HASYIM KASIM, SYAKIB BAKRI

Syndromes in Nephrology
Acute nephritis
Nephrotic syndrome
Asymptomatic urinary abnormalities
Acute renal failure
Chronic kidney disease
Urinary tract infection
Urinary tract obstruction
Renal tubular defects
Hypertension
Nephrolithiasis

Syndromes in Nephrology
Acute nephritis
Nephrotic syndrome
Asymptomatic urinary abnormalities
Acute renal failure
Chronic kidney disease
Urinary tract infection
Urinary tract obstruction
Nephrolithiasis
Hypertension
Renal tubular defects

Acute Renal Failure

An abrupt and sustained decrease (days to weeks) in
renal function resulting in retention of nitrogenous (urea
and creatinine) and non-nitrogenous waste products.
Depending on severity and duration of the renal
dysfunction, this accumulation is accompanied by
metabolic dysturbance, such as metabolic acidosis and
hyperkalaemia, changes in body fluid balance, and effects
on many other organ systems.

Acute Renal Failure

An acute and sustained increase in serum creatinine
concentration of 0.5 mg% if the baseline is < 2.5 mg%,
or an increase in serum creatinine concentration of >
20% if the baseline is > 2.5 mg%.

Acute Renal Failure

Oligouric
Non-oligouric

EPIDEMIOLOGY
1% of hospitalized patients
20% of patients treated in ICU
4-15% of patients after cardiovascular surgery

Prerenal

35 %

Renal

50 %

Postrenal

10 %

CLASSIFICATION
OF
ACUTE RENAL FAILURE

ACUTE RENAL FAILURE

PRERENAL

Absolute decrease in effective blood volume

Haemorrhage
Volume depletion
Relative decrease in blood volume (ineffective arterial volume)
Congestive heart failure, Shock,
Decompensated liver cirrhosis
Arterial occlusion or stenosis of renal artery
Haemodynamic form
NSAIDs
ACE-inhibitors or angiotensin-II
receptor antagonists in renal-artery
stenosis or congestive heart failure

Hypovolemia

Baroreceptor activation

Reduced affective
circulation volume

Respons neurohormonal

Axis renin-angiotensin
aldosterone

Vasopressin

Sympathetic nervous system

Vasoconstriction
contraction of mesangial cells
Reabsorpsi natrium and water

Reduced renal blood flow and glomerular filtration rate

Acute renal failure pre-renal

ACUTE RENAL FAILURE

INTRINSIC RENAL

Vascular
Vasculitis,
Malignant HT

Glomerulonephritis

Ischaemic (50%)

Exogenous
Antibiotics (gentamicin)
Radiocontrast agents
Cisplatin

Acute interstitial nephritis

Drugs
Allergy

Acute tubular
necrosis

Nephrotoxic (35%)

Endogenous
Intratubular pigments (haemoglobinuria,
myoglobinuria)
Intratubular proteins (myeloma)
Intratubular crystals (uric acid, oxalate)

ACUTE RENAL FAILURE

POSTRENAL

Obstruction of collecting system or

extrarenal drainage
Bladder-outlet obstruction
Bilateral ureteral obstruction or
unilateral in one functioning kidney

Assessment of a Patient with

Acute Renal Failure (1)
Procedure

Information Sought

Clinical history and

examination

Clues to the cause of acute renal failure

Indicators of severity of metabolis disturbance
Estimate of volume status (hydration)

Urinalysis and urine

microscopy

Markers of glomerular or tubulointerstitial

inflammation, urinary tract infection or crystal
uropathy

Plasma biochemistry

To assess extent of GFR reduction and metabolic

consequences

Urine biochemistry

To differentiate prerenal from established renal

failure

Full blood count

To determine presence of anemia, leucocytosis, and

platelet consumption

Assessment of a Patient with

Acute Renal Failure (2)
Procedure
Renal ultrasound

Information Sought
To determine kidney size, presence of obstruction,
abnormal renal parenchymal texture

Plus, where appropriate :

Abdominal CT-Scan

To define structural abnormalities of the kidney or

urinary tract

Radionuclide scan

To assess abnormal renal perfusion

Cystoscopy +/retragrade pyelograms

To evaluate / relieve urinary tract obstruction

Renal biopsy

To define pathology of renal parenchymal disease

Findings that suggest prerenal causes

Volume depletion
Congestive heart failure
Severe liver disease or other edematous state
Findings that suggest postrenal causes
Palpable bladder or hydronephrotic kidneys
Enlarge prostat
Abnormal pelvic examination
Large residual bladder urine volume
History of renal calculi (perform USG to screen obstruction)
Findings that suggest intrinsic renal disease
Hypotension, exposure to nephrotoxic drugs
Recent radiographic procedure with contrast

Finding in the urine sediment

If no abnormalities: suspect prerenal or postrenal azotemia
If eosinophils: suspect acute interstitial nephritis
If red blood cell casts: suspect glomerulonephritis or vasculitis
If renal tubular ephitelial cells and muddy brown casts: suspect
acute tubular necrosis

Management priorities in patients

with acute renal failure (1)
Search for and correct prerenal and postrenal factors.
Review medications and stop administration of nephrotoxins.
Optimise cardiac output and renal blood flow.
Monitor fluid intake and output; measure bodyweight daily.
Search for and treat acute complications (hyperkalaemia,
hyponatraemia, acidosis, hyperphospataemia, pulmonary
oedema).

Management priorities in patients

with acute renal failure (2)
Provide early nutritional support.
Search for and aggressively treat infections.
Expert nursing care (management catheter care and
skin in general; physicological support).
Initiate dialysis before uraemic complication emerge.
Give drugs in doses appropriate for their clearance.

Indications for dialysis in acute renal failure

Indications

Characteristics

Uremia

Asterixis, seizures, nausea & vomiting, pericarditis

Hyperkalemia

K+ >6.5 mmol/L; K+ 5.5-6.5 mmol/L if ECG

changes

Fluid overload

Fluid overload resistant to diuretics, especially

pulmonary edema

Metabolic
acidosis

pH < 7.2 despite sodium bicarbonate therapy;

sodium bicarbonate not tolerated because of fluid
overload

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