RENAL FAILURE

DR..M.H.MUMTAZ

TYPES1, REVERSIBLE DYSFUNTION (acute R.failure)2, IRREVERSIBLE DYSFUNTION (Chronic R failure)

ACUTE RENAL FAILURE 1, PRE RENAL 2, RENAL 3, POST RENAL

PRE RENAL FAILURECAUSES a,total body water depletion b,water redistribution ivs--------iss vasodilation,sepsis,anaphy. c,low CO--------low BP (S,M.D)

RENAL a, Interstitial nephritis b, A.T.N. hypoperfusion chemical trauma , toxins sepsis

PATHOLOGY T.obstruction T.damage

T.backleakage

DIAGNOSIS a,History oligurea,concentrated U b,Tests lab. Serum,urine radiodiagnostics C.T. MRI. Ultrasount

ALTERNATIVE CLASS. Filteration failure Tubular dysfuntion

Oliguric/non oliguric

RISK FACTORSAcute diseases sepsis SIRS jaundice I.A.P. renal trauma transfusion DIC

Anaphylaxis muscle injury thermal burn electrocution

RISK FACTORS CHRONIC DISEASES advancing age diabetes mellitis renal disease vascular disease hyperuricaemia

RISK FACTORS Physiological changes 1. ^ age 2. ^ HR hypotension ^ CVP, lowRVPP high or low co,svr abnormal OER olig/polyurea

3. Fluid balance Oedaema high/low protein intake

RISK FACTORS Chronic drug therapy NSAIDS Diuretics Cyclosporins

RISK FACTORSAcute drug therapyA. ATN aminoglycosides cephalosporins diuretics contra. rifampicin lithium cisplatin

B. Interstitial nephritis cephalosporins diuretics aspirin,NSAIDS cemetidine captopril

RISK FACTORS Proceedures a. Aortic/renal cross clamping b.Transfusion c. Major surgery

RISK FACTORS IMPAIRED RBF hypotension/m.hypertension renal art. Occlosion hepatorenal failure endotoxaemia renal vein thrombosis renal venous hypertansion

RISK FACTORS Metaboic causes 1. Electrilytes hyper-cal hypo-k hyper-phosphate 2. High oncotic P.

3. Metabolites Pigments bilirubin myoglobin haemoglobin

RISK FACTORS Post-renal urethral/blader obs. bil.ureter obs. stones/clot/tumur papillary necrosis

Retroperitoneal fibrosisSurgical ligationBlader ruptureRenal pelvic traumaUrethral trauma

ACUTE TUBULAR NECROSIS PHASES

a,Initiation phase

b,Maintenance phase

INITIATION PHASEISCHAEMIA ^ symp.stimulation ^ renin activity PGE2 ANH inhibition ^ ADH ^ adenosine ^ endothelinNEPHROTOXINS

Ischaemia increases the

susceptibility to

nephrotoxic agents

MANTENANCE PHASEFactors acting to maintain filteration failure 1,tubular obstruction 2,tubular backleak 3,vasodilatation of efferent art. 4,decreased GMP

Mechanism of oligurea a,glomerulo-tubular balance

b,decreased GMP

c,itratubular obstruction d,interstitial oedema e,cortical ischaemia

Complications of ARF/ATNA,oligurea

absolute

relativeB, azotaemia normal solute load maximum in catabolic states in ARF ^ urea/d ^ cr/d

ComplicationsC,Biochamical ^NaCl/water ^ K ^ HPO4 hypocalcaemia ^ Mg ^ uric acid M.acidosisD,Haematological Anaemia Thrombocytopaenia

Leukocyte dysf.

ComplicationsE,Immunosupression Lumphopaenia Reduced IgG Reduced comple. Impaired PMN R.I.response Drug effects Infections

F,C.V.S. CCF Hypertention Arrhythmias Pericarditis Effusion

ComplicationsG, G.I.T.

Anorexia,Nausea, Ileus,Hmge.

H,Neurological Lethargy,somnolance Confusion, Convulsions ^ sensitivity to anaesthetics

ComplicationsI,causes of pulmonary infilterates in ARF 1,LVF/CCF 2,bacterial pmeumonia 3,Atypical pneumonia 4,Septicaemia 5,ARDS 6,Autoammune diseases

Causes of Acidosis in ARFA,Tubular dysfuntion

B,Glomerular dysfuntion

C,Other causes low C.O. Resp.F Starvation

Rhabdomyolysis Hyperkalaemia Organic acids

INVESTIGATIONS IN ARFBiochemistry

INVESTIGATIONS

Investigations-1, Biochemistry

Definitions RFI=RENA FAILURE INDEX =urine(Na)/(U/P creatinine)

FEna=%fractional excretio Na

=(U/P Na).100/(U/P creatinine)

Abnormal urea/creatinine ratio

Normal U:C ratio 100:1( R;70-150)

Pre-renal disease >200:1

Abnormal urea/creatinine ratio

High Ratio ^ urea .dehydration/hypovol. .GIT.bleeding .Catabolic state .Hyperalimentation .Drugs low creatinie .elderly,low m. mass

Abnormal urea/creatinine ratioLow Ratio low urea. Liver failure hepato-renal synd Malnutrition High creatinie rhabdomyolysis acute m.disease ketones,drugs

CREATININE CLEARANCE1, clearance(ml/min=(N-age[years])*BW(kg)/serum creat. N = 150 foe female N = 160 for male > 70 N = 170 for male < 70 2, clearance(ml/min)=UV*1000 /p*420 U=urine creatinine level V=urine volume (midnight &7 am) P= plasma creatinine level

2. Urinary sediment.Cast types i,hyaline casts, fever,diuretics,RD ii,red cell casts glomerulonephritis iii,w.cell casts pyelonephritis iv,waxy casts chronic renal disease

3,Imaging 1, Ultrasound 2, CT scan 3, IV pylogram 4, radio-isotope perfusion scan 5, renal angiogram

4,Renal biopsy 1, glomerulonephritis 2, vasculitis 3, SLE 4, Goodpasture syndrome 5, TTP 6, Interstitial nephritis 7, oligurea lasting > 8 weeks

Renal failureprophylaxis&protectionMethods 1, physiological 2,physical 3,pharmacological 4,replacement therapies

Physiological methods a, normalise blood volume iv fluids,(Na containg) b,optimise cardiac output iv fluids.inotropes,vasopressors c, optimise O2 delivery Hb,Spo2,avoid acidosis d, high sodium excretion

Physical methods Detection/management of IOH Detection/management-post renal obs. Limitation of aortic clamp times Avoidance of embolisation Minimise direct trauma

Pharmacological methods Avoid nephrotoxins Avoid inhibitors of autoregulation Diuretics Renodilators Other agents free radical scavengers Ca channel blockers

Renal replacement methods Haemo- filtration

Haemo-diafiltration

Haemodialysis

R. Transplant.

Renal failure---FrusemideBeneficial effects Increased tubular&urine flow Increase Na &osmolar clearance Decreased tubular O2 demand Stimulate vasodilator prostaglandinsDeleterious effects Hypovolaemia Hypokalamia,Hyponatraemia Ototoxicity

Uses in non renal failure Fluid overload Cerebral oedema Hyperkalaemia Renal protection ( decreased O2 demand)

Renal failure---Mannitol 1,Osmotic diuresis

2,Anti sludging ,tubular protect.

3,renal vasodilatory PG synthesis 4,Free radical scavenger 5,Decreased T. swelling

Renal failure---Dopamine Increases Fe Na excretion Increases urine out put Does not increase creatinine clearance Inotropic effect Doesnot prevent ac.renal failure Side effects, gastric stasis,inhibition of ant pit.hormones,hypoxic drive depression.

Renal failure---Nor-adrenaline

Increases perfusion pressure by increase

of efferent arteriolar resistance

more than afferent art.resistance

Other therapies 1,Calcium channel blockers 2,Adenicine recepter antagonists 3,Oxypentifylline 4,Chlorpromazine 5,Clonidine 6,ATP-MgCl2 7,ANF

Conclusion,Renal rescue therapyNormalise;- Blood flow blood volume blood pressure O2 delivery COCI Blood Pressure, s,m,d.