arf kuliah 05
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dokTRANSCRIPT
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Acute Renal FailurePathogenesis and
TreatmentLestariningsih
Subbag Nefrologi/Hipertensi Bagian Penyakit Dalam
FK UNDIP/RS Dr. Kariadi Semarang
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Definition• Abrupt sustained decline in GFR• Rising serum urea and creatinine• Loss of water and salt homeostasis• Life threatening metabolic sequelae• Occurs over hours or days• Incidence approximately 140 p.m.p. per
year• 5% of all surgical and medical admissions
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Subtypes
• Acute or acute on chronic• Single organ or multi-organ failure• Oliguric or polyuric• Mild or severe
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Aetiology
• Pre-renal ARF • Intrinsic ARF• Post-renal ARF
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Pre-renal ARF• Reversible fall in GFR due to renal hypoperfusion
– Hypovolaemia• Haemorrhage, burns, GI fluid loss, renal fluid
loss– Hypotension
• Cardiogenic shock, sepsis– Renal hypoperfusion
• renal vasoconstriction, drugs, liver disease, renal vascular disease
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Renal ARF
• Disease of the renal parenchyma– ATN
• Ischaemia, direct toxicity, myoglobin, sepsis– Vascular disease
• Vasculitis, atheroemboli, infarction– Diseases of glomeruli/arterioles
• RPGN, myeloma, HUS, vasculitis, SLE– Tubulo-interstitial nephritis
• Drug related, paraneoplastic
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Post-renal ARF
• Renal failure secondary to urinary tract obstruction– Ureteric
• Calculi, carcinoma, retroperitoneal fibrosis, stricture
– Bladder neck• prostatic hypertrophy/malignancy, carcinoma,
neuropathy, blocked catheter
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Prevention• Identify at risk patients
– pre-existing CRF, diabetes, jaundice, myeloma, elderly
• Optimise renal perfusion– IV fluids, inotropes, central line
• Maintain adequate diuresis– Mannitol, frusemide, NOT dopamine
• Avoid nephrotoxic agents– ACE inhibitors, NSAIDS, radiological contrast,
aminoglycosides
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Cockcroft Gault equation
(140-age in years) x weight in kgserum creatinine (μmol/L)
(corrected for males x 1.23, females x 1.04)
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Principles of investigation
• Acute or acute on chronic?• Exclude volume depletion• Exclude renal tract obstruction• Exclude major vascular occlusion• Exclude renal parenchymal disease other
than ATN
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History• When did it start?• What was the baseline renal function?
– Pre -existing medical conditions• What were the likely insults?
– Episodes of hypotension– Nephrotoxic agents– Sepsis
• Symptoms of other diseases
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Examination
• Current volume status– Skin turgor, oedema, lung bases, heart
sounds, central pressures, blood pressure• Bladder and kidneys• Signs of systemic disease
– rashes, anaemia,
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Investigations• Laboratory
– U+E’s, Bone, Glucose, Urate, Bicarbonate– Urine urea, sodium, creatinine, protein– FBC, Clotting, ESR– Urine microscopy, MSU, blood cultures– CRP, ANA, ANCA, anti GBM, myeloma
screen
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Investigation
• Radiology– Plain abdomen, renal U/S, IVU, CT
scanning, renal angiography, isotope renography
• Renal biopsy
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Treatment• Correct renal perfusion
– Optimise volume status– Inotropes ( dopamin 3 ug/kgBB/jam )
• Remove nephrotoxins• Relieve obstruction - Bladder catheter
– Nephrostomies
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Treatment
• Make the patient safe• Hyperkalaemia
– Volume overload– Uraemia– Acidosis
• Specific treatments– Antibiotics, steroids
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Methods of treatmentDRUG
Calcium Gluconate
Glucose + Insulin
IV Na Bicarbonate
Ventolin Nebuliser
Resonium
Bendrofluazide
DOSE
10 ml of 10%
50 ml 50% + 8U
1l of 1.4%
5 ml
30 - 60 g (po/pr)
5mg
DURATION
30 minutes
1 - 4 hours
1 - 8 hours
1 - 4 hours
days
days
and there is always dialysis!
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Dialysis
• Acute intermittent haemodialysis• Continuous dialysis treatments• Peritoneal dialysis
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Outcome
• Full recovery• Partial recovery• No recovery - progress to ESRF• Death
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