Acute and Chronic
Renal Failure
By
Dr. Hayam Hebah
Associate professor of Internal Medicine
AL Maarefa College
Objectives:
O Definition
O Classification
O Signs and symptoms
O Lab diagnosis
O Complications
O Management
Function of the normal
kidneys:
-DETOXIFICATION of wastes.
-ENDOCRINE FUNCTION:
*Erythropoietin
*active form of vitamin D
*renin
-BODY FLUIDS AND ELECTROLYTES
REGULATION.
Classifications
O Acute versus chronic
O Pre-renal, renal, post-renal
O Anuric, oliguric, polyuric
Acute Versus Chronic
O Acute
O sudden onset
O rapid reduction in urine output
O Usually reversible
O Tubular cell death and regeneration
O Chronic
O Progressive
O Not reversible
O Nephron loss
ACUTE RENAL
FAILURE
AKI:
O It is sudden and usually reversible loss of
kidney function which develops over days or
weeks and usually accompanied by
reduction of urine volume.
O Rise of serum creatinine may be :
---acute injury
------acute on chronic kidney disease.
Causes of AKI:
O PRERENAL:-cardiac failure
-sepsis
-blood loss or dehydration.
-vascular occlusion
RENAL:- glomerulonephritis
- interstitial nephritis.
- small vessel vasculitis
- ATN.
- drugs , toxins, infections.
POST RENAL:- stones
-SEP
-prostatic or cervical cancer
-urethral valve or stricture or meatal stenosis.
Symptoms of ARF:
O c/p in volume
overloaded
patient .
Pulmonary edema x-ray
O c/p of
O Dehydrated
man with
-Sunken eyes ,
-Dry mouth,
-Loss of skin
turgor ,
-oliguria
Hyperkalemia symptoms:
O Weakness
O Lethargy
O Muscle cramps
O Paresthesias
O Hypoactive DTRs
O Dysrhythmias
Investigations of patients with
AKI:
A. Confirmation of AKI: urea and creatinine.
B. Complications:- electrolytes : k, calcium
and phosphate
- anemia: CBC -ECG
C. Cause of renal failure: urine analysis, urine
C&S, CRP, Abdominal u/s , renal biopsy.
CPK
D. Serology : HIV & hepatitis serology if urgent
dialysis is indicated
MANAGEMENT OF AKI:
1-Hemodynamic status :correct hypovolemia and
optimise systemic hemodynamics with inotropes if
necessary.
O 2-Hyperkalemia :
O Calcium gluconate (carbonate)
O Sodium Bicarbonate
O Insulin/glucose
O Kayexalate
O Lasix
O Albuterol
O Hemodialysis
.
3- Acidosis: sodium bicarbonate if PH<7
4-Cardiopulmonary complications:( pulmonary
edema): -dialysis
- massive diuresis
5-electrolytes disturbance
6-fluid management : match intake to output
(with 500ml for insensible losses).
7-discontinue nephrotoxic drugs and reduce
dose of medications according to renal
function level.
8- Ensure adequate nutritional support
 Treatment of any intercurrent infections.
 -PPI for reduction of upper GIT bleeding risk.
O Treatment of the primary cause e.g steroids
and immunosuppressives in cases of
crescentic GN.
O Surgical relieve of obstructions
O Dialysis may be needed :
- hemodialysis
-CRRT.
- Peritoneal dialysis.
Chronic
Renal
Failure
Stages in Progression of Chronic Kidney Disease
and Therapeutic Strategies
Complications
Normal
Screening
for CKD
risk factors
Increased
risk
CKD risk
reduction;
Screening for
CKD
Damage
 GFR
Kidney
failure
Diagnosis
Estimate
Replacement
& treatment; progression;
by dialysis
Treat
Treat
& transplant
comorbid complications;
conditions;
Prepare for
Slow
replacement
progression
CKD
death
Prevalence of CKD in the US according to different
stages
Stage
Description
GFR
(ml/min/1.73 m2)
1
Kidney Damage with
Normal or  GFR
2
Prevalence*
N
(1000s)
%
 90
5,900
3.3
Kidney Damage with
Mild  GFR
60-89
5,300
3.0
3
Moderate  GFR
30-59
7,600
4.3
4
Severe  GFR
15-29
400
0.2
5
Kidney Failure
< 15 or Dialysis
300
0.1
*Stages 1-4 from NHANES III (1988-1994). Population of 177 million with age 20. Stage 5 from USRDS (1998), includes
approximately 230,000 patients treated by dialysis, and assuming 70,000 additional patients not on dialysis. GFR estimated
from serum creatinine using MDRD Study equation based on age, gender, race and calibration for serum creatinine. For
Stage 1 and 2, kidney damage estimated by spot albumin-to-creatinine ratio 17 mg/g in men or 25 mg/g in women in two
measurements.
Common causes of ESRD:
 Diabetes mellitus 20-40%
 Interstitial diseases 20-30%
 Hypertension 5-20%
 Glomerular diseases 10-20%
 systemic inflammatory diseases (SLE,
Vasculitis) 5-10%
 Congenital and inherited 5%
 Unknown 5-20%
Investigations in CKD:
O Urea and creatinine
O Urine analysis and urine quantification
O K and PH
O Calcium, phosphorus ,PTH and 25(OH)D
O Albumin
O CBC,IRON PROFILE
O U/S
O Hepatitis and HIV
Acute Problems in CRF
O Relating to underlying disease
O Relating to ESRD
O Dialysis related problems
Problems Related to ESRD
O Metabolic – K/Ca
O Volume overload
O Anemia, platelet disorder, GI bleed
O HTN, pericarditis
O Peripheral neuropathy, dialysis dementia
O Abnormal immune function
Dialysis
O ½ of patients with CRF eventually require
O
O
O
O
dialysis
Diffuse harmful waste out of body
Control BP
Keep safe level of chemicals in body
2 types
O Hemodialysis
O Peritoneal dialysis
CRF
Indications of HD:
O GFR<10ml/min
O the uremic syndrome
O hyperkalemia
O acidosis
O fluid overload
Absolute Indications of RRT.
HYPERKALEMIA
II. ACIDOSIS
III. FLUID OVERLOAD AND PULMONARY
EDEMA
IV. SEVERE UREMIA WITH PERICARDITIS
V. UREMIC ENCEPHALOPATHY
I.
Hemodialysis:
Peritoneal dialysis:
Renal transplantation:
Take home messages:
O A great category of renal
failure can
be prevented with early
diagnosis and proper
Management .