Acute Kidney Failure Overview

The kidneys are a pair of small (about the size of your fist) bean-shaped organs that lie on either side of your spine at just below your lowest ribs. They filter by-products and toxins from your blood and preserve the balance of bodily fluids and electrolytes.

The kidneys excrete these compounds with water to make urine.

They also eliminate excess body water while reabsorbing useful chemicals and allowing waste to pass freely into the bladder as urine. They allow a person to consume a variety of foods, drugs, vitamins and supplements, additives, and excess fluids without worry that toxic by-products will build up to harmful levels. The kidneys regulate the amount of various substances in the blood and the amount of water in the body.

Causes

The causes of ARF traditionally are divided into 3 main categories: prerenal, intrinsic/intrarenal, and postrenal.

Prerenal ARF. Problems affecting the flow of blood before it reaches the kidneys Volume depletion Renal losses (diuretics, polyuria) GI losses (vomiting, diarrhea) Cutaneous losses (burns, Stevens-Johnson syndrome) Hemorrhage Decreased cardiac output

Heart failure Pulmonary embolus Acute myocardial infarction Dysrhythmias Systemic vasodilation Sepsis Anaphylaxis Anesthetics Drug overdose Renal artery occlusion

Intrinsic/Intrarenal ARF. Problems affecting the movement of urine out of the kidneys

Prolong renal ischemia resulting from:

Pigment neuropathy (associated with the breakdown of blood

cells containing pigments that in turn occlude kidney structures) Myoglobinuria (trauma, crush injuries, burns) Hemoglobinuria (transfusion reaction, hemolytic anemia) Nephrotoxic agents such as: Aminoglycoside antibiotics(gentamycin, tobramycin) Radiopaque contrast agents Heavy metals (lead, mercury) Solvents and chemicals (ethylene glycol, carbon tetrachloride, arsenic) NSAIDS ACE inhibitors

Infectious processes such as:

Acute pyelonephritis Acute glomerulonephritis

Postrenal ARF. Problems with the kidney itself that prevent proper filtration of blood or production of urine

Urinary tract obstructions, including:

Calculi (stones) Tumors Benign Prostatic hyperplasia Strictures Blood clots

Acute Renal Failure Symptoms

The following symptoms may occur with acute kidney failure. Some people have no symptoms, at least in the early stages. The symptoms may be very subtle.

Decreased urine production Body swelling Problems concentrating Confusion Fatigue Lethargy Nausea, vomiting Diarrhea Abdominal pain Metallic taste in the mouth

Seizures and coma may occur in very severe acute kidney failure. Laboratory Studies Several laboratory tests are useful for assessing the etiology of ARF, and the findings can aid in proper management. These tests include complete blood cell

(CBC) count, serum biochemistries, urine analysis with microscopy, and urine electrolytes.

Blood urea nitrogen (BUN) and serum creatinine o BUN may be elevated in patients with GI or mucosal bleeding, steroid treatment, or protein loading. CBC count, peripheral smear, and serology o The presence of myoglobin or free hemoglobin, increased serum uric acid level, and other related findings may help further define the etiology of ARF. Urinalysis o Findings of granular, muddy-brown casts are suggestive of tubular necrosis. Often, oxalate crystals are observed in cases of ARF. o The dipstick assay may reveal significant proteinuria, which would suggest glomerular or interstitial disease. o The presence of RBCs in the urine is always pathologic. Eumorphic RBCs suggest bleeding along the collecting system. Dysmorphic RBCs or RBC casts indicate glomerular inflammation, suggesting glomerulonephritis is present. o The presence of WBCs or WBC casts suggests pyelonephritis or acute interstitial nephritis. The presence of urine eosinophils is helpful in establishing a diagnosis but is not necessary for allergic interstitial nephritis to be present. o The presence of eosinophils, as visualized with Wright stain or Hansel stain, suggests interstitial nephritis but can also be seen in urinary tract infections, glomerulonephritis, and atheroembolic disease. o The presence of uric acid crystals may represent ARF associated with uric acid nephropathy. Urine electrolytes o Urine electrolyte findings also can serve as valuable indicators of functioning renal tubules.

Imaging Studies In some cases, renal imaging is useful, especially if renal failure is secondary to obstruction. The American College of Radiology recommends ultrasonography, preferably with Doppler methods, as the most appropriate imaging method in ARF.

Ultrasonography o Renal ultrasonography is useful for evaluating existing renal disease and obstruction of the urinary collecting system. o Ultrasonographic scans or other imaging studies showing small kidneys suggest chronic renal failure. Doppler ultrasonography o Doppler scans are useful for detecting the presence and nature of renal blood flow. o Doppler scans can be quite useful in the diagnosis of thromboembolic or renovascular disease.

Procedures

Renal biopsy o A renal biopsy can be useful in establishing the diagnosis of intrarenal causes of AKI and can be justified if it will change management (eg, initiation of immunosuppressive medications). A renal biopsy may also be indicated when renal function does not return for a prolonged period and a prognosis is required to develop long-term management.