ACUTE RENAL FAILURE

Dr. KAW Karunasekera

Definition

When renal function decrease to a point where the body fails to maintain normal homeostasis & to excrete waste products

Types
Pre-renal Any type of shock Renal HUS GN Cortical necrosis Poisoning Hepatorenal Post-renal Post. urthral valves B/L uret. obstr Stones- rare

Clinical features

Evidence of aetiology Oliguria / Anuria

Biochemical changes
Pre-renal U.osm. >400mmol /L U.Na+ <30mmol/L Pl. creat:BU High Urine:plasma uria >10 Fractional excret. <2.5% of Sodium Renal Less High High <10 >2.5%

Clinical test to differentiate types

N.saline 20ml/kg iv for 30min ............................................. Type title here

Good UOP

No UOP

Pre-renal

iv frusemide twice 1-2 hrs apart

good .......................................... UOP No UOP

Pre-renal

Established RF

Investigations

Creatinine Na+ K+ Calcium Phosphate

- Increase - Normal/reduce - Normal/increase - Reduce - Increase

Post renal - USS

Management

Best manage at ICU Monitoring Wt, BP, physical examination UOP / intake BU, SE Ca2+, Phoshpate, blood gas ECG monitoring, CVP

Hyperkalaemia

> 6 mmol/L ---> Dangerous K+ monitoring is essential S. Electrolytes ECG monitoring when >5.5 mmol/L T elv., ST dep,length.PR, wide QRS, VF Treat with +ve ECG /6mmol /L----> measurements to dec.K+

Treatment

No K+ containing food and fluids K exchange resins 1g/Kg ,Caresonium Correct acidosis

Emergency Treatment

10% Ca-gluconate 0.5ml/kg IV 5-10 min Insulin + Dextrose IV 50% dextrose 1ml/kg= .5g/kg S.Insulin 1 unit/ 5g glucose 1 unit + 10ml 50% dextrose Dialysis

Hyponatraemia
Fluid restriction Dialysis for Symptomatic Na dec. Hypocalcaemia & Hyperphoshpataemia Phoshpate restriction in the diet Ca-gluconate for symptomatic Ca2+ dec. Correction of acidosis

Met. acidosis
- ph <7.2 correct the HCO3 NaHco3 mmol = 0.3 x wt(kg)x (12(1/2 the dose ) serumHCo3) - if not severe ----> oral HCO3 - Peritonial dialysis

Hypertension

Fluid reduction Drugs Diazoxide 2-10 mg/kg IV Hydralazine .2-.8mg/kg IV Nifedipine .2- .5mg/kg Propranalol

Convulsion

Dec. Na, dec.Ca2+, HT, Uraemia disease itself Treatment IV/ Rectal diazepam /Phenobarb Treat the cause Nutrition - Adequate diet pro 0.5mg/kg may need NG feeding

Management contd.

Infecions - Look for evidence - AB Dialysis - peritoneal

Peritoneal dialysis

Indications and clinical condition

Fluid overload K+ ,Na+ , acidosis, Ca2+ , Phosphate Uraemia Nephrotoxins Dialysate 30 ml / kg

Prognosis

Depend on the aetiology HUS ,GN ,SB----> Good Other GN ------> Not good

Complications

Fluid overload Arrhythmia HT -----> E pathy Uraemia -------> Epathy GI bleeding , fits

Haemolytic Uraemic Syndrome

ARF Thombocytopaenia Anaemia

Aetiology
Shigella dysenteriae E-coli 0157:H7 Viruses

Clinical fetures

Diarrhoea Oliguria Abdominal pain, GI bleeding, Pallor Fever Lethargy, Bleeding manifestation Hypertension Fits

Investigations

Renal function test Full Blood Count Hb Fragmented RBC Polymorphonuclear leukocytosis Thrombocytopaenia UFR - RBCs

Treatment

Anaemia - 10ml/kg packed cells slow transfusion Platelet transfusion for severe thrombocytopaenia Management of renal failure including early peritoneal dialysis