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Acute Renal Failure Paul M. Palevsky, M.D. Professor of Medicine Chief, Renal Section VA Pittsburgh Healthcare System
Acute Renal Failure ,[object Object],[object Object],[object Object]
Relationship Between GFR and Serum Creatinine in ARF 120 40 80 0 GFR (mL/min) 0 7 14 21 28 4 Days 2 0 6 Serum  Creatinine (mg/dL)
Acute Renal Failure ,[object Object],[object Object],[object Object],[object Object],[object Object]
Manifestations of ARF ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Differential Diagnosis of Azotemia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Differential Diagnosis of Azotemia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Classification of the Etiologies of Acute Renal Failure Acute Renal Failure Acute Tubular Necrosis Acute Interstitial Nephritis Acute GN Acute Vascular Syndromes Intratubular Obstruction Prerenal ARF Postrenal ARF Intrinsic ARF
Physiologic Response  to Volume Depletion Na Reabsorption AII AII PG RPF GFR P GC FF Urea Reabsorption
Prerenal Acute Renal Failure Na Reabsorption AII AII PG RPF GFR P GC FF Urea Reabsorption
Pathogenesis of Prerenal Azotemia Renal Vasoconstriction Decreased GFR Angiotensin II Adrenergic nerves Vasopressin + + + Nitric oxide Prostaglandins - - Volume Depletion Congestive Heart Failure Liver Failure Sepsis
Prerenal Acute Renal Failure ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Prerenal Acute Renal Failure: Clinical Presentation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Prerenal Acute Renal Failure: Clinical Presentation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Prerenal Acute Renal Failure:  Clinical Presentation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Fractional Excretion of Sodium FE Na  =   Filtered Sodium Excreted Sodium FE Na  =   P Na  x GFR U Na  x V FE Na  =   U Cr  / P Cr U Na  / P Na
Fractional Excretion of Sodium ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Treatment of  Prerenal Acute Renal Failure ,[object Object],[object Object],[object Object],[object Object],[object Object]
Postrenal Acute Renal Failure ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Postrenal Acute Renal Failure
Postrenal Acute Renal Failure
Postrenal Acute Renal Failure
Pathophysiology of Renal Failure in Obstructive Uropathy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Etiologies of Postrenal  Acute Renal Failure ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Postrenal Acute Renal Failure: Clinical Presentation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Postrenal Acute Renal Failure: Clinical Presentation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Postrenal Acute Renal Failure: Clinical Presentation ,[object Object],[object Object],[object Object],[object Object],[object Object]
Postrenal Acute Renal Failure: Clinical Evaluation ,[object Object],[object Object],[object Object],[object Object]
Postrenal Acute Renal Failure: Clinical Evaluation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Renal Ultrasound - Hydronephrosis
Treatment of  Postrenal Acute Renal Failure ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Intrinsic Acute Renal Failure ,[object Object],[object Object],[object Object],[object Object],[object Object]
Acute Tubular Necrosis
Acute Tubular Necrosis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Pathophysiology of ATN: Tubular Epithelial Cell Injury and Repair Loss of polarity Normal Epithelium Migration , Dedifferentiation of Viable Cells Differentiation & Reestablishment of polarity Sloughing of viable and dead cells with luminal obstruction Ischemia/ Reperfusion Apoptosis Necrosis Cell death Adhesion molecules Na + /K + -ATPase Proliferation
Pathophysiology of  Acute Tubular Necrosis ,[object Object],[object Object],[object Object],[object Object]
Phases of Ischemic ATN Prerenal Initiation Extension Maintenance Recovery GFR Time
Pathophysiology of ATN Ischemia Endothelial Injury Capillary Obstruction & Continued Ischemia Inflammation Tubular Injury Disruption of Cytoskeleton Loss of Cell Polarity Desquamation of Cells Tubular Obstruction & Backleak Apoptosis & Necrosis Activation of Vasoconstrictors Impaired Vasodilation Increased Leukocyte Adhesion
Acute Tubular Necrosis:  Clinical Presentation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Acute Tubular Necrosis:  Clinical Presentation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Acute Tubular Necrosis:  Clinical Presentation
Acute Tubular Necrosis: Treatment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Prognosis of Acute Tubular Necrosis ,[object Object],[object Object],[object Object]
Mortality in Acute Tubular Necrosis Chertow et al: Arch Int Med 1995; 155:1505-1511 Number of Failed Non-Respiratory Organ Systems
Effect of Contrast Nephropathy on Mortality Levy et al: JAMA 1996; 275:1489-1494
Acute Interstitial Nephritis ,[object Object],[object Object],[object Object],[object Object],[object Object]
Acute Interstitial Nephritis
Acute Interstitial Nephritis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Acute Interstitial Nephritis: Clinical Presentation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Acute Interstitial Nephritis: Clinical Presentation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Acute Interstitial Nephritis: Clinical Presentation
Acute Interstitial Nephritis: Clinical Presentation
Acute Interstitial Nephritis: Treatment ,[object Object],[object Object],[object Object],[object Object]
Acute Glomerulonephritis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Acute Glomerulonephritis
Acute Glomerulonephritis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Acute Vascular Syndromes ,[object Object],[object Object],[object Object],[object Object]
Atheroembolic Disease
Intratubular Obstruction ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Differential Diagnosis of  Acute Renal Failure ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Acute Renal Failure:  Diagnostic Evaluation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Acute Renal Failure: Diagnostic Evaluation ,[object Object],[object Object],[object Object]
Acute Renal Failure: Diagnostic Evaluation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Diagnostic Evaluation of ARF Muddy brown casts; tubular epithelial cells > 2% >40 <10:1 ATN Normal or RBC’s variable >20 variable Vascular RBC’s, RBC casts <1% <40 variable AGN WBC’s WBC casts,  RBC’s, eosinophils >1% >20 <20:1 AIN Intrinsic Normal or RBC’s variable >20 >20:1 Postrenal Normal < 1% <20 >20:1 Prerenal Urine Sediment FE Na U Na  (mEq/L) BUN:Cr Form of ARF
Acute Renal Failure: Management ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Acute Renal Failure: Management ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Acute Renal Failure: Management ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

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10 Palevsky Acute Renal Failure

  • 1. Acute Renal Failure Paul M. Palevsky, M.D. Professor of Medicine Chief, Renal Section VA Pittsburgh Healthcare System
  • 2.
  • 3. Relationship Between GFR and Serum Creatinine in ARF 120 40 80 0 GFR (mL/min) 0 7 14 21 28 4 Days 2 0 6 Serum Creatinine (mg/dL)
  • 4.
  • 5.
  • 6.
  • 7.
  • 8. Classification of the Etiologies of Acute Renal Failure Acute Renal Failure Acute Tubular Necrosis Acute Interstitial Nephritis Acute GN Acute Vascular Syndromes Intratubular Obstruction Prerenal ARF Postrenal ARF Intrinsic ARF
  • 9. Physiologic Response to Volume Depletion Na Reabsorption AII AII PG RPF GFR P GC FF Urea Reabsorption
  • 10. Prerenal Acute Renal Failure Na Reabsorption AII AII PG RPF GFR P GC FF Urea Reabsorption
  • 11. Pathogenesis of Prerenal Azotemia Renal Vasoconstriction Decreased GFR Angiotensin II Adrenergic nerves Vasopressin + + + Nitric oxide Prostaglandins - - Volume Depletion Congestive Heart Failure Liver Failure Sepsis
  • 12.
  • 13.
  • 14.
  • 15.
  • 16. Fractional Excretion of Sodium FE Na = Filtered Sodium Excreted Sodium FE Na = P Na x GFR U Na x V FE Na = U Cr / P Cr U Na / P Na
  • 17.
  • 18.
  • 19.
  • 23.
  • 24.
  • 25.
  • 26.
  • 27.
  • 28.
  • 29.
  • 30. Renal Ultrasound - Hydronephrosis
  • 31.
  • 32.
  • 34.
  • 35. Pathophysiology of ATN: Tubular Epithelial Cell Injury and Repair Loss of polarity Normal Epithelium Migration , Dedifferentiation of Viable Cells Differentiation & Reestablishment of polarity Sloughing of viable and dead cells with luminal obstruction Ischemia/ Reperfusion Apoptosis Necrosis Cell death Adhesion molecules Na + /K + -ATPase Proliferation
  • 36.
  • 37. Phases of Ischemic ATN Prerenal Initiation Extension Maintenance Recovery GFR Time
  • 38. Pathophysiology of ATN Ischemia Endothelial Injury Capillary Obstruction & Continued Ischemia Inflammation Tubular Injury Disruption of Cytoskeleton Loss of Cell Polarity Desquamation of Cells Tubular Obstruction & Backleak Apoptosis & Necrosis Activation of Vasoconstrictors Impaired Vasodilation Increased Leukocyte Adhesion
  • 39.
  • 40.
  • 41. Acute Tubular Necrosis: Clinical Presentation
  • 42.
  • 43.
  • 44. Mortality in Acute Tubular Necrosis Chertow et al: Arch Int Med 1995; 155:1505-1511 Number of Failed Non-Respiratory Organ Systems
  • 45. Effect of Contrast Nephropathy on Mortality Levy et al: JAMA 1996; 275:1489-1494
  • 46.
  • 48.
  • 49.
  • 50.
  • 51. Acute Interstitial Nephritis: Clinical Presentation
  • 52. Acute Interstitial Nephritis: Clinical Presentation
  • 53.
  • 54.
  • 56.
  • 57.
  • 59.
  • 60.
  • 61.
  • 62.
  • 63.
  • 64. Diagnostic Evaluation of ARF Muddy brown casts; tubular epithelial cells > 2% >40 <10:1 ATN Normal or RBC’s variable >20 variable Vascular RBC’s, RBC casts <1% <40 variable AGN WBC’s WBC casts, RBC’s, eosinophils >1% >20 <20:1 AIN Intrinsic Normal or RBC’s variable >20 >20:1 Postrenal Normal < 1% <20 >20:1 Prerenal Urine Sediment FE Na U Na (mEq/L) BUN:Cr Form of ARF
  • 65.
  • 66.
  • 67.