Renal Failure: acute, chronic ESRD

1. Renal Failure: acute, chronic &ESRD Saeed M.G. Al-Ghamdi,FRCPS,FACP Faculty of Medicine King Abdulaziz University Hospital

2. RF: Items for Discussion Definitions of ARF, CRF & ESRD Classification & causes of RF Statistics Presentations Investigations Treatment

3. ARF: Definition Abrupt decline of Glomerular filtration rate which is potentially reversible

4. ARF: Statistics Prevalence: In 5% of medical-surgical ward admission In 25% of non-emergent surgery In 15% of ICU admission Mortality: Oliguric ARF: 50-80% Non-Oliguric ARF: 15-40% Risk of death: 6.2 folds

5. ARF: Classification & Causes Pre-renal ARF: 40-80% Renal ARF: 20-30% Post-renal ARF: 2-10%

6. Pre-renal Causes: 1) Extra-renal fluid loss: Vomiting Continuous un-replaced NG suctioning Continuous un-replaced drainage Diarrhea , intestinal fistula Pancreatitis Intestinal obstruction Excessive Sweating & heat stroke ,burns

7. Pre-renal Causes: 2) Renal fluid loss Osmotic Diuretics: hyperglycemia, mannitol Loop and thiazide diuretics Un-replaced post-obstructive diurecis 3) Change in renal hemodynamics ACEI in bilateral Renal Artery Stenosis NSAIDS in patient with dehydration or CHF

8. Pre-renal Causes 4) Cardiac causes Due to renal hypo-perfusion In severe systolic heart failure (EF <15%) Severe valvular heart disease Arrhythmias: Complete Heart Block Cardiac temponade Right Ventricular Infarction Severe core pulmonale

9. ARF: Pre-renal Causes 5) Peripheral vasodilatation: Anti-hypertensive drugs 6) Hepato-Renal Syndrome Due to renal vaso-constrictors & third spacing In advanced irreversible liver disease Other causes of ARF should be ruled out Very low urine sodium (<10)

10. Renal Causes of ARF 1) acute tubular necrosis (ATN) Septic syndrome (with & without hypotension) Significant bleeding leading to prolonged hypotension Severe dehydration leading to prolonged hypotension Cardiogenic shock Severe PET & ET

11. Renal Causes of ARF (Cont..) 2) Toxic and pigment-induced ATN Aminoglycoside nephrotoxicity Amphotericin-induced nephrotoxicity Contrast-nephropathy Hemoglobinuria (severe intravascular hemolysis) Myoglobinuria (Rhabdomyolysis)

12. Renal Causes of ARF (Cont..) 3) Glomerular diseases and systemic vasculitis Rapidly progressive Glomerulonephritis (RPGN) Immune-complex nephritis: (post-infectious GN, lupus nephritis, HSP, ..Etc.) Anti-GBM disease Pauci-immune nephritis: Wegener's Granulomatosis

13. Renal Causes of ARF (Cont..) 4) acute interstitial nephritis Drug-induced (NSAIDS, beta lactam antibiotics,rifampicin, furosemide, allopurinol ..Etc.) Auto-immune (SLE, Sjogren syndrome, HES ) Infection-related (Legionella, salmonella ,..Etc.) Sarcoidosis Idiopathic

14. Renal Causes of ARF (Cont..) 5) Acute Pyelonephritis In transplant kidney In single functioning kidney 6) Acute Allograft Rejection 7) Lymphomatous Infiltration of the kidneys In HIV+ve Patients PTLD

15. ARF: Renal Causes 8) renal vasular & Ischemic disorders Vasculitis Scleroderma renal crisis Malignant HTN TTP, HUS, DIC Renal artery thrombosis Renal vein thrombosis Cholesterol Athero-embolic disease

16. ARF: Renal Causes (contin..) 9) acute cortical necrosis (ACN) In association with hypotension and DIC Abruptio placenta, placenta previa IUFD Presentation: Loin pain Anuria Gross hematuria Cortical calcification (after healing)

17. Renal Causes of ARF (Cont..) 10) acute papillary necrosis Acute Pyelonephritis in diabetic Sickle cell disease Phenacetin-induced nephropathy Pesentation: Loin pain Oligo-anuria Passage of tissues (papillae)

18. ARF: Presentation (Cont..) Features suggest renal causes of ARF History of arthritis and or arthralgia Recent drug exposure Recent surgery and or intervention Recent URTI or tonsillitis Peri-orbital and facial edema HTN and absence of signs of hypovolemia Vasculitis or livedo reticularis

19. ARF: Post-renal Causes Intra-renal (tubular) obstruction : (medical) Acute uric acid nephropathy Calcium oxalate Crystalluria: ethylene glycol poisoning or high dose vitamin C Myeloma cast nephropathy IV Methotrexate crystalluria IV acylovir and oral Indinavir crystalluria Sulfonamides crystalluria (sulfadiazine, SMZ)

20. Post-renal Causes of ARF Extra-renal (tubular) obstruction (surgical) Ureteral/pelvic Intrinsic: tumor, stone, clot, papilla Extrinsic: retroperitoneal and pelvic malignancies , fibrosis and ligation Bladder: stones, clots, tumor, neurogenic, BPH, Prostatic ca, post-operative Uretheral: PUV, stone �etc

21. ARF: Causes

22. Renal Artery Thrombosis In hyper-coagulable states Presentation: Severe loin pain Gross hematuria Complete anuria if bilateral Diagnosis by Doppler, IVP & Angiogram Treated by thrombolysis and or heparin

23. Renal Vein Thrombosis: S&S Loin pain Macro and or Microhematuria Proteinuria ARF if bilateral or single kidney Diagnosed by U/S Doppler Spiral CT Renal venography

24. RVT: Predisposing Factors Severe dehydration in neonates Severe nephrotic syndrome (S.Alb.<20 g) Hypercoagulable states Protein S or C deficiency Anti-Phospholipids antibody syndrome Homocysteinuria Malignancies

25. Cholesterol Athero-embolic Disease Predisposing factors Follows intravascular intervention May follow bellow renal vascular surgery May occur after anti-coagulation May occur spontaneously

26. CAED: Presentation 3-6 weeks after vascular instrumentation Progressive rise of S.Creatinine Livedo Reticularis Gangrenous toes and peripheral skin Thrombocytopenia Eosinophilia Hypocomplementemia Diagnosed by kidney biopsy

27. ARF: Presentation Features suggest pre-renal. Vomiting, diarrhea , NGT ..Etc. Uncontrolled DM. Diuretic use. Exposure to sun and hot weather. Postural hypotension and tachycardia. Low JVP. Dry axilla and mucous membranes.

28. ARF: Investigations Rapidly rising S.Cr. & hyperkalemia U/S kidneys & bladder Urine analysis RBCs and RBC casts suggest GN WBCs and WBC casts suggest AIN or acute pyelonephritis Brown granular casts suggest ATN

29. ARF: Investigations (Cont..) Urine Eosinophils : In AIN Urine myoglobulin : in Rhabdomyolysis Urine hemoglobin : in Hemoglobinuria Urine sodium : <10 mmol/l, suggest pre-renal Na+ Excretion Fraction: <1% suggest pre-renal > 3% suggest ATN

30. ARF: Investigations Fractional excretion of sodium: UNa X PCr FENa: ----------------- X 100 = PNa X Ucr < 1%: Pre-renal > 3%: ATN

31. ARF: Investigations (Cont..) Positive ANA & Anti-dsDNA in lupus nephritis Low C3 & C4 in : Lupus nephritis Pos-infectious GN MPGN Falsely positive RF in cryoglobulinemia

32. ARF: Investigations (Cont..) Positive ANCA. Wegener's Granulomatosis. Microscopic Poly-Angiitis. Poly-Arteritis Nodosa. Positive Anti-GBM in Good Pasture�s syn. Monoclonal band in Serum and or urine electrophoresis in patients with paraprotein.