| ID | 140 |
|---|---|
| Name | ACUTE RENAL FAILURE |
| Cause | |
| Signs Symptoms | |
| Diagnosis | |
| Investigations | Investigation: 1. Blood- a. T.C, D.C, Hb, E.S.R. b. Blood urea, creatinine, serum potassium, sodium & chloride levels are high in oliguric phase & low in diuretic phase. 2. Urine: a. Routine & microscopic examinations show-R.B.C, epithelial cells, casts & albumin, b. Urine volume is low in oliguric phase & high in diuretic phase. 3. E.C.G- tenting of T-wave indicates severe hyperkalaemia. 4. X-ray K.U.B; Ultrasonography of both kidney and ureters; Cystoscopy and antegrade pyelography may be done. |
| Management | Management: A. Pre-renal acute renal failure: 1. Correction of hypovolaemia by blood, plasma or isotonic saline (0.9%). 2. Monitoring & maintaining blood pressure (critically ill patients may require inotropic drugs to restore an effective blood pressure). 3. Proper antibiotics to minimise the infection and septic shock (if any). 4. Correct metabolic acidosis: Restoration of blood volume will correct acidosis by restoring kidney function. Sodium bicarbonate (e.g 50ml of 8.4%) may be used if acidosis is severe to lessen hyperkalaemia. 5. Establish and corrtect the underlying cause of the acute renal failure. B. ARF due to renal causes: 1. Emergency resuscitation- i.v infusion or transfusion; i.v NaHCO; i.v calcium chloride; haemodialysis or peritoneal dialysis if needed. 2. Determination and treatment of underlying causes. 3. Management of oliguric phase (1-3 weeks)- Maintain fluid and electrolyte balance, maintain nutrition, control the disordered chemistry and protect the patient from infection. Fluid: After initial resuscitation, 500c.c. + volume of fluid lost in last 24 hours. Diet: Nonprotein high carbohydrate diet. 2000-2500 kcal/day. Protein 40 gm/day should be given. Sodium & potassium: Since sodium and potassium are retained, intake of these should be restricted. Restrict fruits and fruit juices. 4. Assessment and follow-up. a. Regular weighing to assess the fluid retention, b. Degree of dehydration, c. Serum urea, electrolytes, creatinine etc. d. For nausia and vomiting- Metochlopramide 10mg orally or i.m or, Prochlorperazine 12.5mg stat. e. For convulsion- Diazepam 10mg i.m stat & s.o.s. f. For hypertension- Sodium restriction. Methyldopa l-2gm/day in divided doses, g. For cardiac failure- Digoxin of the usual dose should be given. 5. Control of infection: Regular clinical examination and microbiological investigation should be done to diagnose and treat this complication promptly. 6. Dialysis: indicated when - - blood urea> 200mg% - serum potassium> 7mg/L 7. Remove the source of obstruction followed by proper antibiotic therapy. 8. Management of diuretic phase (after 3 weeks)-number of patient there is the rapid onset of a diuretic phase when urine output is frequently increased & about 3-5 lit. daily. Sufficient fluid must be given to replace the loss of water and electrolytes & frequent i.v fluid are requird. |
| Introduction | Acute renal failure (ARF) is characterised by an acute and usually reversible deterioration of renal function which develops over a period of day or rarely weeks and is usually accompanied with uraemia and reduction in urine volume. |
| History | |
| Etiology | Etiology: A. Pre-renal disorder: 1. Severe haemorrhage due to any cause: haemate-mesis, malaena, APH, PPH, post traumatic etc. 2. Severe body fluid, plasma and electrolyte loss- e.g bum, diarrhoea, vomiting, intestinal obstruc-tion. 3. Cardiogenic shock. 4. Renal underperfusion in renal arterial throm-bosis, embolism, aortic aneurism. B. Renal disorder: Acute tubuler necrosis due to acute ischaemia or affects of toxic agents like drugs or bacterial endotoxins; accelerated hypertension & DIC also causes ARF. C. Post renal cause: Obstruction at any point of urinary tract may result ARF. |
| Clinical Features | Clinical features: 1. History of trauma or septic foci may be present. 2. Patient usually present with low B.P, severe dehydration, shock etc. 3. Scanty urine (50-500ml/day) initially, excess amount of urine may be present lateron. 4. Features of uraemia- anorexia, nausia, vomiting, diarrhoea, apathy, mental confusion, drowsiness, muscular twitching, hiccups, fits and coma, bleeding disorder may be present. 5. Anemia is common, due to excessive blood loss, hemolysis or decreased erythropoiesis; bleeding is also more likely because of disordered platelet function and disturbances of the coagulation cascade. 6. Features of hyperkalaemia, hypocalcaemia, metabolic acidosis may be present. 7. Respiratory distress, pulmonary oedema, heart failure may occur. 8. History of acute attack of loin pain, renal colic, hematuria, nocturia, dysuria may be present. 9. Severe infections may complicate acute renal failure because humoral and cellular immune mechanisms are depressed. |
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