Acute kidney failure resident survival guide: Difference between revisions

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! style="padding: 0 5px; font-size: 80%; background: #A8A8A8;" align=center| {{fontcolor|#2B3B44|Acute kidney failure<BR>Resident Survival Guide}}
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Overview|Overview]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Causes|Causes]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Diagnosis|Diagnosis]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Treatment|Treatment]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Do's|Do's]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Don'ts|Don'ts]]
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__NOTOC__
__NOTOC__
{{WikiDoc CMG}}; {{AE}}  
{{WikiDoc CMG}}; {{AE}} [[User:Kanwal Khamuani|Kanwal Khamuani, M.B.B.S.]]


{{SK}} Acute renal failure approach, An approach to acute renal failure, Acute kidney injury workup algorithm, Acute kidney injury management algorithm
==Overview==
==Overview==
Acute Renal Failure is an abrupt reduction in [[kidney]] function defined as at-least one of the following: 1. an absolute increase in the serum levels of [[creatinine]] of 26.4 μmol/L(0.3mg/dl) or more; 2. a percentage increase in the serum levels of creatinine of more than 50%(1.5 fold increase from baseline); or 3. a reduction in volume of [[urine]] output(oliguria <0.5 ml/kg hourly for >6 hours. Acute renal failure is increasingly common, particularly in elderly population, hospital inpatients, and critically ill patients and it carries a high mortality. The most common cause of in-hospital acute renal failure in [[acute tubular necrosis]] resulting from multiple nephrotoxic insults such as [[sepsis]], [[hypotension]], and use of [[nephrotoxic drugs]] or [[radio-contrast media]]. Patients at risk include elderly people, [[diabetics]], patients with [[hypertension]] or [[vascular disease]], and those pre-existing renal impairment.
Acute Renal Failure is a sudden decrease in [[kidney]] function defined as at least one of the following: 1. a definite increase in the [[serum]] levels of [[creatinine]] of 26.4 μmol/L(0.3mg/dl) or more; 2. A proportion increase in the [[serum]] levels of creatinine of more than 50% (1.5 fold increase from baseline); or 3. A decrease in the volume of [[urine]] output ([[oliguria]] <0.5 ml/kg hourly for >6 hours. The majority of [[causes]] of in-hospital acute renal failure is [[acute tubular necrosis]] resulting from multiple [[nephrotoxic]] insults such as [[sepsis]], [[hypotension]], and use of [[nephrotoxic drugs]] or [[radio-contrast media]]. [[Patients]] at risk include elderly people, [[diabetics]], [[patients]] with [[hypertension]] or [[vascular disease]], and those with pre-existing [[renal]] impairment.To aid the [[diagnosis]] and management, it is important to find out the underlying [[cause]]; whether it is pre-renal, [[renal]], or postrenal. Initial workup should be performed as soon as the [[patient]] is encountered and any life-threatening situation should be treated promptly.


==Causes==
==Causes==
===Life Threatening Causes===
===Life Threatening Causes===
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
* [[Life threatening cause 1]]
* [[Renal]] [[hypoperfusion]] due to [[abdominal aortic aneurysm]]  
* [[Life threatening cause 2]]
* [[Acute tubular necrosis]]
* [[Life threatening cause 3]]
* [[Sepsis]] leading to [[hypotension]]


===Common Causes===
===Common Causes===
{{familytree/start}}
{{familytree | | | | | | | | | A01 | | | | | |A01=[[Acute renal failure]]}}
{{familytree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }}
{{familytree | | C01 | | | | | C02 | | | | | C03 |C01=Pre-renal [[causes]]/[[Hypotension]]|C02=Intrinsic [[renal]] [[causes]]|C03=Post-renal [[causes]]/Obstructive causes}}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | |,|-|-|-|-|v|-|-|^|-|-|-|v|-|-|-|-|.| | }}
{{familytree | |!| | | | |!| | | | | | |!| | | | |!| | | }}
{{familytree | D01 | | | D02 | | | | | D04 | | | D05 |D01=[[Glomerular]] [[disease]]|D02=Tubular insult|D04=Interestitial [[nephritis]]|D05=[[Vascular]] [[causes]]}}
{{familytree | |!| | | | |!| | | | | | | | | | | |!| }}
{{familytree | |!| | | | |)|-| E03 | | | | | | | |)|-| E02 |E02=[[Inflammation]] ([[vasculitis]])|E03=[[Ischemia]]}}
{{familytree | |!| | | | |!| | | | | | | | | | | |!| | |}}
{{familytree | |)|-| G01 |`|-| G04 | | | | G02 |-|'| | |G01=[[Inflammation]]|G02=Oclusion ([[thrombosis]] or [[embolism]]|G04=[[Toxins]]}}
{{familytree | |!| | | | | | | | | | | | | | | | | | |}}
{{familytree | |`|-| G03 | | | | | | | | | | | | | | | G03=[[Thrombosis]]}}
{{familytree/end}}
{|
! colspan="2" style="background:#DCDCDC;" align="center" + |This algorithm developed and modified according to a clinical review published in BMJ.<ref name="pmid17038736">{{cite journal| author=Hilton R| title=Acute renal failure. | journal=BMJ | year= 2006 | volume= 333 | issue= 7572 | pages= 786-90 | pmid=17038736 | doi=10.1136/bmj.38975.657639.AE | pmc=1601981 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17038736  }} </ref>
|-
|}


===Pre Renal Causes===
===Pre Renal Causes===
 
* [[Hypovolaemia]]
* Hypovolaemia
:* [[Haemorrhage]]
: * [[Haemorrhage]]
:* [[Volume depletion]](for example [[vomiting]], [[diarrhea]], [[burns]], and inappropriate diuresis)
: * [[Volume depletion]](for example vomiting, diarrhea, burns, inappropriate diuresis)
* [[Renal]] hypoperfusion
* Renal Hypoperfusion
:* [[Non-steroidal anti-inflammatory drugs]]/[[selective cyclo-oxygenase 2 inhibitors]]
: * [[Non-steroidal anti-inflammatory drugs]]/[[selective cyclo-oxygenase 2 inhibitors]]
:* [[Angiotension converting enzyme inhibitors]]/[[angiotension receptor antagonist]]
: * [[Angiotension converting enzyme inhibitors]]/[[angiotension receptor antagonist]]
:* [[Abdominal aortic aneurysm]]
: * [[Abdominal aortic aneurysm]]
:* [[Renal artery stenosis]]/occlusion
: * [[Renal artery stenosis]]/occlusion
:* [[Hepatorenal syndrome]]
: * [[Hepatorenal syndrome]]
* [[Hypotension]]
* Hypotension
:* [[Cardiogenic shock]]
: * [[Cardiogenic shock]]
:* [[Distributive shock]](for example [[sepsis]], [[anaphylaxis]])
: * [[Distributive shock]](for example [[sepsis]], [[anaphylaxis]])
* Oedematous States
* Oedematous States
: * [[Cardiac failure]]
:* [[Cardiac failure]]
: * [[hepatic cirrhosis]]
:* [[Hepatic cirrhosis]]
: * [[Nephrotic syndrome]]
:* [[Nephrotic syndrome]]


===Intrinsic Renal Causes===
===Intrinsic Renal Causes===


* Glomerular disease
* [[Glomerular]] [[disease]]
: * [[Inflammatory]]- [[post-infectious glomerulonephritis]], [[cryoglobulinaemia]], [[Henoch-Schonlein purpura]], [[systemic lupus erythematosus]],      antineutrophil cytoplasmic antibody associated glomerulonephritis, [[anti-glomerular basement membrane disease]]
:* [[Inflammatory]]- [[post-infectious glomerulonephritis]], [[cryoglobulinaemia]], [[Henoch-Schonlein purpura]], [[systemic lupus erythematosus]],      antineutrophil cytoplasmic antibody associated glomerulonephritis, [[anti-glomerular basement membrane disease]]
: * [[Thrombotic]]- [[disseminated intravascular coagulation]], [[thrombotic  microangiopathy]]
:* [[Thrombotic]]- [[disseminated intravascular coagulation]], [[thrombotic  microangiopathy]]
*Interstitial Nephritis
*[[Interstitial nephritis]]
: * Drug Induced- [[Non-steriodal anti-inflammatory drugs]], antibiotics
:* Drug Induced- [[Non-steriodal anti-inflammatory drugs]], [[antibiotics]]
: * Infiltrative- [[Lymphoma]]
:* Infiltrative- [[Lymphoma]]
: * Granulomatous- [[Sarcoidosis]], [[Tuberculosis]]
:* Granulomatous- [[Sarcoidosis]], [[Tuberculosis]]
: * Infection related- post-infective, [[Pyelonephritis]]
:* [[Infection]] related- post-infective, [[Pyelonephritis]]
*Tubular Injury
*[[Tubular injury]]
: * [[Ischemia]]- prolonged renal hypoperfusion
:* [[Ischemia]]- prolonged renal hypoperfusion
: * Toxins- drugs(such as [[aminoglycosides]]), radiocontrast media, pigments(such as [[myoglobin]]), heavy metals(such as [[cisplatinum]])
:* [[Toxins]]- drugs(such as [[aminoglycosides]]), radiocontrast media, pigments(such as [[myoglobin]]), heavy [[metals]] (such as [[cisplatinum]])
: * Metabolic- [[hypercalcemia]], immunoglobin light chains
:* Metabolic- [[hypercalcemia]], immunoglobin light chains
: * Crystals- [[urate]], [[oxalate]]
:* [[Crystals]]- [[urate]], [[oxalate]]
*Vascular
*[[Vascular]]
: * [[Vasculitis]](usually associated with antineutrophil cytoplasmic antibody)
:* [[Vasculitis]](usually associated with antineutrophil cytoplasmic antibody)
: * [[Cryoglobulinaemia]]
:* [[Cryoglobulinaemia]]
: * [[Polyarteritis nodosa]]
:* [[Polyarteritis nodosa]]
: * [[Thrombotic microangiopathy]]
:* [[Thrombotic microangiopathy]]
: * [[Cholesterol emboli]]
:* [[Cholesterol emboli]]
: * [[Renal artery thrombosis]]/[[renal vein thrombosis]]
:* [[Renal artery thrombosis]]/[[renal vein thrombosis]]


===Post Renal Causes===
===Post Renal Causes===


*Intrinsic
*Intrinsic
: * Intra-luminal- stone, blood clot, [[papillary necrosis]]
:* Intra-luminal- stone, blood clot, [[papillary necrosis]]
: * Intra-mural- [[urethral stricture]], [[prostatic hypertrophy]] or malignancy, [[bladder tumor]], [[radiation fibrosis]]
:* Intra-mural- [[urethral stricture]], [[prostatic hypertrophy]] or malignancy, [[bladder tumor]], [[radiation fibrosis]]
*Extrinsic
*Extrinsic
: * [[pelvic malignancy]]
:* [[pelvic malignancy]]
: * [[retroperitoneal fibrosis]]
:* [[retroperitoneal fibrosis]]


==Diagnosis==
==Diagnosis==
Shown below is an algorithm summarizing the diagnosis of <nowiki>[[disease name]]</nowiki> according the the [...] guidelines.
Shown below is an algorithm summarizing an step by step approach to diagnosis the cause of [[Acute Renal Failure]] to aid in the management.<ref name="pmid16461473">{{cite journal| author=Fry AC, Farrington K| title=Management of acute renal failure. | journal=Postgrad Med J | year= 2006 | volume= 82 | issue= 964 | pages= 106-16 | pmid=16461473 | doi=10.1136/pgmj.2005.038588 | pmc=2596697 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16461473  }} </ref><ref name="pmid17038736">{{cite journal| author=Hilton R| title=Acute renal failure. | journal=BMJ | year= 2006 | volume= 333 | issue= 7572 | pages= 786-90 | pmid=17038736 | doi=10.1136/bmj.38975.657639.AE | pmc=1601981 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17038736  }} </ref>
{{familytree/start |summary=PE diagnosis Algorithm.}}
<span style="font-size:85%">'''Abbreviations:''' '''NSAIDs:''' [[Non-steroidal anti-iflammatory drugs]]; '''ACE:''' [[Angiotensin converting enzyme]]; '''ARF:''' [[acute renal failure]]; '''RRT:''' [[Renal replacement therapy]]; '''ATN:'''[[acute tubular necrosis]]; '''ECG:'''[[Electrocardiogram]]
{{familytree | | | | A01 | | | A01= }}
 
{{familytree | | | | |!| | | | }}
{{familytree/start}}
{{familytree | | | | B01 | | | B01= }}
{{familytree | | | | | | | A01 | | A01= <div style="float: left; text-align: left; width: 28em; padding:1em;">'''Patient presenting features'''<br>
{{familytree | | |,|-|^|-|.| | }}
❑ [[Oliguria]] (sudden or gradual)<br>
{{familytree | | C01 | | C02 | C01= | C02= }}
❑ [[Anuria]]<br>
❑ [[Edema]]<br>
❑ [[Hypotension]]<br>
❑ [[Hematuria]]<br>
❑ [[Loin pain]]<br>
❑ [[Renal colic]]<br>
❑ [[Bone pain]]<br>
❑ [[Fever]]</div>}}
{{familytree | | | | | | | |!| | | | | | | | | }}
{{family tree| | | | | | | B01 | | | | B01=<div style="float: left; text-align: left;width: 28em; padding:1em;"> '''Medical History and Risk Factors''' <div class="mw-collapsible mw-collapsed"><br>
❑ inquire about previous similar episodes<br>
❑ co-morbidities
:❑ [[Diabetes]]-long standing poorly controlled diabetes can precipitate ARF
:❑ [[Hypertension]]
:❑ [[Heart Failure]]
:❑ [[Vascular disease]] (such as renal artery stenosis
❑ Inquire about medication history
:❑ [[ACE inhibitors]]- can precipitate ARF in [[renal artery stenosis]]
:❑ [[NSAIDs]]-associated with [[interstitial kidney disease]]
:❑ [[Penicillins]]-associated with [[renal papillary necrosis]] <br>
❑ inquire about recent hospitalization-rule out [[ATN]]<br>
❑ Inquire about recent trauma/surgery-rule out [[sepsis]]-look for [[fever]] and [[hypotension]]/rule out [[hemorrhage]] and [[hypovolemia]]<br>
❑ Age factor-elderly people-rule out [[Benign Prostate hypertrophy]]/[[prostate cancer]]<br>
:❑ Elderly patient with bone pain-[[Multiple Myeloma]]?
❑ History of [[kidney stones]]<br>
❑ Associated symptoms
:❑ Nasal stuffiness/[[epistaxis]]-suggest [[Wagener's Granulomatosis]]?
:❑ recent [[sore throat]]-streptococcal [[Glomerulonephritis]]
❑ Social history-[[Alcohol]] use/[[tobacco]] use/drug abuse<br>
❑ history of [[autoimmune]] disorders- [[Systemic Lupus Erythromatosus]], [[Good Pasture syndrome]] <br>
</div> }}
{{familytree | | | | | | | |!| | | | | | | | | }}
{{family tree| | | | | | | C01 | | | | C01=<div style="float: left; text-align: left;width: 28em; padding:1em;"> '''Initial work-up''' <div class="mw-collapsible mw-collapsed"><br>
❑ Basic Blood
:❑ [[Full blood count]] with differentials
:❑ [[Blood glucose]]
:❑ [[Urea]] and [[electrolytes]]
:❑ [[Coagulation]] screen
:❑ Inflammatory markers
:❑ Urea/electrolytes
:❑ [[Liver]] function test
:❑ [[Calcium]] and [[phosphate]]
:❑ Blood culture if infection suspected
:❑ Arterial blood gases or venous [[bicarbonate]]
❑ [[Urine]] analysis<br>
❑ Urine microscopy/urine sediment/[[culture]]<br>
❑ Renal [[ultrasound]]<br>
❑ Chest radiograph<br>
❑ [[ECG]] <br>
❑ [[Renal biopsy]] may be indicated if intrinsic cause is suspected <br>
</div> }}
{{familytree | | | | | | | |!| | | | | | | | | }}
{{family tree| | | | | | | B01 | | | | B01=<div style="float: left; text-align: left;width: 28em; padding:1em;"> '''Draw a conclusion''' <div class="mw-collapsible mw-collapsed"><br>
❑ Treat any life threatening features first—[[shock]], [[respiratory failure]], [[hyperkalaemia]] <br>
❑ Is this acute or chronic [[renal impairment]]?<br>
❑ A full [[drug]] history (current, recent, and alternative medication) is vital<br>
❑ Is there a pre‐renal cause? What is the patient's current fluid status?<br>
❑ Could this be obstruction?<br>
❑ Is [[intrinsic renal disease]] probable—what does [[urine]] analysis show? <br>
</div> }}
{{familytree/end}} <br>


{{familytree/start}}
{{familytree | D01 | | | | | | | | | | | | | | | | | |D01=[[Renal failure]] [[diagnostic]] approach}}
{{familytree | |!| | | | | | | | | | | | | | | | | | | |}}
{{familytree | |)|-| G01 |-| G02 | | | | | | | | | | | |G01=<div style="float: left; text-align: left; height: 5em; width: 10em; padding:2em;">Is this acute or chronic [[renal failure]]</div>|G02=<div style="float: left; text-align: left; height: 5em; width: 17em; padding:2em;">❑ History and [[physical examination]]<br>❑ Previous [[creatinin]] measurement<br>❑ Small [[kidneys]] on [[ultrasound]] except in [[diabetes]]</div>}}
{{familytree | |!| | | | | | | | | | | | | | | | | | |}}
{{familytree | |)|-| D01 |-| D02 | | | | | | | | | | | |D01=<div style="float: left; text-align: left; height: 5em; width: 10em; padding:2em;">Has obstruction been excluded?</div>|D02=<div style="float: left; text-align: left; height: 5em; width: 10em; padding:2em;">❑ Complete anuria <br> ❑ Palpable [[bladder]] <br> ❑ [[Renal]] [[ultrasound]]</div>}}
{{familytree | |!| | | | | | | | | | | | | | | | | | |}}
{{familytree | |)|-| F01 |-| F02 | | | | | | | | | | | |F01=<div style="float: left; text-align: left; height: 5em; width: 10em; padding:2em;">Is the [[patient]] euvolemic?</div>|F02=<div style="float: left; text-align: left; height: 8em; width: 20em; padding:2em;">❑ Check [[pulse]], [[JVP]], [[orthostatic hypotension]], daily weights, fluid balance<br>❑ Check for [[BUN]]/[[Cr]] ratio<br>❑ Check for urinary [[sodium]]<br> ❑ Do fluid challeng test </div>}}
{{familytree | |!| | | | | | | | | | | | | | | | | | |}}
{{familytree | |)|-| C01 |-| C02 | | | | | | | | | | | |C01=<div style="float: left; text-align: left; height: 5em; width: 10em; padding:2em;">Does evidence of [[renal]] parenchymal disease exist? (other than [[ATN]]) <div>|C02=<div style="float: left; text-align: left; height: 5em; width: 20em; padding:2em;">❑ History and [[physical examination]] (clinical features)<br>❑ Check urine dipstick and microscopy for [[RBC]], [[WBC]], and [[protein]] [[sodium]]</div>}}
{{familytree | |!| | | | | | | | | | | | | | | | | | |}}
{{familytree | |`|-| G03 |-| G04 | | | | | | | | | | | G03=<div style="float: left; text-align: left; height: 5em; width: 10em; padding:2em;">Has a major [[vascular]] occlusion occurred?</div>|G04=<div style="float: left; text-align: left; height: 8em; width: 20em; padding:2em;">❑ Ask for a history of atherosclerotic vascular disease<br>❑ Check for [[renal]] asymmetry<br>❑ Check for loin pain<br>❑ Check for macroscopic [[hematuria]]<br>❑ Check for complete anuria</div>}}
{{familytree/end}}
{{familytree/end}}


==Treatment==
==Treatment==
Shown below is an algorithm summarizing the treatment of <nowiki>[[disease name]]</nowiki> according the the [...] guidelines.
Definitive treatment rely upon the underlying cause; however, the initial approach is directed to manage any life-threatening feature in order to halt or reverse the decline of the renal function, and if unsuccessful, support is provided by [[renal replacement]] to aid recovery.
[[Hyperkalemia]], [[pulmonary edema]], and severe [[acidosis]] require immediate attention.<ref name="pmid16461473">{{cite journal| author=Fry AC, Farrington K| title=Management of acute renal failure. | journal=Postgrad Med J | year= 2006 | volume= 82 | issue= 964 | pages= 106-16 | pmid=16461473 | doi=10.1136/pgmj.2005.038588 | pmc=2596697 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16461473  }} </ref>
<span style="font-size:85%">'''Abbreviations:''' '''DDAVP:''' [[1-deamino-8-D-arginine vasopressin]]; '''DVT:''' [[deep venous thrombosis]]; '''ARF:''' [[acute renal failure]]; '''RRT:''' [[Renal replacement therapy]]; '''I/V:'''[[Intravenous]]
 
===1. HYPERKALEMIA TREATMEMT===
Severe [[hyperkalemia]] is a medical emergency and should be at once treated with infusion of [[calcium]]. Infusion of calcium is a temporary management, therefore measures are started to decrease the serum potassium by increasing cellular uptake simultaneously. Overall these steps are enough to normalize the serum potassium; however, still, the body will be in excess. If pure pre-renal failure, measures can be taken to excrete the [[potassium]] through the kidney by giving [[resins]]. Ultimately, if hyperkalemia is refractory to all the above measures, [[hemodialysis]] can be started.<ref name="pmid16461473">{{cite journal| author=Fry AC, Farrington K| title=Management of acute renal failure. | journal=Postgrad Med J | year= 2006 | volume= 82 | issue= 964 | pages= 106-16 | pmid=16461473 | doi=10.1136/pgmj.2005.038588 | pmc=2596697 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16461473  }} </ref>
 
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | | | | | A01 |A01= }}  
{{familytree | | | | | | | | A01 |A01='''Serum [[potassium]]>6.5 is a medical emergency'''}}  
{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
{{familytree | | | |,|-|-|-|-|+|-|-|-|-|.| | | }}
{{familytree | | | B01 | | | | | | | | B02 | | |B01= |B02= }}
{{familytree | | | B01 | | | B03 | | | B02 | | |B01='''Immediate action''' |B02='''Removal of [[potassium]] from the body'''| B03='''Reduction in plasma [[potassium]] concentration'''}}
{{familytree | | | |!| | | | | | | | | |!| }}
{{familytree | | | |!| | | | |!| | | | |!| | | }}
{{familytree | | | C01 | | | | | | | | |!| |C01= }}
{{familytree | | | C01 | | | |!| | | | F01 | |C01=[[Calcium gluconate]] or [[carbonate]]|F01=If pure pre-renal failure, renal excretion will serve to return the whole body levels to normal }}
{{familytree | |,|-|^|.| | | | | | | | |!| }}
{{familytree | | | |!| | | | |!| | |,|-|^|-|.| | | | | }}
{{familytree | D01 | | D02 | | | | | | D03 |D01= |D02= |D03= }}
{{familytree | | | C02 | | | |!| | F02 | | F03 |C02=to stabilize the [[myocardium]] and prevent [[cardiac arrythmias]]|F02=Ion exhange resins [[calcium polystrene]] or [[sodium polystrene]]| F03=[[Hemodialysis]] for refractory [[hyperkalemia]] }}
{{familytree | |!| | | | | | | | | |,|-|^|.| }}
{{familytree | | | | | | | | |!| | | | | | | | | | | |}}
{{familytree | E01 | | | | | | | E02 | | | E03 |E01= |E02= |E03= }}
{{familytree | | | | |,|-|-|-|+|-|-|-|.| | | | | | | |}}
{{familytree | | | | | | | | | | |!| | | | |!| }}
{{familytree | | | | E01 | | E02 | | E03 | | | | |E01=[[Insulin]] with [[glucose]] |E02=beta-2 agonist |E03=[[Sodium bicarbonate]]}}
{{familytree | | | | | | | | | | F01 | | | F02 |F01= |F02= }}
{{familytree/end}}
 
===2. TREATING PULMONARY EDEMA===
Excessive fluid therapy can lead to [[Pulmonary oedema]], especially in patients with known [[cardiac dysfunction]], the elderly, and those who were volume replete at the start—and can be prevented by judicious [[intravenous]] fluid therapy. If [[respiratory failure]] ensues, patient should be intubated and [[mechanical ventilation]] started. Simultaneouly, pharmacological treatment can be started to disburden the decompensated heart. If these measures fail, [[hemodialysis]] or [[hemofiltration]] can be used.<ref name="pmid16461473">{{cite journal| author=Fry AC, Farrington K| title=Management of acute renal failure. | journal=Postgrad Med J | year= 2006 | volume= 82 | issue= 964 | pages= 106-16 | pmid=16461473 | doi=10.1136/pgmj.2005.038588 | pmc=2596697 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16461473  }} </ref>
 
{{familytree/start}}
{{familytree | | | | | | | | | A01 | | | | | | | | | | A01='''PULMONARY EDEMA'''}}
{{familytree | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | |}}
{{familytree | | | | B01 | | | | | | | | B02 | | | | | B01='''[[Respiratory failure]]'''|B02='''Pharmacological treatment'''}}
{{familytree | | | | |!| | | | | |,|-|-|-|+|-|-|-|.| |}}
{{familytree | | | | |!| | | | |D01| | | D02 | | D03 |D01=I/V [[opioids]](diamorphine)| D02=I/V infusion of [[glyceryl  nitrate]]| D03=provoke [[diuresis]] with large doses of [[diuretics]] such as furesemide}}
{{familytree | | | | C01 | | | | | | | | | | | | | | |C01=Supplemental [[oxygen]] OR intubate and [[mechanically ventilate]]}}
{{familytree | | | | | | | | | | | | | | | | | | | | |}}
{{familytree/end}}
 
===3. TREATING ACIDOSIS===
Variety of mechanisms can cause severe [[metabolic acidosis]] (blood pH <7.2) in patients with ARF either due to reduced renal function or due to underlying cause of the patient's illness. Systemic [[acidosis]] diminishes [[cardiac contractility]], induces [[bradycardia]], develop [[vasodilatation]], and further expands [[hyperkalemia]]. Although there is very little known benefit, [[Alkaline]] solution-[[sodium bicarbonate]] is administered to reverse [[acidosis]]. [[Isotonic]] (1.26%) solutions may have a role as fluid replacement therapy in stable patients with a moderate to severe acidosis and a requirement for fluid replacement, in whom dialysis is not needed. [[Haemodialysis]] or [[haemofiltration]] will usually be required to treat severe acidosis in [[oligoanuric]] patients.<ref name="pmid16461473">{{cite journal| author=Fry AC, Farrington K| title=Management of acute renal failure. | journal=Postgrad Med J | year= 2006 | volume= 82 | issue= 964 | pages= 106-16 | pmid=16461473 | doi=10.1136/pgmj.2005.038588 | pmc=2596697 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16461473  }} </ref>
 
===4. OTHER GENERAL MEASURES===
 
<br>
{{familytree/start}}
{{familytree | | | | | | | A01 | | A01= <div style="float: left; text-align: left; width: 28em; padding:1em;">'''General Measures'''<br>
❑ Fluid Balance-[[normal saline]] preferred but avoid fluid overload<br>❑ Relief of Obstruction-[[Bladder outflow obstruction]] if suspected should be relieved by passage of [[urethral catheter]]<br>❑ [[Uremic Platelet Dysfunction]]-[[RRT]] may improve but [[DDAVP]] and [[cryoprecipitate]] may be required<br>❑ [[Carbohydrate]] and [[protein]] requirement should be tailored individually and ideally delivered by enteral route<br> ❑ Practice good infectious control<br> ❑ Care of pressure areas<br> ❑ [[DVT]] prophylaxis if prolonged immobility<br></div>}}
{{familytree | | | | | | | | | | |}}
{{familytree/end}}
{{familytree/end}}


==Do's==
==Do's==
* The content in this section is in bullet points.
* [[Normal Saline]] is the preferred fluid for resuscitation.
* Treat acute renal failure keeping in mind the cause behind it.
* Start [[Dialysis]] when needed.
* Correction of [[coagulopathy]] if needed with [[DDAVP]] and [[cryoprecipitate]].
* [[DVT]] prophylaxis if needed.
* Avoid [[pressure ulcers]].


==Don'ts==
==Don'ts==
* The content in this section is in bullet points.
* Avoid fluid overload.
* Do not use [[dopamine]] to increase renal perfusion.
* Cautiously use [[diuretics]] if oliguria persists.
* Do not use [[nephrotoxic]] drugs ([[NSAIDs]], [[ACE-I]], [[Aminoglycosides]])
* Avoid use of [[contrast media]].


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


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Latest revision as of 17:13, 5 December 2020

Acute kidney failure
Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kanwal Khamuani, M.B.B.S.

Synonyms and keywords: Acute renal failure approach, An approach to acute renal failure, Acute kidney injury workup algorithm, Acute kidney injury management algorithm

Overview

Acute Renal Failure is a sudden decrease in kidney function defined as at least one of the following: 1. a definite increase in the serum levels of creatinine of 26.4 μmol/L(0.3mg/dl) or more; 2. A proportion increase in the serum levels of creatinine of more than 50% (1.5 fold increase from baseline); or 3. A decrease in the volume of urine output (oliguria <0.5 ml/kg hourly for >6 hours. The majority of causes of in-hospital acute renal failure is acute tubular necrosis resulting from multiple nephrotoxic insults such as sepsis, hypotension, and use of nephrotoxic drugs or radio-contrast media. Patients at risk include elderly people, diabetics, patients with hypertension or vascular disease, and those with pre-existing renal impairment.To aid the diagnosis and management, it is important to find out the underlying cause; whether it is pre-renal, renal, or postrenal. Initial workup should be performed as soon as the patient is encountered and any life-threatening situation should be treated promptly.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

Common Causes

 
 
 
 
 
 
 
 
Acute renal failure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pre-renal causes/Hypotension
 
 
 
 
Intrinsic renal causes
 
 
 
 
Post-renal causes/Obstructive causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Glomerular disease
 
 
Tubular insult
 
 
 
 
Interestitial nephritis
 
 
Vascular causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ischemia
 
 
 
 
 
 
 
 
 
 
Inflammation (vasculitis)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inflammation
 
 
 
Toxins
 
 
 
Oclusion (thrombosis or embolism
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Thrombosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
This algorithm developed and modified according to a clinical review published in BMJ.[1]

Pre Renal Causes

  • Oedematous States

Intrinsic Renal Causes

Post Renal Causes

  • Intrinsic
  • Extrinsic

Diagnosis

Shown below is an algorithm summarizing an step by step approach to diagnosis the cause of Acute Renal Failure to aid in the management.[2][1] Abbreviations: NSAIDs: Non-steroidal anti-iflammatory drugs; ACE: Angiotensin converting enzyme; ARF: acute renal failure; RRT: Renal replacement therapy; ATN:acute tubular necrosis; ECG:Electrocardiogram

 
 
 
 
 
 
Patient presenting features

Oliguria (sudden or gradual)
Anuria
Edema
Hypotension
Hematuria
Loin pain
Renal colic
Bone pain

Fever
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History and Risk Factors

❑ inquire about previous similar episodes
❑ co-morbidities

Diabetes-long standing poorly controlled diabetes can precipitate ARF
Hypertension
Heart Failure
Vascular disease (such as renal artery stenosis

❑ Inquire about medication history

ACE inhibitors- can precipitate ARF in renal artery stenosis
NSAIDs-associated with interstitial kidney disease
Penicillins-associated with renal papillary necrosis

❑ inquire about recent hospitalization-rule out ATN
❑ Inquire about recent trauma/surgery-rule out sepsis-look for fever and hypotension/rule out hemorrhage and hypovolemia
❑ Age factor-elderly people-rule out Benign Prostate hypertrophy/prostate cancer

❑ Elderly patient with bone pain-Multiple Myeloma?

❑ History of kidney stones
❑ Associated symptoms

❑ Nasal stuffiness/epistaxis-suggest Wagener's Granulomatosis?
❑ recent sore throat-streptococcal Glomerulonephritis

❑ Social history-Alcohol use/tobacco use/drug abuse
❑ history of autoimmune disorders- Systemic Lupus Erythromatosus, Good Pasture syndrome

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initial work-up

❑ Basic Blood

Full blood count with differentials
Blood glucose
Urea and electrolytes
Coagulation screen
❑ Inflammatory markers
❑ Urea/electrolytes
Liver function test
Calcium and phosphate
❑ Blood culture if infection suspected
❑ Arterial blood gases or venous bicarbonate

Urine analysis
❑ Urine microscopy/urine sediment/culture
❑ Renal ultrasound
❑ Chest radiograph
ECG
Renal biopsy may be indicated if intrinsic cause is suspected

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Draw a conclusion

❑ Treat any life threatening features first—shock, respiratory failure, hyperkalaemia
❑ Is this acute or chronic renal impairment?
❑ A full drug history (current, recent, and alternative medication) is vital
❑ Is there a pre‐renal cause? What is the patient's current fluid status?
❑ Could this be obstruction?
❑ Is intrinsic renal disease probable—what does urine analysis show?

 
 
 

Renal failure diagnostic approach
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is this acute or chronic renal failure
 
❑ History and physical examination
❑ Previous creatinin measurement
❑ Small kidneys on ultrasound except in diabetes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Has obstruction been excluded?
 
❑ Complete anuria
❑ Palpable bladder
Renal ultrasound
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the patient euvolemic?
 
❑ Check pulse, JVP, orthostatic hypotension, daily weights, fluid balance
❑ Check for BUN/Cr ratio
❑ Check for urinary sodium
❑ Do fluid challeng test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does evidence of renal parenchymal disease exist? (other than ATN)
 
❑ History and physical examination (clinical features)
❑ Check urine dipstick and microscopy for RBC, WBC, and protein sodium
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Has a major vascular occlusion occurred?
 
❑ Ask for a history of atherosclerotic vascular disease
❑ Check for renal asymmetry
❑ Check for loin pain
❑ Check for macroscopic hematuria
❑ Check for complete anuria
 
 
 
 
 
 
 
 
 
 
 
 
 

Treatment

Definitive treatment rely upon the underlying cause; however, the initial approach is directed to manage any life-threatening feature in order to halt or reverse the decline of the renal function, and if unsuccessful, support is provided by renal replacement to aid recovery. Hyperkalemia, pulmonary edema, and severe acidosis require immediate attention.[2] Abbreviations: DDAVP: 1-deamino-8-D-arginine vasopressin; DVT: deep venous thrombosis; ARF: acute renal failure; RRT: Renal replacement therapy; I/V:Intravenous

1. HYPERKALEMIA TREATMEMT

Severe hyperkalemia is a medical emergency and should be at once treated with infusion of calcium. Infusion of calcium is a temporary management, therefore measures are started to decrease the serum potassium by increasing cellular uptake simultaneously. Overall these steps are enough to normalize the serum potassium; however, still, the body will be in excess. If pure pre-renal failure, measures can be taken to excrete the potassium through the kidney by giving resins. Ultimately, if hyperkalemia is refractory to all the above measures, hemodialysis can be started.[2]

 
 
 
 
 
 
 
Serum potassium>6.5 is a medical emergency
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Immediate action
 
 
Reduction in plasma potassium concentration
 
 
Removal of potassium from the body
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Calcium gluconate or carbonate
 
 
 
 
 
 
 
 
If pure pre-renal failure, renal excretion will serve to return the whole body levels to normal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
to stabilize the myocardium and prevent cardiac arrythmias
 
 
 
 
 
 
Ion exhange resins calcium polystrene or sodium polystrene
 
Hemodialysis for refractory hyperkalemia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Insulin with glucose
 
beta-2 agonist
 
Sodium bicarbonate
 
 
 
 

2. TREATING PULMONARY EDEMA

Excessive fluid therapy can lead to Pulmonary oedema, especially in patients with known cardiac dysfunction, the elderly, and those who were volume replete at the start—and can be prevented by judicious intravenous fluid therapy. If respiratory failure ensues, patient should be intubated and mechanical ventilation started. Simultaneouly, pharmacological treatment can be started to disburden the decompensated heart. If these measures fail, hemodialysis or hemofiltration can be used.[2]

 
 
 
 
 
 
 
 
PULMONARY EDEMA
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Respiratory failure
 
 
 
 
 
 
 
Pharmacological treatment
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
I/V opioids(diamorphine)
 
 
I/V infusion of glyceryl nitrate
 
provoke diuresis with large doses of diuretics such as furesemide
 
 
 
Supplemental oxygen OR intubate and mechanically ventilate
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

3. TREATING ACIDOSIS

Variety of mechanisms can cause severe metabolic acidosis (blood pH <7.2) in patients with ARF either due to reduced renal function or due to underlying cause of the patient's illness. Systemic acidosis diminishes cardiac contractility, induces bradycardia, develop vasodilatation, and further expands hyperkalemia. Although there is very little known benefit, Alkaline solution-sodium bicarbonate is administered to reverse acidosis. Isotonic (1.26%) solutions may have a role as fluid replacement therapy in stable patients with a moderate to severe acidosis and a requirement for fluid replacement, in whom dialysis is not needed. Haemodialysis or haemofiltration will usually be required to treat severe acidosis in oligoanuric patients.[2]

4. OTHER GENERAL MEASURES


 
 
 
 
 
 
General Measures
❑ Fluid Balance-normal saline preferred but avoid fluid overload
❑ Relief of Obstruction-Bladder outflow obstruction if suspected should be relieved by passage of urethral catheter
Uremic Platelet Dysfunction-RRT may improve but DDAVP and cryoprecipitate may be required
Carbohydrate and protein requirement should be tailored individually and ideally delivered by enteral route
❑ Practice good infectious control
❑ Care of pressure areas
DVT prophylaxis if prolonged immobility
 
 
 
 
 
 
 
 
 
 
 

Do's

Don'ts

References

  1. 1.0 1.1 Hilton R (2006). "Acute renal failure". BMJ. 333 (7572): 786–90. doi:10.1136/bmj.38975.657639.AE. PMC 1601981. PMID 17038736.
  2. 2.0 2.1 2.2 2.3 2.4 Fry AC, Farrington K (2006). "Management of acute renal failure". Postgrad Med J. 82 (964): 106–16. doi:10.1136/pgmj.2005.038588. PMC 2596697. PMID 16461473.