summary sheet in arf

SUMMARY SHEET OF ACUTE SENA FAILUR ((ARF))

CRITERIA OF ARF DIAGNOSIS:

I. Raising plasma urea and creatinine concentration.II. Rising plasma potassium ,sulphate & falling calcium and bicarbonate

III. A fall in urine volume to 400ml/day( 25% non oliguric)

AETIOLOGY OF ARF:

1.PRE-RENAL ----------–HYPOPERFUSION-----75%

2.RENAL -------------------RENAL PARENCHYMA DAMAGE OR DYSFUNCTION -10-20%

3.POST-RENAL------------ACUTE OBSTRUCTION OF THE URINE FLOW ---2-15%

WHAT ARE THE PRE-RENA CAUSES?

1. Hypovolemia2. Decreased cardiac out put3. Septicemic shock4. Renal artery occlusion5. Drugs causing reduction in renal blood flow

WHAT ARE THE RENAL CAUSES?

1. Vascular—HHS,TTP,DIC , vasculitis ,scleroderma ,malignant HTN ,eclampsia 2. Glomerular ---rapidly progressive glomerulonephritis3. Acute interstitial nephritis—

A. DrugsB. Infections –bacterial interstitial nephritis -----streptococal ,leptospiral ,EB virus,

Mycoplasma pneumonias ,legionella pneumophilia pneumonia

4. ATN------ A. Ischemia---prolonged pre-renal insult

B.Toxins-------myoglobinuria ,haemoglobinuria ,bens jones myeloma

WHAT ARE THE CAUSES OF POST-RENAL ARF?

A. Prostate hyperatrophy, urinary bladder tumor, pelvic tumorB. Drugs and crystals

1 DR MAGDI AWAD SASI 2014 ARF SUMMARY SHEET

NATURAL HISTORY OF ARF:

1. Incidence: 50 cases annually / million population(UK)1% OF all population2—5% major surgery5—15% intensive care units

2. Three phases:A. Initiating phase=precipitating factors ˂ 24 hours

B. Established oliguric phase (ATN) Few days 60 days

C. Recovery =diuretic phase1.Gradual increase in GFT and urine volume2.Gradual increase in tubular concentration ability3.Follow up of ARF cases (RFT never return to normal as before )4.Increased mortality rate=50% (up to 90% of patients with severe trauma ,sepsis ,multiple organ failure). Only 105 die as a result of ARF due to HYPERKALEMIA

HISTORY AND EXAMINATION OF A PATIENT WITH ARF:

1. ARF/CRF---- ARF AND stigma of CRF e.g.:I. Pigmentation and anemia

II. Pruritis and hypocalcemiaIII. Bone diseases

2. ARF due to 3 main causes:I. Pre –renal : compatable history

1. Check input/output2. Signs of dehydration----decreased CVP is the most important sign3. Body weight---- over loaded or dehydrated


4. Change in the urine characters which differentiate it from established ATN

5. Effect of fluid challenge and diuretic :A. Diuresis---prerenalB. Pulmonary oedema-----ATN

II. Renal(ATN)History of precipitating factorsClinical S&S of precipitating cause and acute uremiaComplication of ARF

III. Post –renal:History of renal symptoms---renal colic ,haematuriaAnurea (˂50 ml/day)Full urinary bladder (abdomen palpation and USS adomen)Palpable kidney’s tumor

CLINICAL POINTS TO BE REMMEBERED:1. ATN is the commonest histology in ARF secondary to pre-renal causes or nephrotoxic drugs.2. A urine output ˂25-30ml/hour in adult should be investigated and urgently corrected. If oliguria persists ˃2-3 hour, it may be irreversible3. The simplest screening test for RF in ICU patients are : I. Hourly urine output ( at least 0.5ml/kg/hour) II. Accurate I/O fluid chart

III. Daily serum creatinine assessment 4.Rhabdomyolysis-----myoglobinuria---it is a cause of hypercatabolic ARF and hypocalcemia and hyperphosphatemia ( hypercalcemia occur in recovery phase).

SUMMARY OF ARF MANAGEMENT

Initial assessmentResuscitation


Management of emergencies

Exclude prerenal element

Renal ultrasound

Dilated pelvicalyceal system normal sized kidneys small kidneys /PCKD

OBSTRUCTION HISTORY COMPATIBLE ATN H/O NOT COMBATIPLE ATN ACUTE ON CRF

OR HISTORY AND EXAMINATION

SUGGESTIVE OF 1RY PARENCHYMAL DISEASE

SURGERY RENAL BIOPSY

MANAGEMENT OF ESTABLISHED ACUTE RENAL FAILURE

RECOVERY---MANAGEMENT OF RECOVERY PHASE NON RECOVERY IN 3—4WEEKS

FURTHER INVESTIGATIONS INCLUDING RENAL BIOPSY TO EXCLUDE OTHER DX


summary sheet in arf

Health & Medicine