ACUTE RENAL FAILURE

from Deepak Kumar

Admin Of Pharma-TrendSetter
https://www.facebook.com/groups/pharmarockz/ http://deepak-pharmatrendsetter.blogspot.in/

INTRODUCTION
KIDNEYS:
The kidneys are a pair of small beanshaped organs that lie on either side of your spine at just below your lowest ribs. They eliminate excess body water & reabsorbs useful chemicals and allowing waste to pass freely into the bladder as urine. The also regulate blood pressure and secrete hormones that contribute to red blood cell production.

NEPHRON
Nephron is the basic structural & functional unit of kidney. The human body, each kidney is made up of nearly 80,00,000 to 1 million nephrons. These are mainly meant for the elimination of wastes from the human body in the form of urine. The re-absorption of the electrolytes & soluble salts into the body from the urine is also carried by these units.

REABSORPTION OF FLUID AND SOLUTE IN THE KIDNEY

Filtered/ day Na+ (mmol) 25000 Excreted/ day 150 % reabsorbed 99+

K+(mmol) Cl-(mmol)

600 18000

90 150

93+ 99+

HCO3(mmol) Total solute (mosmol)

4900

100

54000

700

87

Water (litres)

180

<1.5

99+

ACUTE RENAL FAILURE

Acute kidney injury (AKI), formerly referred to as acute renal failure (ARF), is defined as an abrupt reduction in kidney function measured by a rapid decline in glomerular filtration rate. ARF results in the disturbance of renal physiological functions including : Impairment of nitrogenous waste product excretion. Loss of water and electrolyte regulation. Loss of acid-base regulation. ARF is an important contributing factor to the morbidity and mortality of critically ill infants and children.

 Acute kidney failure occurs in about 5% of people who are

hospitalized for any reason. It is even more common in those receiving intensive care. Medications such as antibiotics, anti-inflammatory medicines (for example, aspirin, ibuprofen), and water pills (diuretics) are the most common causes.

Other causes include infections and immune-related diseases such as lupus, leukemia, lymphoma, and sarcoidosis. It is usually reversible if the kidney damage is not severe.

Pre renal failure is the most common type of acute renal failure (60%-70% of all cases). The kidneys do not receive enough blood to filter (heart and liver failure) Post renal failure is referred to as obstructive renal failure, since it is often caused by something blocking elimination of urine produced by the kidneys. It is the rarest cause of acute kidney failure (5%-10% of all cases) (kidney stones, cancer, blood clot). Primary renal damage is the most complicated cause of renal failure (accounts for 25%-40% of cases). It includes glomerulonephritis.

CAUSES:
Acute nephritis (inflammation of kidneys), which usually develops by immune reaction. Damage of renal tissues by poisons like lead, mercury and carbon tetra chloride. Renal ischemia which develops during circulatory shock. Diabetes.

Acute tubular necrosis caused by hemorrhage, toxins.

Severe transfusion diseases. Sudden fall in blood pressure during hemorrhage, diarrhea and cholera. Blockade of ureter due to formation of calculi (renal stones) or tumor.

SYMPTOMS: Decreased urine production

Body swelling (EDEMA) Confusion Fatigue Nausea, vomiting Diarrhea Abdominal pain Metallic taste in the mouth Seizures and coma may also occur.

DIAGNOSIS & EVALUATION:

Kidney failure is detected from blood or urine tests.
URINE TEST: Specific gravity test: Normal range: 1.010 to 1.025mg/dl If there is any rise than the normal range it indicates the presence of ARF.

BLOOD TEST:
1) ESTIMATION OF PLASMA PROTEINS:

Normal values: Serum albumin Serum globulin Fibrinogen

- 4.7g/dl - 2.3g/dl 0.3g/dl

Any alterations in the levels of plasma proteins indicates the presence of kidney disorder.

2) ESTIMATION OF UREA, URIC ACID & CREATININE:

Normal values: Urea Uric acid Creatinine -

25-40mg/dl 2.5mg/dl 0.5-1.5mg/dl

The blood level of these substances increases in case of acute renal failure.

 RENAL CLEARANCE: It is defined as the amount of plasma that is cleared off a substance in a given unit of time.

C=UV/P
U= concentration of substance in urine. V= Volume of urine flow. P=concentration of substance in plasma.

IMAGING TESTS:
Computed axial tomography scan: This test is also called a CT or CAT scan. Magnetic resonance imaging: During the MRI, computerized pictures are taken of your kidneys and other parts of your body using radio waves. Percutaneous kidney biopsy: A percutaneous kidney biopsy is when a very small piece of your kidney is taken out and tested. A needle into your back and through to your kidney. The needle has a sharp edge that will cut out a tiny piece of your kidney.

 Renal ultrasound: This is a test using sound waves to look at your kidneys. Pictures of your kidneys show up on a TV-like screen. A renal ultrasound can show if you have kidney stones, an abscess, or other problems.

KUB x-ray: An x-ray machine takes pictures of your kidneys (K), ureters (U), and bladder (B). They use these pictures to check for problems with your intestines , kidneys, or abdomen.

MANAGEMENT:
Ensuring the intake of 30-50kcal/kg/day Restriction of protein intake.

NOT TO BE TAKEN:
Sodium chloride - NMT 2-4g/day potassium - NMT 40meq/day phosphorus - NMT 800mg/day Avoid magnesium containing drugs. Maintain blood pressure. haemodialysis.

TREATMENT:
Treatment of acute renal failure depends partly on the cause and extent of the failure. The first goal is to pinpoint the exact cause of the kidney failure, as that will partly dictate the treatment. Secondly, the degree to which accumulating wastes and water are affecting the body will impact treatment decisions about medications and the need for dialysis.

 Discontinue any medicines that may be causing the problem. These may include some antibiotics, common pain medicines (nonsteroidal antiinflammatory drugs) such as aspirin or ibuprofen, blood pressure medicines, and medicines used to treat cancer (chemotherapy). Treat it by using plasma exchange, glucocorticoids (such as cortisol), or other medicines, depending on the specific disease. Replace lost fluids, such as water, blood, and plasma, and restore blood flow to the kidneys.

 Use immunosuppressant's, such as cyclophosphamide, when an autoimmune disorder is causing acute renal failure. These disorders include lupus and other diseases that cause inflammation of the blood vessels (vasculitis). Remove or bypass a blockage in the urinary tract (postrenal ARF). Kidney function often rapidly returns to normal after a blockage is removed and urine can flow out of the kidneys. Some blockages, such as kidney stones, can be removed.

If the blockage cannot be removed, urine flow may be rerouted around the blockage using a catheter or a stent.

y Anti hypertensives: These medicines lower blood pressure. y Diuretics: These medicines are often called water pills. Diuretics help your body get rid of extra fluid (edema) in your legs and ankles. y Steroids: This medicine group decreases inflammation (swelling) and pain.

Dialysis: Dialysis is a treatment that cleans your

Kidney transplant: Surgery may be done to put a

blood of wastes when your kidneys no longer work well.

healthy kidney from another person into your body. The donated kidney does the work that your two failed kidneys used to do. Your diseased or injured kidneys will be removed during the transplant.

Surgery: You may need surgery if your kidney

failure is caused by a blockage in your urinary system.

CONTRA INDICATED DRUGS:

REDUCE DOSE EVEN IN MILD FAILURE:

Aminoglycosides Cephalosporins Vancomycin Ethambutol Amphotericin b Flucytosine

REDUCE DOSE ONLY IN SEVERE FAILURE:

Metronidazole Cotrimazole Carbenicillin Clarithromycin Imipenem Aztreonam Fluoroquinolones Meropenem

DRUGS TO BE AVOIDED:
Cephalothin Tetracyclines Nalidixic acid Nitrofurantoin Talampicillin Pyrazinamide Erythromycin estolate Pefloxacin Isoniazid

DURING PREGNANCY: Sulfonamides Benzodiazepenes Ciprrofloxacin (lactation) Lorazepam Furosemide Tetra cyclines.

PROGNOSTIC FACTORS:
1) Serum Creatinine Increase

>= 3 mg/dl < 2mg/dl

Mortality: 64% Mortality: 5-20%

2) Multiple Organ Failure : Mortality: 30% per organ system that fails Specific organ related risks Respiratory failure: 8 fold increased mortality Liver disease: 2-3 fold increased mortality Catabolic state: 2 fold increased mortality Heart disease: 3-4 fold increased mortality

NUTRITION:
PROTEIN-FREE CALORIE SUPPLY Energy Carbohydrates Fat Protein (amino acids) Conservative therapy Extracorporeal therapy 20-30 kcal/kg/d 3-5 (max. 7) g/kg/d 0.8-1.2 (max. 1.5) g/kg/d 0.8-1.0g/kg/d 0.6-0.8 (max. 1.0) g/kg/d 1.0-1.5 g/kg/d

DIFFERENCES: ACUTE
Sudden decline of kidney function Causes- obstruction in urine flow, immunological disorders. Kidney transplantation is not required. Reversible & curable Temporary.

CHRONIC
Progressive declining in the kidney function. Causes-Diabetes, high B.P. It may require transplantation. Irreversible & requires dialysis. Progressive worsening can be seen.

REFERENCES:

1) Text book of pharmacology -RANG & DALE 2) Medical pharmacology K.D.TRIPATI 3) Medical physiology SEMBULINGAM 4) INTERNET: www.emedicinehealth.com www.pharmadrugs.com

Thank you