The document discusses acute renal failure (ARF), now referred to as acute kidney injury (AKI). It defines AKI, describes diagnostic criteria and staging systems like RIFLE. Common causes of AKI like sepsis, hypotension, nephrotoxins are mentioned. Prevention of AKI through adequate hydration, maintaining perfusion and minimizing nephrotoxin exposure is emphasized. Treatment of established AKI focuses on renal replacement therapy. Diuretics are not recommended for treatment of oliguria.

1. How Best to Prevent & Manage Acute Renal Failure ? Dr. T.R.Chandrashekar Director Critical Care, K.R. Hospital Bangalore

6. Acute Dialysis Quality Initiative (ADQI) -RIFLE classification of AKI. Three stages of increasing severity Two outcome variables

7. Modified RIFLE criteria for AKI Classification/Staging system for AKI <0.3ml/kg/hr for 24 hrs or Anuria for 12 hrs Increase to >= to 300% from baseline SC >= 4.0mg/dl with an acute increase of at least 0.5mg/dl 3 < 0.5ml/kg/hr for more than 12 hrs Increase to >= to 200%-300 % from baseline 2 < 0.5ml/kg/hr for more than 6 hrs Increase in SC of >= to 0.3 mg/dl or increase to >= to150-200% from baseline 1 U.O criteria Serum Creatinine criteria Stage

10. Pre renal causes Low volume states NSAIDS,ACEI Renal artery stenosis Post renal causes Renal stones, ureteric stones Ca Cervix Prostate hypertrophy, tumors Renal papillary necrosis Renal causes Glomerular –Glomerularnephritis ATN Hypoperfusion and toxins Tubulointerstitial Drugs, Myeloma Causes of AKI

11. Etiology of ARF ATN is the cause in more than 90% Sepsis is the leading cause of ATN

13. Laboratory Findings in Acute Renal Failure Cr improves with IVF Cr won’t improve much Response to volume ATN: muddy brown granular casts, cellular debris, tubular epithelial cells Bland Urinary Sediment >2% <1% Fractional excretion of sodium <350 >500 Urine osmolality, mosmol/L H 2 O >40 <20 Urine sodium (U Na ), meq/L 10-15:1 >20:1 BUN/P Cr Ratio Oliguric Acute Renal Failure (ATN) Prerenal Azotemia Index

15. Mechanism of ATN Hypo-perfusion GFR Renal blood flow Cortical vasoconstriction Anuria Oliguric Renal failure Septic shock Volume depletion Drugs Low cardiac output Toxins Tubular malfunction Non-oliguric renal failure Cell shedding Death Tubular obstruction Medullary hypoxia Endothelial damage Back leak

16. MECHANISM OF ATN Prognosis in ATN

19. 24 – 48 hrs For Anaesthesiologist This is when and where prediction and prevention strategies must be applied Window of Opportunity

28. Monitoring & Management - ACS Surgical decompression or if the pt is sick put flank drains

35. Prevention of AKI summary Loop diuretics Dopamine and dopamine receptor agonists ANPs Prophylactic hemofiltration Strategies that are not effective NAC Theophylline Low-dose recombinant ANP (in cardiac surgical patients) Strategies of unknown efficacy Isotonic hydration (IV route) Once-daily dosing of aminoglycosides Use of lipid formulations of amphotericin B Use of iso-osmolar nonionic contrast media Strategies that are likely to be effective

39. Renal Replacement therapy =

44. Thank you “ Back to basics&quot;: Optimise Volume and Defend Pressure. There are no magic bullets just high quality intensive care