management of arf

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Management of Management of Acute Renal Failure Acute Renal Failure Dr. Sachin Verma MD, FICM, FCCS, ICFC Dr. Sachin Verma MD, FICM, FCCS, ICFC Fellowship in Intensive Care Medicine Fellowship in Intensive Care Medicine Infection Control Fellows Course Infection Control Fellows Course Consultant Internal Medicine and Critical Consultant Internal Medicine and Critical Care Care Web:- Web:- http://www.medicinedoctorinchandigarh.com Mob:- +91-7508677495 Mob:- +91-7508677495 References References Brenner & Rector’s The Kidney, 7 Brenner & Rector’s The Kidney, 7 th th ed. ed. Harrison’s Principles of Internal Medicine, Harrison’s Principles of Internal Medicine, 16 16 th th ed. ed.

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Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.

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Page 1: Management of arf

Management of Management of Acute Renal FailureAcute Renal Failure

Dr. Sachin Verma MD, FICM, FCCS, ICFCDr. Sachin Verma MD, FICM, FCCS, ICFC

Fellowship in Intensive Care MedicineFellowship in Intensive Care Medicine

Infection Control Fellows Course Infection Control Fellows Course

Consultant Internal Medicine and Critical CareConsultant Internal Medicine and Critical Care

Web:- Web:- http://www.medicinedoctorinchandigarh.com

Mob:- +91-7508677495Mob:- +91-7508677495

ReferencesReferences Brenner & Rector’s The Kidney, 7Brenner & Rector’s The Kidney, 7thth ed. ed. Harrison’s Principles of Internal Medicine, 16Harrison’s Principles of Internal Medicine, 16thth ed. ed.

29/9/0529/9/05

Page 2: Management of arf

DefinitionDefinition

Acute renal failure is a syndrome Acute renal failure is a syndrome characterized by a rapid (hours to week) characterized by a rapid (hours to week) decline in GFR and retention of decline in GFR and retention of nitrogenous waste products such a BUN nitrogenous waste products such a BUN and creatinineand creatinine

Page 3: Management of arf

Etiology & Classification of ARFEtiology & Classification of ARF

A. Pre renal azotemia (55-60%)A. Pre renal azotemia (55-60%) Intravascular volume depletionIntravascular volume depletion Decreased cardiac output Decreased cardiac output Renal vasoconstrictionRenal vasoconstriction

B. Acute intrinsic renal azoteniaB. Acute intrinsic renal azotenia Disease involving large renal vesselsDisease involving large renal vessels Diseases of glomeruli and renal microvasculature Diseases of glomeruli and renal microvasculature Injury to renal tubules. Exogenous toxins and Injury to renal tubules. Exogenous toxins and

endogenous toxins endogenous toxins Acute disease of tubulo interstitium. Acute disease of tubulo interstitium.

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C. Post renal azotemiaC. Post renal azotemia Ureteric obstruction (Intraluminal, intramural, Ureteric obstruction (Intraluminal, intramural,

Extraureteric, periureteric)Extraureteric, periureteric) Bladder neck obstruction Bladder neck obstruction Uretheral obstruction Uretheral obstruction

Etiology & Classification of ARFEtiology & Classification of ARF

Page 5: Management of arf

Clinical Approach to the Clinical Approach to the Diagnosis of ARFDiagnosis of ARF

History (Drug history)History (Drug history)↓↓

Physical examination (Fundus & Weight)Physical examination (Fundus & Weight)↓↓

UrinanalysisUrinanalysis↓↓

Flow chart of serial BP, Wt, BUN, S. Cr. Flow chart of serial BP, Wt, BUN, S. Cr. Major clinical events interventionsMajor clinical events interventions

↓↓Routine blood chemistry Routine blood chemistry

↓↓Radiologic evaluation (plain abdominal film)Radiologic evaluation (plain abdominal film)

Renal USG, IVP, renal angiography, MR angiography Renal USG, IVP, renal angiography, MR angiography ↓↓

Renal Biopsy Renal Biopsy

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Clinical Assessment Clinical Assessment

Pre renalPre renal Fluid loss in any formFluid loss in any form Symptoms of thirstSymptoms of thirst Orthostatic dizziness and hypotension Orthostatic dizziness and hypotension TachycardiaTachycardia Decreased skin turgor dry mucus membrane Decreased skin turgor dry mucus membrane Decreased axillary sweatingDecreased axillary sweating

Definitive diagnosisDefinitive diagnosis Resolution of ARF after restoration of renal Resolution of ARF after restoration of renal

perfusionperfusion

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IntrinsicIntrinsic Increased muscular activity (Rhabdomyolysis)Increased muscular activity (Rhabdomyolysis) Recent transfusion (Hemolysis) Recent transfusion (Hemolysis) Flank pain Flank pain Hyperreflexia and asterixisHyperreflexia and asterixisPost renalPost renal Suprapubic pain (Acute distension of bladder)Suprapubic pain (Acute distension of bladder) Colicky flank pain radiating to groin Colicky flank pain radiating to groin Definitive diagnosisDefinitive diagnosis Radiologic investigation and rapid improvement Radiologic investigation and rapid improvement

in renal function after relief of obstruction in renal function after relief of obstruction

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UrinanalysisUrinanalysis1. Urine volume1. Urine volume

2. Urine sediment 2. Urine sediment Acellular / Transparent hyaline cast (pre renal)Acellular / Transparent hyaline cast (pre renal) Pigmented “muddy brown” granular cast, tubule epithelial Pigmented “muddy brown” granular cast, tubule epithelial

cell cast (renal)cell cast (renal) Benign sediment, hematuria, pyuria (post renal)Benign sediment, hematuria, pyuria (post renal) Broad granular cast characteristics of chronic renal disease Broad granular cast characteristics of chronic renal disease

and reflect interstitial fibrosis and dilatation of tubulesand reflect interstitial fibrosis and dilatation of tubules Granular cast Granular cast

ATN, GN / vasculitis, Interstitial nephritis ATN, GN / vasculitis, Interstitial nephritis RBC cast RBC cast

GN / Vasculitis, Malignant hypertension GN / Vasculitis, Malignant hypertension

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WBC cast WBC cast Acute interstitial nephritis, Severe pyelonephritis, Acute interstitial nephritis, Severe pyelonephritis,

Marked leukemic or lymphomatous infiltration Marked leukemic or lymphomatous infiltration

3. Eosinophiluria (>5%)3. Eosinophiluria (>5%) Drug induced allergic interstitial nephritis Drug induced allergic interstitial nephritis

4. Crystalluria4. Crystalluria Uric acid crystals (pleomorphic), oxalate (envelop Uric acid crystals (pleomorphic), oxalate (envelop

shaped), Hippurate (needle shaped)shaped), Hippurate (needle shaped)

5. Tubule proteinuria (<1g/d)5. Tubule proteinuria (<1g/d) : proximal tubule cell injury, : proximal tubule cell injury, glomerular proteinuria (>1g/d)glomerular proteinuria (>1g/d) injury to glomerular injury to glomerular ultrafiltration barrier ultrafiltration barrier

6. Haemoglobinuria6. Haemoglobinuria

7. Myoglobinuria7. Myoglobinuria

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Confirmatory testConfirmatory test

Plain abdominal film Plain abdominal film USG USG CT Scan CT Scan Radio nuclide scan Radio nuclide scan MRAMRA

Doppler USG and Spiral CTDoppler USG and Spiral CT Contrast angiography (Gold standard)Contrast angiography (Gold standard) Renal biopsy Renal biopsy

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FENa (Fractional Excretion FENa (Fractional Excretion of Na+(%) of Na+(%)

Most sensitive index to differentiate pre renal Most sensitive index to differentiate pre renal azotemia from ATN azotemia from ATN

UNa X PcrUNa X Pcr <1 prerenal <1 prerenal

PNa X UcrPNa X Ucr >1 ATN>1 ATNX100

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TreatmentTreatment

Pre renal azotemiaPre renal azotemia Correction of Hypovolemia by packed red cells, Correction of Hypovolemia by packed red cells,

isotonic saline, Hypotonic saline (0.45%)isotonic saline, Hypotonic saline (0.45%) Loop blocking diuretic, (Frusemide high dose 20 Loop blocking diuretic, (Frusemide high dose 20

– 160 mg orally or IV twice daily) to effect – 160 mg orally or IV twice daily) to effect adequate diuresis and convert oliguric to non-adequate diuresis and convert oliguric to non-oliguric RF. oliguric RF.

ARF with cirrhosis (fluid challenge) paracentesis ARF with cirrhosis (fluid challenge) paracentesis with albumin administrationwith albumin administration

Renal dose dopamine (1-3 mg/kg/min) Renal dose dopamine (1-3 mg/kg/min)

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TreatmentTreatmentIntrinsic ATNIntrinsic ATN Optimization of CV function & intravascular Optimization of CV function & intravascular

volume volume Prophylactic oral acetylcysteine (600 mg BD 24 Prophylactic oral acetylcysteine (600 mg BD 24

hour before and after procedure) hour before and after procedure) Use of less nephrotoxic contrast agent Use of less nephrotoxic contrast agent

(Gadolinium and CO(Gadolinium and CO22)) Cautious use of diuretics, NSAIDs, ACE inhibitorsCautious use of diuretics, NSAIDs, ACE inhibitors Lipid encapsulated formulation of amphotericin B Lipid encapsulated formulation of amphotericin B Allopurinol (Acute urate nephropathy)Allopurinol (Acute urate nephropathy) Amifostine an organic thiophosphate (Cisplatin) Amifostine an organic thiophosphate (Cisplatin)

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Forced diuresis and alkanization of urine Forced diuresis and alkanization of urine (Rhabdomyolysis)(Rhabdomyolysis)

N Acetylcysteine within 24 hour N Acetylcysteine within 24 hour (Acetaminophen)(Acetaminophen)

Dimercaprol (Chelating agent) (heavy metal)Dimercaprol (Chelating agent) (heavy metal) Ethanol (ethylene glycol toxicity)Ethanol (ethylene glycol toxicity) Plasma pharesis (Myeloma cast nephropathy) Plasma pharesis (Myeloma cast nephropathy) Systemic arterial pressure control (malignant Systemic arterial pressure control (malignant

htpertensive nephrosclerosis)htpertensive nephrosclerosis) Acute GN (pulse glucocorticoid therapy)Acute GN (pulse glucocorticoid therapy)

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ANPANP 28 amino acid polypeptide. Synthesized in cardiac 28 amino acid polypeptide. Synthesized in cardiac

atrial muscle. Increased GFR by triggering afferent atrial muscle. Increased GFR by triggering afferent arteriolar vasodilatation and increasing ultrafiltration. arteriolar vasodilatation and increasing ultrafiltration. Inhibits Na transport and lower oxygen requirement. Inhibits Na transport and lower oxygen requirement.

Post renal ARFPost renal ARF Transuretheral or suprapubic placement of bladder Transuretheral or suprapubic placement of bladder

catheter (obstruction of urethra or bladder neck) catheter (obstruction of urethra or bladder neck) Percutaneous catheterization of dilated renal pelvis or Percutaneous catheterization of dilated renal pelvis or

ureter (ureteric obstruction) ureter (ureteric obstruction) Removal of obstructing lesion percutaneously or Removal of obstructing lesion percutaneously or

bypassed by insertion of ureteric stentbypassed by insertion of ureteric stent

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Management of complicationManagement of complication

Intravascular volume overloadIntravascular volume overload Salt (1-2 gm/day) and water (<1 lt/day) restrictionSalt (1-2 gm/day) and water (<1 lt/day) restriction Diuretics, usually loop Diuretics, usually loop ++ thiazide thiazide Ultrafiltration or dialysis Ultrafiltration or dialysis

HyponatremiaHyponatremia Restriction of enteral free water intake (<1lt/day)Restriction of enteral free water intake (<1lt/day) Avoid hypotonic intravenous solution (including Avoid hypotonic intravenous solution (including

dextrose)dextrose)

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HyperkalemiaHyperkalemia Restriction of dietary KRestriction of dietary K++ intake (<40 mmol/day) intake (<40 mmol/day) Eliminate KEliminate K++ supplement and K supplement and K++ sparing diuretic, sparing diuretic, Potassium binding ion-exchange resin (Na Potassium binding ion-exchange resin (Na

polystyrene sulphonate)polystyrene sulphonate) Glucose (50 ml of 50% Dextrose) and insulin (10 Glucose (50 ml of 50% Dextrose) and insulin (10

U regular) U regular) NaCONaCO33 (50-100 mmol) (50-100 mmol) Calcium gluconate (10 ml of 10% solution) over 5 Calcium gluconate (10 ml of 10% solution) over 5

minuteminute Dialysis (with low KDialysis (with low K++ dialysate) dialysate)

Page 18: Management of arf

Metabolic acidosisMetabolic acidosis Restriction of dietary protein (0.6 g/Kg/day of high Restriction of dietary protein (0.6 g/Kg/day of high

biologic value)biologic value) Na bicarbonate (maintain serum bicarbonate >15 Na bicarbonate (maintain serum bicarbonate >15

mmol/L or arterial pH >7.2) mmol/L or arterial pH >7.2) Dialysis Dialysis

HyperphosphatemiaHyperphosphatemia Restriction of dietary phosphate intake (<800 Restriction of dietary phosphate intake (<800

mg/day)mg/day) Phosphate binding agents (Ca carbonate, Phosphate binding agents (Ca carbonate,

Aluminium hydroxide)Aluminium hydroxide)

Page 19: Management of arf

HypocalcemiaHypocalcemia Calcium CarbonateCalcium Carbonate Calcium gluconate (10 – 20 ml of 10% solution) Calcium gluconate (10 – 20 ml of 10% solution)

HypermagnesemiaHypermagnesemia Avoid MgAvoid Mg2+2+ containing antacids containing antacids

HyperuricemiaHyperuricemia Treatment usually not necessary (<15 mg/dl)Treatment usually not necessary (<15 mg/dl)

NutritionNutrition Restriction of dietary protein (0.6 g/kg/day)Restriction of dietary protein (0.6 g/kg/day) Carbohydrate (100 g/day)Carbohydrate (100 g/day) Enteral / Parenteral nutritionEnteral / Parenteral nutrition

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Indication for DialysisIndication for Dialysis

Clinical evidence (signs & symptoms) of uremia Clinical evidence (signs & symptoms) of uremia Intractable intravascular volume over loadIntractable intravascular volume over load Hyperkalemia Hyperkalemia Severe acidosis (resistant to conservative Severe acidosis (resistant to conservative

measures)measures) Prophylactic dialysis when urea >100-150 mg/dl Prophylactic dialysis when urea >100-150 mg/dl

or creatinine >8-10 mg/dlor creatinine >8-10 mg/dl

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OutcomeOutcome

Mortality rate approximately 50%Mortality rate approximately 50% Poor prognosis – Oliguria (<400 mg) or serum Poor prognosis – Oliguria (<400 mg) or serum

creatinine (>3 mg/dl), older debilitated patient creatinine (>3 mg/dl), older debilitated patient and multiple organ failure at the time of and multiple organ failure at the time of presentation presentation

50% subclinical impairment of renal function 50% subclinical impairment of renal function 5% never recover (require dialysis or 5% never recover (require dialysis or

transplantation)transplantation) 5% progressive decline in GFR5% progressive decline in GFR

Page 22: Management of arf