Clinical Presentation of Renal Disease

• Chronic renal failure (CRF)

• Acute renal failure (ARF)
• Hypertension
• Asymptomatic proteinuria and
persistent urinary abnormalities
• Nephrotic syndrome (NS)
• Urinary tract infection (UTI)
• Acute nephritis
• Obstructive nephropathy
• Renal stones
• Renal tubular defects
Acute Renal Failure
Acute renal failure (ARF) is a clinical
characterized by an abrupt decline in
glomerular filtration rate (GFR) and the
accumulation of nitrogenous waste (urea
nitrogen and creatinine)
 Prerenal
Prerenal Hipovolemia
Reduced “effective” extra cellular volume
Causes of acute renal failure

Renal Arterial Occlusion

Intrarenal vascular
Vasculitis
Hemolytic uremic syndrome
Trombotic thrombocytopenic purpura
Accelerated hypertension

Glomerulonephritis

Ischemic acute tubular necrosis (ATN)

Renal
Renal
parenchymal Toxic ATN
Endogenous toxin
Exogenous toxin

Interstitial
Acute allergic interstitial nephritis
Bilateral acute pyelonephritis

Intrarenal Obstruction
Casts
Crystal's

Renal Vein occlusion

Postrenal Urinary tract obstruction

 Causes of prerenal failure
Prerenal failure

Reduced efective Impaired renal

Extracellular fluid volume autoregulation

Preglomerular
Hypovolemia Systemic vasoconstriction
Vasodilatation
Hemorrhage Cardiac failure Sepsis
Sepsis Postglomerular
Fluid loss : Myocardial dysfunction Hypercalcemia vasoconstriction
gastrointestinal, Cirrhosis
renal, skin, Valvular dysfunction Hepatorenal syndrome ACE inhibitors
respiratory, Anaphylaxis
surgical Cardiac tamponade Pharmacologic agents : Angiotensin T1
Anesthesia NSAIDs, receptor antagonists
Hypoalbuminemia Pulmonary hypertension Cyclosporin A
Pharmacologic Amphotericin B
Third spacing vasodilatation Epinephrine
norepinephrine
 Decreased effective
Hypovolemia
Arterial blood volume

Baroreceptor activation

Neurohormonal responses

Renin angiotensin Sympathetic

Vasopressin
Aldosteron axis nervous system

Renal blood flow maintained Vasoconstriction

Initially through : Mesangial cell contraction
Local myenteric reflex Avid salt and water reabsorption
prostaglandin synthesis Reduce sweating
actions of angiotensin II Thirst and salt appetite

Homeostatic goal :
Prerenal acute renal failure
Restore intravascular volume Dramatic reduction in
Dramatic reduction in renal
And blood pressure to maintain Splanchnic, skin, and
Blood flow, glomerular filtration,
Perfusion of essential Musculoskeletal blood flow
Urine flow
organs
Clinical evaluation of ARF is achieved by
answering the following five question

• Is it ARF or acute on chronic renal failure ?

• Is there renal tract obstruction ?
• Is there reduction in effective ECF
volume ?
• Has there been a major vascular
occlusion ?
• Is there parenchymal renal disease other
than ATN ?
 Urine sediment in ARF
Condition Proteinuria Hematuria Microscopy
Prerenal azotemia - - Normal

Valvular occlusion - - Normal

Dysmorphic red cells,

Glomerulonephritis +++ +++ red cell cast, granular
casts
White cell (pyuria) and
Acute interstitial
++ + occasionally white cell
nephritis
cast
Hemolytic uremic
Syndrome/Thrombotic
+/- + Normal
thrombocytopenic
purpura
Muddy brown granular
‘ATN’ casts, tubular
Acute Tubular Necrosis epithelial cell casts
- -
(ATN) (fewer casts,
sometimes none in
nonoliguric ATN)
 Renal ultrasound in acute renal failure
Observation Indication
Pelvicalyceal dilatationa Obstructive nephropathy

Shrunken kidneys Chronic intrinsic renal disease

Normal size kidneys echogenic Acute glomerulonephritis, acute

normal echo pattern tubular necrosis
Prerenal azotemia, renal artery
occlusion
Enlarged kidneys Malignant infiltration, renal vein
thrombosis, HIV-associated
nephropathy, amyloid
aPC dilatation is usual but not universal in the presence of obstruction
 Clinical assessment of patients with
acute renal failure
Search for reversible factors that may be exacerbating acute renal failure,
e.g. hypovolemia, ongoing administration of nephrotoxins

Examine for clinical evidence of uremic syndrome, e.g. asterixis, confusion,

hiccups, nausea, vomiting, pericarditis

Clinical assessment of intravascular volume

Review most recent laboratory results for metabolic complications:

hyperkalemia, acidosis, hype rphosphatemia

Review drug prescription: discontinue all non-essential drugs and adjust

dose or dose interval of drugs eliminated by kidney

Review nutritional status: consider protein, salt, potassium, and

phosphate restriction; consider need for enteral nutrition or
hyperalimentation
 Assessment of a Patient with
Acute Renal Failure (1)
Procedure Information Sought
Clinical history and Clues to the cause of acute renal failure
examination Indicators of severity of metabolis disturbance
Estimate of volume status (hydration)

Urinalysis and urine Markers of glomerular or tubulointerstitial

microscopy 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 Information Sought

Renal ultrasound To determine kidney size, presence of obstruction,
abnormal renal parenchymal texture
Plus, where appropriate :
Abdominal CT-Scan To define structural abnormalities of the kidneys or
Radionuclide scan urinary tract
Cystoscopy +/- retragrade To assess abnormal renal perfusion
pyelograms To evaluate / relieve urinary tract obstruction
Renal biopsy To define pathology of renal parenchymal disease
Changes in plasma biochemistry
in acute renal failure

Hyperkalaemia
Decreased bicarbonate
Elevated urea
Elevated creatinine
Elevated uric acid
Hypocalcaemia
hyperphosphataemia
Management
of ARF
 Prerenal
Prerenal Hipovolemia
Reduced “effective” extra cellular volume
Classification of the major Causes of acute renal failure

Renal Arterial Occlusion

Intrarenal vascular
Vasculitis
Causes of renal failureHemolytic uremic syndrome Management
Trombotic thrombocytopenic purpura
Accelerated hypertension
Hipovolemia Stop diuretic, administer blood,
crystalloid, colloid infusions
Glomerulonephritis

Reduced “effective”
Ischemic acute tubular necrosis (ATN)
Renal
Renalarterial blood volume
parenchymal Inotropes, diuretics, afterload reduction
cardiac failure Toxic ATN
Endogenous toxin
sepsis Pressor agents, crystalloid, antibiotics
Exogenous toxin

Interstitial
Acute allergic interstitial nephritis
Drug impaired Stop nonsteroidal anti-inflammatory
Bilateral acute pyelonephritis

autoregulation agents, ACE inhibitors, cyclosporine

Intrarenal Obstruction
Casts
Crystal's

Renal Vein occlusion

Postrenal Urinary tract obstruction

 Prerenal
Prerenal Hipovolemia
Reduced “effective” extra cellular volume
Classification of the major Causes of acute renal failure

Renal Arterial Occlusion

Intrarenal vascular
Vasculitis
Hemolytic uremic syndrome
Trombotic thrombocytopenic purpura
Accelerated hypertension

Causes of renal failure

Glomerulonephritis Management

Ischemic acute tubular necrosis (ATN)

Renal
Renal Anticoagulation, thrombolysi
parenchymal
Renal Arterial Occlusion Toxic ATN
Endogenous toxin
Exogenous toxin
Angioplasty/stent/surgery

Interstitial
Acute allergic interstitial nephritis
Bilateral acute pyelonephritis

Intrarenal Obstruction
Casts
Crystal's

Renal Vein occlusion

Postrenal Urinary tract obstruction

 Prerenal
Prerenal Hipovolemia
Reduced “effective” extra cellular volume
Classification of the major Causes of acute renal failure

Renal Arterial Occlusion

Intrarenal vascular
Vasculitis
Hemolytic uremic syndrome
Trombotic thrombocytopenic purpura
Accelerated hypertension
Causes of renal
Management
failure Glomerulonephritis

Intrarenal vasculature Ischemic acute tubular necrosis (ATN)

Renal
RenalVasculitis Immunosuppressant
parenchymal Toxic ATN
Hemolytic uremic syndrome/
Endogenous toxinPlasma exchange/plasma infusion
Exogenous toxin
Trombotic thrombocytopenic
Interstitial
purpura Acute allergic interstitial nephritis
Bilateral acute pyelonephritis
Accelerated hypertension Lower blood pressure; sodium
nitroprusside, labetalol, etc
Intrarenal Obstruction
Casts
Crystal's

Renal Vein occlusion

Postrenal Urinary tract obstruction

 Prerenal
Prerenal Hipovolemia
Reduced “effective” extra cellular volume
Classification of the major Causes of acute renal failure

Renal Arterial Occlusion

Intrarenal vascular
Vasculitis
Hemolytic uremic syndrome
Trombotic thrombocytopenic purpura
Accelerated hypertension

Causes of renal failure

Glomerulonephritis
Management

Renal Consider Immunosuppressant

Ischemic acute tubular necrosis (ATN)

Renal
Glomerular disease
parenchymal Toxic ATN
Antibiotics of endocarditis
Endogenous toxin
Supportive care if postinfectioous
Exogenous toxin

Interstitial
Acute allergic interstitial nephritis
Bilateral acute pyelonephritis

Intrarenal Obstruction
Casts
Crystal's

Renal Vein occlusion

Postrenal Urinary tract obstruction

 Prerenal
Prerenal Hipovolemia
Reduced “effective” extra cellular volume
Classification of the major Causes of acute renal failure

Renal Arterial Occlusion

Intrarenal vascular
Vasculitis
Hemolytic uremic syndrome
Trombotic thrombocytopenic purpura
Accelerated hypertension

Causes of renal failure

Glomerulonephritis Management

Ischemic acute tubular necrosis (ATN)

Renal
Renal Supportive care
Ischemic parenchymal
tubular acute Toxic ATN
Threat cause of circulatory failure
Endogenous toxin
Exogenous toxin

Interstitial
Acute allergic interstitial nephritis
Bilateral acute pyelonephritis

Intrarenal Obstruction
Casts
Crystal's

Renal Vein occlusion

Postrenal Urinary tract obstruction

 Prerenal
Prerenal Hipovolemia
Reduced “effective” extra cellular volume
Classification of the major Causes of acute renal failure

Renal Arterial Occlusion

Intrarenal vascular
Vasculitis
Hemolytic uremic syndrome
Trombotic thrombocytopenic purpura
Accelerated hypertension

Causes of renal failure

Glomerulonephritis Management

Ischemic acute tubular necrosis (ATN)

Renal
Renal Supportive care
Toxic ATNparenchymal Toxic ATN
Discontinue toxin
Endogenous toxin
Exogenous toxin

Interstitial
Acute allergic interstitial nephritis
Bilateral acute pyelonephritis

Intrarenal Obstruction
Casts
Crystal's

Renal Vein occlusion

Postrenal Urinary tract obstruction

 Prerenal
Prerenal Hipovolemia
Reduced “effective” extra cellular volume
Classification of the major Causes of acute renal failure

Renal Arterial Occlusion

Intrarenal vascular
Vasculitis
Hemolytic uremic syndrome
Trombotic thrombocytopenic purpura
Causes of renal Accelerated hypertension
Management
failure
Glomerulonephritis

Interstitial disease Ischemic acute tubular necrosis (ATN)

Renal
Renal
Allergic interstitial nephritis Discontinue offending drugs ; consider corticosteroid
parenchymal Toxic ATN
Bilateral acute pyelonephritis Antibiotics
Endogenous toxin
Exogenous toxin
Malignant infiltration Chemotherapy
Interstitial
Acute allergic interstitial nephritis
Bilateral acute pyelonephritis

Intrarenal Obstruction
Casts
Crystal's

Renal Vein occlusion

Postrenal Urinary tract obstruction

 Prerenal
Prerenal Hipovolemia
Reduced “effective” extra cellular volume
Classification of the major Causes of acute renal failure

Renal Arterial Occlusion

Intrarenal vascular
Vasculitis
Hemolytic uremic syndrome
Trombotic thrombocytopenic purpura
Causes of renal Accelerated hypertension
Management
failure Glomerulonephritis

Intrarenal obstruction
Renal
Ischemic acute tubular necrosis (ATN)

Renal
Myeloma cast parenchymal Consider plasma exchange and chemotherapy
Toxic ATN
Exogenous crystals Stop offending
Endogenous toxin drugs
Exogenous toxin
Endogenous crystals Alkaline diuresis for rhabdomyolysis or acute urate
nephropathy
Interstitial
Acute allergic interstitial nephritis
Bilateral acute pyelonephritis

Intrarenal Obstruction
Casts
Crystal's

Renal Vein occlusion

Postrenal Urinary tract obstruction

 Prerenal
Prerenal Hipovolemia
Reduced “effective” extra cellular volume
Classification of the major Causes of acute renal failure

Renal Arterial Occlusion

Intrarenal vascular
Vasculitis
Hemolytic uremic syndrome
Trombotic thrombocytopenic purpura
Accelerated hypertension

Causes of renal failure

Glomerulonephritis Management

Ischemic acute tubular necrosis (ATN)

Renal Anticoagulation
Renal
parenchymal
Renal Vein occlusion Toxic ATN Treat glomerular disease if
Endogenous toxin
nephrotic
Exogenous toxin

Interstitial
Acute allergic interstitial nephritis
Bilateral acute pyelonephritis

Intrarenal Obstruction
Casts
Crystal's

Renal Vein occlusion

Postrenal Urinary tract obstruction

 Prerenal
Prerenal Hipovolemia
Reduced “effective” extra cellular volume
Classification of the major Causes of acute renal failure

Renal Arterial Occlusion

Intrarenal vascular
Vasculitis
Hemolytic uremic syndrome
Trombotic thrombocytopenic purpura
Accelerated hypertension

Causes of renalGlomerulonephritis
Management
failure
Ischemic acute tubular necrosis (ATN)
Renal
Renal
parenchymal Toxic ATN Bladder catheter / nephrostomy
Urinary tract obstructionEndogenous toxin
Radiologic / surgical treatment of
Exogenous toxin

Interstitial obstructing lesion

Acute allergic interstitial nephritis
Bilateral acute pyelonephritis

Intrarenal Obstruction
Casts
Crystal's

Renal Vein occlusion

Postrenal Urinary tract obstruction

Non-dialytic management of acute tubular necrosis (1)
Complication Treatment
Intravascular Restrict salt (1-2g/day) and water (usually <1L/day)
Volume overload Diuretics (usually loop diuretics - thiazide)
Hyponatremia Restrict enteral water intake (<1Uday). Avoid hypotonic
intravenous solutions (including dextrose solutions)

Hyperkalemia Restrict dietary K' intake (usually <40mmol/day)

Eliminate K` supplements and K'-sparing diuretics Potassium-
binding ion-exchange resins e.g. sodium polystyrene
sulfonate (calcium resonium')
Glucose (50mL of 50% dextrose) and insulin (10 units regular)
Sodium bicarbonate (usually 50-100mmol) (32 Agonist (e.g.
albuterol 10-20 mg inhaled or 0.5-1mg i.v.)
Calcium gluconate (10mL of 10% solution over 2-5 minutes)
Metabolic acidosis Restrict dietary protein (usually 0.6g/kg per day of high
biologic value)
Sodium bicarbonate (maintain serum bicarbonate >15mmol/L
and arterial pH >7.2)
 Non-dialytic management of acute tubular necrosis (2)
Complication Treatment
Hyperphosphatemia Restrict dietary phosphate intake (usually <800mg/day)
Phosphate-binding agents (calcium carbonate, calcium
acetate, aluminum hydroxide)
Hypocalcemia Calcium carbonate (if symptomatic or if sodium bicarbonate to
be administered)
Calcium gluconate (10-20mL of 10% solution)
Hypermagnesemia Discontinue Mg2+-containing antacids
Hyperuricemia Treatment usually not necessary [if urate <900pmol/L
(<15mg/dL)]
Nutrition Restrict dietary protein (-0.6g/kg per day) if not catabolic
Carbohydrate (-100g/day)Enteral or parenteral nutrition (if
course prolonged or very catabolic)
 Indications for dialysis in acute renal failure
Indications Characteristics
Uremia Obtundation, asterixis, seizures, nausea and vomiting.
pericarditis
Hyperkalemia K'>6.5mmol/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