Renal Failure Disease
DESCRIPTION
A syndrome of rapidly deteriorating kidney function with the accumulation of nitrogenous wastes
- System(s) affected: Renal/Urologic, Cardiovascular
- Genetics: No known genetic pattern
- Incidence/Prevalence in USA: 5% of patients admitted to the hospital develop ARF; 10-15% of ICU patients develop ARF; 2-7% post open heart patients develop ARF; 50% of hospital ARF is iatrogenic.
- Predominant age: All ages (average age increasing)
- Predominant sex: Male = Female
SIGNS AND SYMPTOMS
- Anorexia
- Asterixis
- Back pain
- Coma
- Delirium
- Diarrhea
- Dyspnea
- Ecchymosis
- Edema
- Encephalopathy
- Epistaxis
- Fasciculation
- Fatigue
- GI hemorrhage
- Headache
- Hiccups
- Hyperpnea
- Hypertension
- Left ventricular failure
- Lethargy
- Muscle cramps
- Myoclonus
- Nausea
- Oliguria
- Pericarditis
- Petechiae
- Purpura (vasculitis)
- Rales
- Rash (acute interstitial nephritis)
- Retinopathy
- Seizure
- Somnolence
- Tachycardia
- Tachypnea
- Uriniferous odor
- Vomiting
- Weakness
- Xerostomia
CAUSES
- Pre-renal (30-60% of all cases)
- Hypovolemia
- Ineffective circulating volume: Congestive heart failure, cirrhosis, nephrotic syndrome and early sepsis
- Renal
- Tubular, interstitial: Acute interstitial nephritis (AIN) (drugs, infection); nephrotoxins; acute tubular necrosis; reflex anuria; contrast media (40-70% of all cases)
- Glomerular: Rapidly progressive (crescentic) glomerulonephritis (RPGN) (Immunofluorescence biopsy staining: linear, immune complex or pauci-immune); pregnancy (2%); systemic lupus erythematosus
- Vascular
- Ischemic nephropathy (renal artery stenosis)
- Dissecting aortic aneurysm
- Ruptured abdominal aortic aneurysm
- Post-renal
- Obstruction (See topic for Hydronephrosis) (1-10% of all cases)
RISK FACTORS
- Surgery (especially with increased age, elevated creatinine, simultaneous cardiac valve and bypass surgery)
- Volume depletion (especially in diabetes)
- Aminoglycoside therapy, congestive heart failure, contrast exposure, septic shock
- Nephrotoxic drugs (e.g., ACE inhibitors in renal artery stenosis)
- Rhabdomyolysis
- Administration of contrast (parenteral) in susceptible individuals
- Dopamine and mannitol appear to increase the risk of acute renal failure in some groups; particularly patients with diabetes mellitus.
LABORATORY
- Urinalysis
- Proteinuria
- Hematuria
- Brown granular urinary casts
- Urinary renal tubular epithelial cells
- Urine sediment
- Coarse granular casts
- Renal tubular epithelial cells
- Eosinophils (AIN?)
- Red cell or hemoglobin casts (RPGN)
- Crystals (lithiasis, obstruction)
- Urine electrolytes/osmolality
- Increased urine sodium (> 20 mEq/L [>20 mmol/L]), increased fractional excretion of sodium (> 3%) (e.g., renal)
Calculation: Fractional excretion of sodium = [(urine Na+/serum Na+) / (urine creatinine/serum creatinine)] × 100 - Urine isotonic to plasma
- Low urine sodium < 10 mEq/L (< 10 mmol/L), low fractional excretion of sodium (≤ 1%), concentrated urine osmolality (≥ 500 mOsm/liter) (e.g., pre-renal)
- Increased urine sodium (> 20 mEq/L [>20 mmol/L]), increased fractional excretion of sodium (> 3%) (e.g., renal)
- Other
- Azotemia
- Decreased creatinine clearance
- Hyperosmolarity
- Hyperphosphatemia
- Hyperkalemia
- Decreased serum bicarbonate
- Increased plasma volume
- Decreased hemoglobin
- Decreased hematocrit
- Hypocapnia
- Increased serum magnesium
- Acidemia (increased anion gap)
- Increased serum amylase/lipase
- Hyponatremia
- Hypocalcemia
- Increased serum uric acid
- Increased bleeding time
- Impaired phagocytic function
PATHOLOGICAL FINDINGS
- Kidney biopsy
- Not particularly helpful in acute tubular necrosis (ATN)
- Diagnostic in AIN and RPGN
- In acute ischemic or toxic injury, necrosis or apoptosis of renal tubular cells
SPECIAL TESTS
- Angiogram (renal vascular disease)
- Cystoscopy - retrograde
- Bleeding time
IMAGING
- Obstruction - renal scan, CT scan
- Kidney ultrasound
- Renal cause: "Medical" renal disease (renal echogenicity = liver), normal size kidneys, kidney size disparity: ischemia
- Post renal cause - hydronephrosis
DIAGNOSTIC PROCEDURES
Renal biopsy (ARF, unknown cause), diagnostic for AIN, RPGN
APPROPRIATE HEALTH CARE
Inpatient and intensive care
GENERAL MEASURES
- Correction of underlying hemodynamic abnormalities, especially volume
- Hemodialysis as soon as diagnosis of uremia is established (or continuous renal replacement therapy). The use of biocompatible membranes (e.g., polymethyl methylacrylate) as opposed to cuprophane results in a higher rate of recovery of renal function, more rapid recovery and better patient survival.
- Decrease catabolism
- Convert oliguria to nonoliguria
- Daily weight
- Correct reversible causes (volume and mannitol)
- Modify dosages of renal excreted drugs (see under Medications - Precautions)
- If drug induced, discontinue offending agent
- Meticulous aseptic technique
- Continuous arteriovenous hemofiltration
- Intravenous human immunoglobulin G
- Correct easy bleeding with DDAVP, estrogen and cryoprecipitate
- Question prednisone in AIN
- Hyperkalemia - severe (1 amp Ca gluconate IV); other IV insulin + glucose, if acidosis also present (1 amp NaHCO3) Kayexalate po 15-60 gm/day if gastrointestinal tract functions
- Mannitol - alkaline diuresis in rhabdomyolysis
SURGICAL MEASURES
N/A
ACTIVITY
As tolerated
DIET
- Restrict fluids to volume of urine output plus 500 mL/day
- Eliminate potassium if serum level increased
- Oral and IV amino acids
- Increase carbohydrates to decrease catabolism
- Alimentation to decrease catabolism
PATIENT EDUCATION
National Kidney & Urologic Diseases Information Clearinghouse, Box NKUDIC, Bethesda, MD 20893, (301)468-6345 and The National Kidney Foundation, Inc., 30 East 33rd Street, NY, NY 10016. "What Everyone Should Know About Kidneys and Kidney Disease" (Order #01-01BP - English), (Order #01-02BP -Spanish).
PREVENTION/AVOIDANCE
- See risk factors
- Allopurinol prior to chemotherapy for hematologic malignancy
- Hydration most important, especially prior to contrast and chemotherapy
- Non biocompatible membranes
- Hypotension
POSSIBLE COMPLICATIONS
- Sepsis - infection (leading cause of mortality)
- Convulsions
- Edema
- Pulmonary edema
- Congestive heart failure
- Hyperkalemia
- Paralysis
- Arrhythmias
- Death (50%)
- Pericarditis/tamponade
- Uremia
- Bleeding
- Hypotension
EXPECTED COURSE AND PROGNOSIS
Recover usually in days to 6 weeks. High mortality rate (5-80%) depending on cause/multi-organ involvement, and age.
ASSOCIATED CONDITIONS
- Hyperphosphatemia
- Hydronephrosis
- Muscle injury
- Congestive heart failure
- Cirrhosis
- Malignant hypertension
- Vasculitis
- Bacterial infections
- Drug reactions
- Hypercalcemia
- Hyperuricemia
- Sepsis
- Severe trauma
- Burns
- Transfusion reactions
- Internal bleeding
AGE-RELATED FACTORS
Pediatric: Congenital
Geriatric: Greater occurrence in this age group especially after surgery
Others: N/A
PREGNANCY
- Infected uterus (e.g., C. welchii [C. perfringens])
- Toxemia and a related obstetric complication
- Cortical necrosis
- Postpartum renal failure
OTHER NOTES
N/A
ABBREVIATIONS
- ATN = acute tubular necrosis
- AIN = acute interstitial nephritis
- RPGN = rapidly progressive glomerulonephritis
- ACE = angiotensin converting enzyme
Clinical Investigations
- Cardiology
- Dermatology
- General Destistry
- Cardiology
- Dermatology
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