Acute Renal Failure

Definition
 Acute renal failure (ARF) is defined as
the sudden decrease of normal kidney
function that compromisees the normal
renal regulation of fluid, electrolyte,
and acid-base homeostasis ( Thadani et
al. 1996 )

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 acute renal insufficiency is characterized by
 an abrupt increase in the blood concentration
of creatinine serum and nitrogenous waste
products (BUN)
 a decrease in the glomerular filtration rate
(GFR)
 the inability of the kidney to appropriately
regulate fluid and electrolyte homeostasis.
 Pre renal
(hypoperfusion)

Renal
( ischaemic and injury )

Post renal ( obstruction )

 Prerenal hypoperfusion caused by
intravascular volume contraction, decreased
effective circulating blood volume, or from
altered intrarenal hemodynamics
Prerenal ARF of Newborns and Infants

The most common cause of ARF is prerenal

etiologies.

Prerenal ARF:
 Perinatal hemorrhage -Twin-twin transfusion,
complications of amniocentesis, abruptio
placenta, birth trauma
 Neonatal hemorrhage -Severe intraventricular
hemorrhage, adrenal hemorrhage

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Prerenal ARF of Newborns and Infants

 Perinatal asphyxia and hyaline

membrane disease (newborn respiratory
distress syndrome) both may result in
preferential blood shunting away from
kidneys (ie, prerenal) to central
circulation.

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Prerenal ARF of Children
The most common cause of ARF is
prerenal etiologies.
Prerenal ARF:
 The most common cause of
hypovolemia in children is
gastroenteritis.
 Congenital and acquired heart diseases
are also important causes of decreased
renal perfusion in this age group.
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Intrinsic renal diseases

Vascular
tubular
Glomerular
Interstitiel
Intrinsic Renal Failure in new borns and infants

Acute tubular necrosis (ATN) can occur in the setting of

perinatal asphyxia. ATN also has been observed secondary to
medications (eg, aminoglycosides, NSAIDs) given to the
mother perinatally.
ACE inhibitors can traverse placenta, resulting in a
hemodynamically mediated form of ARF.
Acute glomerulonephritis is rare and most commonly the result
of maternal-fetal transfer of antibodies against the neonate's
glomeruli or transfer of chronic infections (syphilis,
cytomegalovirus) associated with acute glomerulonephritis
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Intrinsic Renal Failure in children
Hemolytic uremic syndrome (HUS) often is cited as the most
common cause of ARF in children. The most common form
of the disease is associated with a diarrheal prodrome
caused by Escherichia coli O157:H7. These children usually
present with microangiopathic anemia, thrombocytopenia,
colitis, mental status changes, and renal failure.
Acute poststreptococcal glomerulonephritis should be
considered in any child who presents with HTN, edema,
hematuria, and renal failure

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Intrinsic Renal Failure
 Glomerular diseases: Nephritic
syndrome of hematuria, edema, and
HTN is synonymous with a glomerular
etiology of ARF.

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Intrinsic Renal Failure
 Tubular diseases: ATN should be
suspected in any patient presenting after
a period of hypotension secondary to
cardiac arrest, hemorrhage, sepsis, drug
overdose, or surgery.

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Intrinsic Renal Failure
 Interstitial diseases - Acute interstitial
nephritis, drug reactions, autoimmune
diseases (eg, systemic lupus erythematosus
[SLE]), infiltrative disease (sarcoidosis,
lymphoma), infectious agents (Legionnaire
disease, hantavirus)
 Vascular diseases - Hypertensive crisis,
polyarteritis nodosa, vasculitis

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Intrinsic Renal Failure
 A careful search for exposure to
nephrotoxins should include a detailed
list of all current medications and any
recent radiologic examinations (ie,
exposure to radiologic contrast agents).

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Intrinsic Renal Failure

 Allergic interstitial nephritis should be

suspected with recent drug ingestion,
fevers, rash, and arthralgias.

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Post-renal ARF
 Diseases causing urinary obstruction from
the level of the renal tubules to the urethra
 Tubular obstruction from crystals (eg, uric
acid, calcium oxalate, acyclovir, sulfonamide,
methotrexate, myeloma light chains)
 Ureteral obstruction - Retroperitoneal
tumor, retroperitoneal fibrosis
(methysergide, propranolol, hydralazine),
urolithiasis, papillary necrosis

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 Post-renal ARF
Urethral obstruction :
 congenital anomalies are most
common i.e posterior urethral valve

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 In pediatric individuals with two functioning kidneys,
postrenal ARF will occur only with urethral obstruction,
bladder neck obstruction, or bilateral ureteric
obstruction, because a single normal kidney has
sufficient ability to maintain a normal GFR. Most
patients with acute obstruction leading to ARF have
oliguric ARF, although non-oliguric ARF can occur with
partial obstruction. Renal calculi, ureteral blood clots,
retroperitoneal fibrosis,neurogenic bladder, bladder
tumors and urethral strictures can cause an obstruction
at different levels of the urinary tract and lead to ARF
Clinical findings

 Non specific uremic symtomps

 Oliguria, anuria
 Hyperventilation due to acidosis
 Edema
 Hypertension
 Hematuria, proteinuria
 Signs of genitourinary obstruction
 Signs of dehidration
Diagnostic Approach

 Hystory taking and physical examination

 Urine Study
 Blood Study
 Diagnostic Imaging
 Renal Biopsy
Diagnostic tests

 Complete blood count

 Routine blood chemistry
 Urinalysis
 Serologic test if needed
 Biologic Marker
 Radiologic Evaluation
 Renal biopsy
Management

There are five main principles in managing ARF:

 1 Maintaining appropriate renal perfusion
 2 Avoidance of nephrotoxic agents
 3 Establishing fluid balance
 4 Maintaining electrolyte and acid–base
balance
 5 Providing nutritional support
Dialysis

The indications for initiating dialysis in ARF

include:
 1 Volume overload unresponsive to
conservative management
 2 Hyperkalemia, acidosis, or hypocalcemia
unresponsive to medical therapy
 3 Uremia (mental status changes, serositis,
or bleeding diathesis)
 4 Nutritional support
complications
 Acid base imbalance
 Fluid and electrolit imbalance
 Anemia
 Hypertension
 encephalopathy
 Infection
 Pulmonary edema
 Malnutrition
 Fluid overload