Renal Failure

Shakhawan Hama-amin Said

Urologist and Renal Transplantation Surgeon
MBCHB, FICMS, CABU, MSc Transplantation
• The term renal failure denotes inability of the
kidneys to perform excretory function leading
to retention of nitrogenous waste products
from the blood.
• Acute and chronic renal failure are the two
kinds of kidney failure.
• When a patient needs renal replacement
therapy, the condition is called end-stage renal
disease (ESRD).
Functions of the kidney are as follows:
• Electrolyte and volume regulation
• Excretion of nitrogenous waste
• Elimination of exogenous molecules, for
example, many drugs
• Synthesis of a variety of hormones, for example,
erythropoietin
• Metabolism of low molecular weight proteins,
for example, insulin
 Acute Renal Failure (ARF)

• ARF is the syndrome in which glomerular

filtration declines abruptly (hours to days) and
is usually reversible.
According to the KDIGO criteria in 2012, AKI can
be diagnosed with any one of the following:
• (1) creatinine increase of 0.3 mg/dL in 48
hours
• (2) creatinine increase to 1.5 times baseline
within last 7 days
• (3) urine volume less than 0.5 mL/kg per hour
for 6 hours.
 Causes of acute kidney injury
• Prerenal
• Renal
• Postrenal
• Prerenal (approximately 60%):
Hypotension
Volume contraction (e.g., sepsis, hemorrhage),
Severe organ failure such as heart failure or liver
failure,
Drugs like non-steroidal anti-inflammatory drugs
(NSAIDs), angiotensin receptor blockers (ARB)
and angiotensin-converting enzyme inhibitors
(ACEI), and cyclosporine
• Intrarenal (approximately 35%):
 Acute tubule necrosis (from prolonged prerenal failure,
radiographic contrast material, drugs like aminoglycosides,
or nephrotoxic substances), acute interstitial nephritis (drug-
induced), connective tissue disorders (vasculitis),
 Arteriolar insults,
 Fat emboli,
 Intrarenal deposition (seen in tumor-lysis syndrome,
increased uric acid production and multiple myeloma-Bence-
Jones proteins),
 Rhabdomyolysis
• Postrenal (approximately 5%):
Extrinsic compression (prostatic hypertrophy,
carcinoma)
intrinsic obstruction (calculus, tumor, clot,
stricture), decreased function (neurogenic
bladder)
 History and Physical examination
History
• Detailed present medical illness history
• Medical history such as diabetes mellitus, hypertension
• A family history of kidney diseases
• Review of hospital records
• Previous renal function
• Medications especially start date, drug levels of
nephrotoxic agents, NSAIDs
• Any use of a contrast agent or any procedure
performed
Physical examination
• Hemodynamics including blood pressure, heart rate,
weight
• Volume status, look for edema, jugular venous
distention, lung crackles, and S3 gallop
• Skin: check for any diffuse rash or uremic frost
• Look for signs of uremia: asterixis, lethargy, seizures,
pericardial friction rub, peripheral neuropathies
• Abdomen exam: check for bladder distention, note
any suprapubic fullness
 Evaluation
Many patients are asymptomatic and are
incidentally found to have an elevated serum
creatinine concentration, abnormal urine studies
(such as proteinuria or microscopic hematuria),
or abnormal radiologic imaging of the kidneys.
Laboratory Tests
• Urinalysis, dipstick, and microscopy
• Dipstick for blood and protein; microscopy for
cells, casts, and crystals
• Casts:
 Pigmented granular/muddy brown casts-ATN
 WBC casts-acute interstitial nephritis
 RBC casts-glomerulonephritis
• Urine electrolytes
• Fractional excretion of sodium
(FENa) = [(UNa x PCr)/ (PNa x UCr)] x 100
U is urine
P is plasma
Na is sodium
Cr is Creatinine.
If FeNa less than 1, then likely prerenal; greater
than 2, then likely intrarenal; greater than 4, then
likely postrenal
• If the patient is on diuretics, use FEurea
instead of FENa.
• Complete blood count
• BUN
• creatinine (Cr)
• arterial blood gases (ABGs)
• Special Labs
• Creatinine Kinase (CK)
• Immunology antibodies based on the clinical scenario
• Imaging
• Renal ultrasound (US)
• Doppler-flow kidney US depending upon the clinical scenario
• An abdominal x-ray (KUB): Rules out renal calculi
• More advanced imaging techniques should be considered if initial
tests do not reveal etiology:
• Radionucleotide renal scan, CT scan, and/or MRI
• Cystoscopy with retrograde pyelogram
• Kidney biopsy
 Treatment / Management
• Treatment options for renal failure vary widely
and depend on the cause of failure. Broadly
options are divided into two groups:
FIRST treating the cause of renal failure in acute
states
SECOND replacing the renal function in acute or
chronic situations and chronic conditions.
• Mainstay is treating the underlying cause and associated complications
• In case of oliguria and no volume overload is noted, a fluid challenge
may be appropriate with monitoring for volume overload
• In the case of hyperkalemia with ECG changes. These measures drive
potassium into cells:
 IV calcium
 Sodium bicarbonate
 Glucose with insulin
 Supplemented with polystyrene sulfonate, which removes potassium
from the body.
 Hemodialysis is also an emergency method of removal.
• Oliguric patients should have a fluid restriction
of 400 mL + the previous day's urine output
(unless there are signs of volume depletion or
overload).
• If acidosis: Serum bicarbonate intravenous or
per oral, versus emergency/urgent dialysis
based on the clinical situation
• If obstructive etiology present treat
accordingly or if bladder outlet obstruction
secondary to prostatic hypertrophy may
benefit from selective alpha-blockers
( tamsulosin), 5alpha reductase
inhibitor( dutasteride, finasteride) or surgical
intervention e.g Transuretthral resection of
prostate.
General Measures
• Always review the drug list.
• Stop nephrotoxic drugs and renally adjust others.
• Many supplements not approved by the FDA can be
nephrotoxic.
• Always record fluid intake and output
• Monitor daily weights
• Watch for complications, including
 Hyperkalemia
 pulmonary edema
 acidosis
• Ensure good cardiac output and subsequent renal
blood flow.
• Pay attention to diet:
Total caloric intake should be 35 to 50 kcal/kg per day
to avoid catabolism.
Potassium intake restricted to 40 mEq per day;
Phosphorus restricted to 800 mg per day. If it
becomes high, treat with calcium carbonate or other
phosphate binder.
• Treat infections aggressively.
Immediate Dialysis Indications
• Severe hyperkalemia
• Acidosis
• Volume overload refractory to conservative
therapy
• Uremic pericarditis
• Encephalopathy
• Alcohol and drug intoxications
 Chronic Renal Failure (CRF)
• CRF or chronic kidney disease (CKD) is defined
as a persistent impairment of kidney function
• Abnormally elevated serum creatinine for
more than 3 months
• calculated glomerular filtration rate (GFR) less
than 60 ml per minute / 1.73m2.
• It often involves a progressive loss of kidney
function necessitating renal replacement
therapy (dialysis or transplantation). When a
patient needs renal replacement therapy, the
condition is called end-stage renal disease
(ESRD).
CKD classified based on stage:
• Stage 1: GFR greater than 90
• Stage 2: 60 to 89
• Stage 3: 30 to 59
• Stage 4: 15 to 29
• Stage 5: Less than 15
 GFR
• Glomerular filtration rate (GFR) is an
important clinical indicator of kidney function.
It can be used as an independent predictor of
long-term survive
 GFR
• The exact calculation of the GFR requires an injection of
exogenous or endogenous markers and the subsequent
measurement of its filtration by the kidneys. Inulin is normally
used and is considered as the most accurate estimate of GFR
• Measurement of endogenous creatinine clearance, which is
another way to get the GFR, requires the concentration of
creatinine in serum and urine, and 24-hour urine volume [3
• Again, this takes time and can be affected by muscle mass. It is
seldom performed in postoperative cardiac surgical patients
who are not in renal failure or acute renal insufficiency.
 GFR
• Calculator uses the abbreviated MDRD
(modification of diet in renal disease)
equation: Estimated GFR (ml/min/1.73m2) =
186 x (Creat / 88.4)-1.154 x (Age)-0.203 x
(0.742 if female) x (1.210 if black)
 Causes of CRF

• Diabetes mellitus, especially type 2 diabetes mellitus, is the most

frequent cause of ESRD.
• Hypertension is the second most frequent cause.
• Glomerulonephritis
• Polycystic kidney diseases
• Renal vascular diseases
• Other known causes, like prolonged obstruction of the urinary tract,
nephrolithiasis
• Vesicoureteral reflux, a condition in which urine to back up into the
kidneys
• Recurrent kidney infections/ pyelonephritis
• Unknown etiology
Commonly noted symptoms are as follows:
• Nausea
• Vomiting
• Loss of appetite
• Fatigue and weakness
• Sleep problems
• Changes in the amount of urine
• Decreased mental sharpness
• Muscle twitches and cramps
• Swelling of feet and ankles
• Persistent itching
• Chest pain
• Shortness of breath
• High blood pressure
 Treatment CRF

• Optimize control of specific causes of CKD such as diabetes mellitus

and hypertension
• Measure sequentially and plot the rate of decline in GFR in all patients
• Any acceleration in the rate of decline should prompt a search for
superimposed acute or subacute process that may be reversible
 Extracellular fluid volume depletion
 Uncontrolled hypertension
 Urinary tract infection
 New obstructive uropathy
 Exposure to nephrotoxic agents (such as NSAIDs or contrast dye),
reactivation or flare of the original disease such as lupus or vasculitis
• Reduce proteinuria; effective meds include ACE/ARB
• Strict glycemic control
• Prevent and treat complications of CKD
• Discuss renal replacement therapy with patients
appropriately and timely
• Periodically review medications and avoid
nephrotoxic medicines.
• Patients with CKD should be referred to
nephrologist as this provides enough time for
adequate preparation for kidney replacement
therapy.
 Complications
• Fluid retention which can lead to swelling in legs or arms and
pulmonary edema
• A sudden rise in potassium levels, hyperkalemia
• Heart and blood vessel disease
• Anemia
• Decreased sex drive, erectile dysfunction
• Damage to central nervous system which can lead to seizures
• Decreased immune response
• Pericarditis
• Pregnancy complications