Renal Failure
By:Michele Ritter, M.D.
Assessment of Renal Function
* Glomerular Filtration Rate (GFR)
* Creatinine
* Creatinine Clearance
Major causes of Kidney Failure
* Prerenal Disease
* Vascular Disease
* Glomerular Disease
* Interstitial/Tubular Disease
* Obstructive Uropathy
* Vasculitis (cryoglobulinemia)
Glomerular Disease – Nephrotic Syndrome
* Minimal Change Disease
* Focal glomerulosclerosis
+ HIV
+ Massive Obesity
+ NSAIDS
* Membranous nephropathy
+ NSAIDS, penicillamine, gold
+ Etanercept, infliximab
+ SLE
+ Hep. C, Hep. B
+ Malignancy (usually of GI tract or lung)
+ GVHD
+ s/p renal transplant
* Mesangial proliferative glomerulonephritis
* Diabetic nephropathy
* Post-infectious glomerulonephropathy (later stages)
* Amyloidosis
* IgA nephropathy
o Infections: HIV, CMV, Staph. aureus, Haemophilus parainfluenza
o Celiac disease
o Chronic Liver disease
Interstitial/Tubular Disease
Acute Tubular Necrosis- muddy brown casts
Acute Interstitial Nephritis
Cast nephropathy – Multiple myeloma tubular casts
Obstructive Uropathy
Chronic Kidney Disease
Stages of Chronic Kidney Disease
Kidney damage with mildly decreased GFR
Moderately decreased GFR
Kidney Failure
Severely decreased GFR
Kidney damage with normal or increased GFR
Risk factor for acute renal failure
Urine Output in Acute Renal failure
* Oliguria
* Anuria
Most common causes of ACUTE Renal Failure
* Prerenal
* Acute tubular necrosis (ATN)
* Acute on chronic renal failure (usually due to ATN or prerenal)
* Obstructive uropathy
* Glomerulonephritis/Vasculitis
* Acute Interstitial nephritis
* Atheroemboli
Assessing the patient with acute renal failure
* History:
o Cancer?
o Recent Infections?
o Blood in urine?
o Change in urine output?
o Flank Pain?
o Recent bleeding?
o Dehydration? Diarrhea? Nausea? Vomiting?
o Blurred vision? Elevated BP at home? Elevated sugars?
* Family History:
+ Cancers?
+ Polycystic kidney disease?
* Meds:
o Any non-compliance with diabetic or hypertensive meds?
o Any recent antibiotic use?
o Any NSAID use?
Assessing the patient with acute renal failure – Physical exam
* Vital Signs:
* Neuro: + Confusion: hypercalcemia, uremia, malignant hypertension, infection, malignancy
* HEENT: + Dry mucus membranes: Concern for dehydration (pre-renal)
* Abd: + Ascites: Concern for liver disease (hepatorenal syndrome), or nephrotic syndrome
* Ext: + Edema: Concern for nephrotic syndrome
* Skin:
Assessing the patient with acute renal failure – Laboratory analysis
* Fractional excretion of sodium:
(UrineNa+ x PlasmaCreatinine)
FENa= ______________________ x 100
(PlasmaNa+ x UrineCreatinine)
* Renal Ultrasound
* Hematuria
* Protein
Assessing patient with acute renal failure – Urinary Casts
Nephrotic syndrome, Minimal change disease
Fatty casts
Acute tubular necrosis
Muddy Brown casts
Acute Interstitial nephritis
White Cell casts
Glomerulonephritis
Vasculitis
Red cell casts
Assessing patient with acute renal failure – Renal Biopsy
Treatment of Acute Renal Failure
Indications for Hemodialysis
* Refractory fluid overload
* Hyperkalemia (plasma potassium concentration >6.5 meq/L) or rapidly rising potassium levels
* Metabolic acidosis (pH less than 7.1)
* Azotemia (BUN greater than 80 to 100 mg/dL [29 to 36 mmol/L])
* Signs of uremia, such as pericarditis, neuropathy, or an otherwise unexplained decline in mental status
* Severe dysnatremias (sodium concentration greater than 155 meq/L or less than 120 meq/L)
* Hyperthermia
* Overdose with a dialyzable drug/toxin
Renal Failure.ppt
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