericardial effusion and pericardial tamponade due to retention of uremic waste products and inadequate dialysis.
3. Hypertension due to sodium and water retention and malfunction of the R-A-A system
4. Anemia due to decreased erythropoietin production, decreased RBC life span, bleeding in the GIT from irritating toxins and ulcer formation, and blood loss during hemodialysis
5. Bone disease and metastatic and vascular calcifications due to retention of phosphorous, low serum calcium levels, abnormal vitamin D metabolism and elevated aluminum levels.
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33. THANK YOU
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