Acute Renal Failure

Anil Menon 11/27/06

A simple algorithm
Malingering Rapid fall in GFR leading to increased waste products

Relevance
Complicates up to 7% of admissions Mortality when dialysis is required ranges 50%-75%

DDX

Diagnostic Approach
Cr/BUN, UOP, serum cystatin K, IL18 H&P Meds Labs Imaging

Acute or Chronic?
History Previous creatinine Small kidneys on u/s

Obstruction excluded?
History Complete anuria Palpable bladder Renal u/s

Euvolemic?
Pulse, JVP/CVP, orthostatic, wgt, I/O Disproportionate inc in urea:Cr ratio FENA Fluid challenge

Evidence of parenchymal dz? Other than ATN

H+P (systemic factors) Urine dipstick and micro (red cells, red cell casts, eosinophils, prot)

Major vascular occlusion?

Athreosclerosis Renal Assymetry Groin pain Complete Anuria Macro Hematuria

Treatment
Prevention
Risk factors (age,DM,HTN,Vasc,renal) Maintain BP and Volume, avoid neprhotox Measure plasma aminoglycoside Allopurinol/urine alk in cancer

General
Correct prerenal/postrenal factors Optimise CO, RBF Review meds Monitor I/O Nutritional support Treat infection, bleeding Start dialysis before uremic

No strong evidence
Loop diuretic Dopamine Natriuretic peptide Intermittent HD vs Continuous ILF Thyroxine

ATN
Sepsis in ICU 35-50% Prerenal azotemia spectrum with ischemic ATN Initiation, maintenance, recovery BUN/Cr normal 10:1 Rapid rise plasma Cr Muddy brown epi casts FENa > 2% Ucr / PCr

Post Op
18-40% hospital aquired. 1.2% surgery. Pre-op BP control (Carmaichael J Surgery 2003) Hydration and prevention Poor prognosis of ARF when adjusted
(Svensson J Vasc Surg 1989)

Nephrology

Contrast
Isotonic crystalloid 1-1.5ml/kg for 3-12 hours pre proc and 6-24 hours post Mucomyst not consistently useful Current eval of theophyline, statins, vit c, pg E CCB, L-arg, fenoldopam, dopamine, ANP not useful Prophylactic HD no gain
(Stacul 2006 CIN consensus working panel)