Hanan fathy

Assistant lecturer
Pediatric Nephrology Department
Alexandria university
 ARF is a syndrome of multiple causes; defined as a
sudden loss of renal functions (over several hours to
several days).

 ARF results in derangement in extracellular fluid

balance, acid base, electrolytes, and divalent cation
regulation.

 An increase in serum creatinine concentration,

accumulation of other nitrogenous waste products, and
often a decline in urinary output are the hall marks of
ARF.
 Acute Renal Failure

Pre-renal Intrinsic Post-renal

Glomerular Interstitial Tubular Vascular

• Intravascular volume depletion
• Low cardiac output.
• Impaired renal autoregulatory responses.
– Interstitial nephritis,
– Acute glomerulonephritis
– Acute tubular necrosis
– Ischemia
– Toxins
 :

Obstruction of urine flow may result in ARF.

Various clinical causes of urinary tract

obstruction are: calculi, ureteropelvic junction
obstruction, posterior urethral valves, prune
belly, ureterocele, neurogenic bladder, and
duplicated ureters.
The most important factors determining
recovery of renal and tubular function are the
degree and severity of obstruction.
• Basically this is renal impairment caused by chronic
urinary tract obstruction.

• It produces a detectable rise in creatinine, and

eventually can be seen on ultrasound as thinning of
the renal cortex.

• It means that the best treatment is operative relief of

obstruction.
The Second International Consensus Conference of
the Acute Dialysis Quality Initiative (ADQI) Group
Radiographic signs of PUV:
• distended prostatic
urethra
• valve leaflets
• bladder and/or bladder
neck hypertrophy
• diverticula
• narrow stream in the
penile urethra
• incomplete emptying
of the bladder
• Nausea/Vomiting
• HTN
• Pulmonary edema
• Ascites
• Asterixis
• Encephalopathy
• Pruritus
• Seizures
• Chest pain
• Shortness of breath
Some of the most common signs and symptoms
of obstruction-related postrenal ARF follow:

• Difficult urination
• Distended bladder
• Edema (fluid retention and swelling)
• Hypertension
• Pain in the lower back, lower abdomen, groin,
genitalia
• sometimes hematuria.
Along with the loss of renal function, some
people with postrenal ARF develop
irreversible tubular defects( typeIV distal
RTA) , which may produce the following
symptoms:

• Hyperkalemia.
• Metabolic acidosis.
• Polyuria.
• Vital signs: espec temp and BP
• Fluid status: mucous membranes, JVP, peripheral
edema
• CVS: murmur, pericardial rub, CHF
• Resp: rales consistent with edema
• Abdo: bladder distension, masses, ascites, CVA
tenderness
 Laboratory investigation
• Blood
– CBC-D
– Lytes, Ca, Mg, P
– Urea
– Creatinine
• Urine
– Urine sodium
– Urine osmolality
– Urinalysis Consists of:
– dipstick for heme pigment, protein, glucose, ketones,
pH, leukocytes, and nitrites
– Microscopic examination of urine
 Radiological Investigations
• Radiology
– CXR
– Renal U/S
– CT
– VCUG

Other investigations
– ECG
– serum C3
– Antineutrophil cytoplasmic antibodies.
– Glomerular basement membrane antigens
• Postrenal ARF is diagnosed after a complete physical
examination and medical history. Often, the
catheterization of a bladder holding a large amount of
urine (2–3 liters) helps make the diagnosis.

• Ultrasound of the kidneys, ureters, and bladder is the

test of choice to detect obstruction. If the kidneys
show signs of hydronephrosis—that is, if they are
stretched, or dilated, beyond normal dimensions
because of fluid buildup—the patient usually has
obstructive ARF.
Acute Renal Failure Management

• Make/think about the diagnosis

• Treat life threatening conditions
• Identify the cause if possible
– Hypovolemia
– Toxic agents (drugs, myoglobin)
– Obstruction
• Treat reversible elements
– Hydrate
– Remove drug
– Relieve obstruction
The most urgent aspects of ARF are:
• Hyperkalaemia
• Severe hypertension
• Severe plasma and extracellular volume
expansion leading to heart failure and
pulmonary edema.
• Unremitting metabolic acidosis.
• Hypocalcemia / hyperphosphatemia.
• Uremia.
• Obstruction relief is the goal of treatment of postrenal ARF.

• If the problem is bladder outlet obstruction , the placement of a

catheter into the bladder will alleviate the obstruction
temporarily.

• If there are kidney stones in both ureters, the stones must be

removed.

• If the physician is unable to remove the stones, the patient may

need to be fitted with tubes that drain urine from the kidneys
through an opening in the skin (called percutaneous nephrostomy
tubes).
Dialysis:
Indications of dialysis:
 Severe derangements in electrolyte
concentrations .
 Volume overload.
 Acid-base imbalance.
 Pronounced azotemia; blood urea
nitrogen >100mg/dl
 Florid symptoms of uremia
(pericarditis,encephalopathy, bleeding,
nausea, vomiting or pruritus).
 Prognosis

• The rate of recovery is largely determined by the

duration and severity of obstructive disease.

• In general, the extent of recovery is determined

within 7 to 14 days after the obstruction has been
removed.

• Some patients may require short-term treatment

with dialysis.
• High urine output that may, initially, exceed 500 to
1000 milliliters per hour.

• This frequently occurs after an obstruction is

removed.

• The renal tubules typically cannot reabsorb water

and electrolytes in a normal manner after having
been obstructed for a period of time.