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acute renal failure

…from basics to the latest advances

Joel M. Topf, MD
Clinical Nephrologist
http://pbfluids.com
the house
moment
Dr. Haas invented the first dialysis machine designed
for humans and in 1928 he treated 6 patients.

All of them died.


In 1943, Willem Kolff’s, working in Nazi
occupied Netherlands created the
second human dialysis machine.

In 1943 he dialyzed his first patient, a


young man with acute nephritis.


 Dr. Haas

In 1945, a 67-year-old woman in


uremic coma presented to Dr Kolff.
Regained consciousness after 11
hours of hemodialysis.
Mortality by Etiology

80

 Commonly quoted 70

mortality of 70% is 60

Mortality (%)
for dialysis requiring 50

ICU patients 40
30
 For hospital acquired
20
ARF: 20%
10
0
Sepsis Other Causes
 37 year old AA female
 Multiple GSW
 Prolonged hypotension
 Aorta was cross
clamped during
exploratory laparotomy
 Anuric x 18 hours
 Cr from 0.8 to 2.2
 36 y.o. African American
women with menorrhagia.
 Has prolonged bleeding
following fibroidectomy
 Contrasted CT scan used to
determine source of
bleeding.
 Cr rises from 0.8 to 2.2
 Patient is non-oliguric
Two women.
Same age.

Same race.

Same rise in creatinine.

Same diagnosis: acute renal failure.

Two completely different diseases.


definition of acute renal failure
“Acute and sustained reduction in renal function.”
biochemical
definitions
Contrast nephropathy
ARF is defined by a 0.5
mg/dL or 25% increase
in serum creatinine
event driven
definitions
Dialysis dependent
ARF is often used in
retrospective cohorts
 Easy to capture
 Unambiguous
 Important end-point
rifle criteria for
stratifying arf
R isk
I njury
F ailure
L oss of function
E nd-Stage Renal disease
R isk
 Increase in Cr of 1.5-2.0 X baseline or
 urine output < 0.5 mL/kg/hr for more than 6 hours.

I njury
F ailure
L oss of function
E nd-Stage Renal disease
R isk: Inc Cr 50-100% or U.O. < 0.5 mL/kg/hr for > 6 hrs
I njury
 increase in Cr 2-3 X baseline (loss of 50% of GFR) or
 urine output < 0.5 mL/kg/hr for more than 12 hours.

F ailure
L oss of function
E nd-Stage Renal disease
R isk: Inc Cr 50-100% or U.O. < 0.5 mL/kg/hr for > 6 hrs
I njury: Inc Cr 100-200% or U.O. < 0.5 mL/kg/hr > 12 hrs
F ailure
 increase in Cr rises > 3X baseline Cr (loss of 75% of GFR) or
 an increase in serum creatinine greater than 4 mg/dL, or
 urine output < 0.3 mL/kg/hr for more than 24 hours or
anuria for more than 12 hours.

L oss of function
E nd-Stage Renal disease
R isk: Inc Cr 50-100% or U.O. < 0.5 mL/kg/hr for > 6 hrs
I njury: Inc Cr 100-200% or U.O. < 0.5 mL/kg/hr > 12 hrs
F ailure: Inc Cr > 200% or > 4 mg/dL or U.O. < 0.3 mL/kg/hr >
24 hrs or anuria for more than 12 hours

L oss of function
 persistent renal failure (i.e. need for dialysis) for more than 4
weeks.

E nd-Stage Renal disease


R isk: Inc Cr 50-100% or U.O. < 0.5 mL/kg/hr for > 6 hrs
I njury: Inc Cr 100-200% or U.O. < 0.5 mL/kg/hr > 12 hrs
F ailure: Inc Cr > 200% or > 4 mg/dL or U.O. < 0.3 mL/kg/hr >
24 hrs or anuria for more than 12 hours

L oss of function: Need for dialysis for more than 4 weeks


E nd-Stage Renal disease
 persistent renal failure (i.e. need for dialysis) for more than 3
months.
R isk: Inc Cr 50-100% or U.O. < 0.5 mL/kg/hr for > 6 hrs
I njury: Inc Cr 100-200% or U.O. < 0.5 mL/kg/hr > 12 hrs
F ailure: Inc Cr > 200% or > 4 mg/dL or U.O. < 0.3 mL/kg/hr >
24 hrs or anuria for more than 12 hours

L oss of function: Need for dialysis for more than 4 weeks


E nd-Stage Renal disease : Need for dialysis for more than 3
months
nice criteria. do they work?

 20,126 consecutive
admissions to a Risk
university hospital 9% Injury
5%
 Excluded kids
 Kidney transplant and Failure
4%
dialysis patients
 Patients admitted for <
24 hours
No
 Using RIFLE: Renal
 Risk 9.1% failure
82%
 Injury 5.2%
 Failure 3.7%
Uchino S, Bellomo R, Goldsmith D. Crit Care Med 2006 Vol 34 1913-1917.
>3x BL Cr

Cr > 4

Hospital Mortality
nice criteria. do they work in the icu?
 University of Pittsburgh
has 7 ICUs
Risk
 5,383 patients 12%
No
 Excluded dialysis Renal
 Subsequent admissions failure
33%
 Frequency of acute Injury
Kidney failure: 27%

 No AKD 1,766
 Risk 670 Failure
 Injury 1,436 28%

 Failure 1,511

Hoste E, Clermont G, Kersten A. Crit Care 2006 Vol 310


30

25

20 Mortality
RRT
15
LOS
10 ICU LOS

0
No AKI Risk Injury Failure
RIFLE is dependent on creatinine.
creatine is a functional marker of
organ damage

Functional
markers: old
and busted
biomarkers are foot prints of actual
organ damage

Biomarkers,
new hotness
functional versus biomarkers

Functional
Marker Biomarker
SGOT
Hypoalbuminemia
Liver damage Coagulopathy
SGPT
GGT
functional versus biomarkers

Functional
Marker Biomarker
SGOT
Hypoalbuminemia
Liver damage Coagulopathy
SGPT
GGT
Troponin I
Hypotension
Heart damage Arrhythmia
Troponin T
CK-MB
functional versus biomarkers

Functional
Marker Biomarker
SGOT
Hypoalbuminemia
Liver damage Coagulopathy
SGPT
GGT
Troponin I
Hypotension
Heart damage Arrhythmia
Troponin T
CK-MB
Creatinine
KIM-1
Kidney damage BUN
NGAL
Cystatin C
creatinine as a lagging indicator

 4,118 Cardiac surgery patients


 Prospectively looked at changes of creatinine
48 hours post-op on 30-day mortality
 All odds ratios were controlled for 26
variables found to be significant predictors of
mortality in univariate analysis
Creatinine falls Creatinine rises

<0.5 0.4 0.2 0.1 0.3 0.5 0.7 0.9


Delta Creatinine (mg/dL)
candidates for a renal troponin:
candidates for a renal troponin:
kidney injury molecule-1 (kim-1)
 Transmembrane
protein expressed 2.00
in the proximal
tubule. 0.69
 Expression is 0.34
increased 0.13
following ischemic
damage
 Can be found 12
hours after renal
insult
Han WH, Bailly V, Abichandani. Kidney Int 2002 62, 237–244.
Liangos O, Han WK, Wald R. Abstract J Am Soc Nephrol 16: 318A, 2005.
candidates for a renal troponin:
kidney injury molecule-1 (kim-1)

 Transmembrane Time starts at aorta cross


protein expressed clamp. Cr rose to 2.1.
in the proximal
tubule.
 Expression is inc-
reased following
ischemic damage
 Can be found 12
hours after renal
insult
Han WH, Bailly V, Abichandani. Kidney Int 2002 62, 237–244.
Liangos O, Han WK, Wald R. Abstract J Am Soc Nephrol 16: 318A, 2005.
urinary neutrophil gelatinase-
associated lipocalin (ngal)

 Protein that is secreted  Prospective


by the kidney in res- observational trial
ponse to ischemic injury  81 adults going for
 Early data in children Cardiac surgery
showed nearly perfect  65 No AKI
sensitivity and  1 died of MOF
specificity  16 AKI (Risk or higher)
 5 required CVVH
 False positives with UTI
 5 died of MOF

Mishra J, Ma Q, Prada A. J Am Soc Nephrol 2003; 14: 2534-43.


Wagener G, Jan M, K M. Anesthesia 2006; 105: 485-91.
differential diagnosis
etiologies of arf

 Seventy percent have concurrent oliguria


 < 400 mL/day
 < 0.5 mL/kg/hr in children
 < 1 mL/kg/hr in infants
 Complicates 5-7% of hospitalizations
Hospital Community
acquired acquired
50.3% 49.7%

Hou SH, Bushinsky DA, Wish JB. Am J Med 1983; 74: 243-8.
Nash K, Hafeez A, Hou S. Am J Kidney Dis. 2002; 39: 930-6.
Kaufman J, Dhakal M, Patel B, Et al. Am J Kidney Dis 1991; 17: 191-8.
Hou SH, Bushinsky DA, Wish JB. Am J Med 1983; 74: 243-8.
Nash K, Hafeez A, Hou S. Am J Kidney Dis. 2002; 39: 930-6.
Kaufman J, Dhakal M, Patel B, Et al. Am J Kidney Dis 1991; 17: 191-8.
N=389 N=256 N=103

100% other
17 12 11
80% 11 Post Renal
7 20
Pre Renal
21 29
60% Renal
30
40%
56 48
20% 39

0%
< 65 65-79 > 79
Ages

Pascual J, Liano F. J Am Geriatr Soc 1998, 46: 1-5.


hospital acquired acute renal failure
Hypotension Obstruction
2% Other
11% 7%
Unknown
3%
CHF
4%
Other
2%

Sepsis
Volume 7%
Contraction
22%

Medication
16%

Post-Op
15%
Contrast
11%
hospital acquired acute renal failure
Pre-renal azotemia
No BP, no pee pee
differentiation of prerenal from
intrinsic renal disease
 Use of FENa
 Fraction of filtered sodium which is excreted in the
urine.
 Patients with prerenal azotemia will be sodium
avid and minimize renal excretion of sodium
Fractional excretion of
sodium:

Excreted Na
Filtered Na
Calculating the Numerator

Excreted Na = Urine Na x Urine Volume


Calculating the Denominator

Filtered Na = Serum Na x GFR

GFR = Urine Cr x Urine Volume


Serum Cr

Filtered Na = Serum Na x UrCr x UrVol


Serum Cr
Excreted Na
FENa = Filtered Na

Urine Na x Urine Volume


FENa = Serum Na x UrCr x Urine Volume
Serum Cr
Urine Na
FENa = Serum Na x UrCr
Serum Cr

Urine Na x Serum Cr
FENa = Serum Na x UrCr
FENa the easy way

 FENa is a small number 0.1% to 3%


 So the calculation will be 0.001-0.03 prior to
converting to percent by X 100
 So make the fraction small by putting the small
numbers over the big numbers

 Sr Na
 Sr Cr Sr Cr x Ur Na
FENa =
 Ur Na Sr Na x Ur Cr
 Ur Cr
FeNa. what is it good for?

 The discriminator for differentiating between prerenal azotemia


and ATN is 1%:

 FENa < 1 indicates pre-renal  FENa > 1 indicates ATN


azotemia

Pre-renal ATN (oliguric and Pre-renal ATN (oliguric and


azotemia non-oliguric) azotemia non-oliguric)

FENa < 1 27 4 FENa > 1 3 51

FENa > 1 3 51 FENa < 1 27 4

 Sensitivity: 90%  Sensitivity: 93%


 Specificity: 93%  Specificity: 90%

Miller, Schrier, Et al. Annals Int Med, 1978 Vol 89. p 47-50
Low
FENaFENa,
False Not pre-renal
Positive
 Pre-renal Azotemia  ATN tested too early
 Contrast Nephropathy  ATN with CHF
 Hemoglobinuric  ATN with cirrhosis
nephropathy  ATN with severe burns
 Myoglobinuric nephropathy  Non-oliguric acute renal
 Acute rejection failure
 Cyclosporin and Tacrolimus  Acute Glomerulonephritis
toxicity*  ACEi in bilateral RAS or in
 Hepatorenal syndrome RAS with solitary kidney
 Acute interstitial nephritis  NSAID induced ARF
FeNaFENa,
High false negatives
but pre-renal

 Diuretics  Metabolic alkalosis


fractional excretion of urea

 Based on the physiologic increase in urea


reabsorption with pre-renal azotemia
 Normal FE Urea is 50-65% in well hydrated
individuals
 In prerenal azotemia this falls below 35%
 Not affected by diuretics
Sr Cr x Ur Urea
Na
FEurea
FENa ==
Sr Na
Urea
x Ur
x Ur
Cr Cr
Kaplan, Kohn. American J Nephrol, 1992; 12: 49-54.
FEurea in the differential diagnosis
of atn
 102 patients with ARF
 Gold standard was consultants full analysis
and retrospective analysis of response to
treatment.
 Divided the cases into:
 ATN
 Prerenal without diuretic
 Prerenal treated with diuretics

Carvounis, Sabeeha, Nisar, Et al. Kidney Int, 2002 Vol 62. p 2223-2229
FEUrea

FENa

100 92 91 90
80
Sensitivity (%)

60 50
FENa
40
FEUrea
20

0
Pre-Renal, No Pre-Renal, Diuretics
diuretics
therapy
Renal replacement therapy
Furosemide
Dopamine
Fenoldapam
hANP (Anaritide)
renal replacement therapy
Conventional Dialysis
Diffusive Clearance 67
136 108
5.8 17
3.8

0
145 110
2 35
0
Dialysate
Isolated Ultrafiltration: CHF Solutions 80 mmol K
= 13.8 liters
5.8 mmol/L
Minimal clearance 67
136 108
5.8 17
3.8

67
136 108
5.8 17
3.8
CVVH
Convective clearance 67
136 108
5.8 17
3.8

Ultrafilter 3+
liters/hour

Replace all ultrafiltrate 0


with sterile fluid at ideal 140 108
plasma concentrations 4
2 30
0
CVVH
Convective clearance

Post-filter replacement fluid


CVVH
Convective clearance Pre-filter replacement fluid
CVVHDF
Convective and Diffusive
high dose dialysis

High dose
survival

Low dose

Severity of illness (CCARF Score)


Ronco’s landmark dialysis dose
study
 425 patients with dialysis dependent acute
renal failure were randomized to one of three
doses of CVVH
 20 mL/kg/hr of effluent
 35 mL/kg/hr
 45 mL/kg/hr
45 mL/kg/hr

35 mL/kg/hr

20 mL/kg/hr

Ronco C, Bellomo R, Hormea P, Et al. Lancet 2000; 355: 26-30.


Schiffl: daily dialysis versus three
days/wk dialysis
 160 patients

Hospital mortality Duration of ARF


16
100 16
90 14
80 P=0.01 P=0.001
12
Frequency (%)

70
60 10 9

Days
50 46 8
40 6
28
30
4
20
10 2
0 0
3 days/week HD Daily HD 3 days/week HD Daily HD

Schiffl, H. et al. N Engl J Med 2002;346:305-310


odds ratio of death

P=0.002

4.0 P=0.005
3.92
P=0.007
3.5 3.27
3.02
3.0
Odds Ratio

2.5
2.0
P=0.02
1.5
1.06
1.0
0.5
0.0
Apache III Oliguria Sepsis Alternate-
score day HD

Schiffl, H. et al. N Engl J Med 2002;346:305-310


adding dialysis to CVVH

 206 dialysis patients randomized to


 CVVH 1-2.5 L/hr
 CVVH plus 1-1.5 liters of dialysate (CVVHDF)
28-day survival 90-day survival

59 59
60 60
P=0.03 P=0.008
50 50
39
Fraction (%)

Fraction (%)
40 40 34
30 30

20 20

10 10

0 0
CVVH CVVHDF CVVH CVVHDF

Saudin P, Niederberger S, De Seigneux S, Et al. Kidney Int 2006; 70: 1312-7.


Study n treatment groups

Ronco 425 CVVH 20/h vs. 35-45 ml/kg/h*

Bouman 106 CVVH 20ml/kg/h* vs. 48 ml/kg/h

Schiffl 160 Alternate day vs. daily hemodialysis

Saudan 206 CVVH 25 ml/kg/h vs. CVVHDF 42 ml/kg/h

Total (fixed effects)

Total (random effects)

1 10
Odds ratio

*For purposes of analysis the two high-dose arms in Ronco were combined, as were the two low-dose arms in
Bouman. If these groups are removed the odds ratio is unchanged (1.94; P <0.001).

Kellum J. Nature Clin Practice Nephrol 2007 3: 128-9.


ATN trial

 US trial
 Prospective randomized, multi-center trial
 27 institutions
 primarily veterans hospitals
 Dose finding study, modality agnostic
 Conventional dialysis
 SLED
 CVVH
 CVVHD
 CVVHDF
interventions

Standard RRT Intensive RRT

Stable (intermittent
3 days a week 6 days a week
hemodialysis)

Unstable (continuous Effluent 20 Effluent 35


therapy) mL/kg/hr mL/kg/hr
endpoint

 Primary Endpoint: All-cause mortality at day


60.
 Secondary endpoints:
 In-hospital death
 Recovery of renal function (CrCl>20)
defined as complete if Cr was <0.5 over the baseline
 Duration of renal replacement therapy
 Dialysis free at 60 days
 Duration of ICU stay
 Return to previous home at day 60
results

563 enrolled in standard care


561 randomized to intensive therapy
 60% sepsis

 80% vented

 Apache II score 26
(predicted mortality
55%)

 BUN at initiation of
RRT 65

 Roughly half in the


MICU and half in
the SICU
This report currently should be

the definitive
viewed as

study defining
dialysis dosing in
critically ill patients with
AKI
H. David Hume
…the patient dies
from multi-organ
failure while in
exquisite electrolyte &
fluid balance .
Fluid balance?
 Patients stratified by net fluid gain from
admission to initiation of CRT

Fluid in – fluid out


X 100
ICU admit weight
More fluid. More sick.
 longer ICU stay

 higher mortality

 more multi-organ
dysfunction

 more likely to be
intubated

 more inotropes

 more sepsis

 higher PRISM score


Worse fluid overload severity remained
independently associated with mortality
(OR, 1.03; 95% CI, 1.01-1.05). The
relationship was satisfactorily linear and

the OR 3%
suggests a

increase in mortality for


each 1% increase in
degree of fluid overload
at CRRT initiation.
 80 kg adult
 Is and Os: 2,400 mL in (100 mL/hr) and
1,600 mL of urine (67 mL/hr)
 Positive balance of 800 mL. If after 3 days
and the patient becomes oliguric with only
400 mL of urine output for two days (2,000
mL positive per day) before initiating CRT.
 That patient would be up 6,400 mL or 8% of
bodyweight
 24% increase in mortality compared to
someone with matched ins and outs
[in regards to the kidney] these
excretory operations are incidental to
the major task of keeping our internal
environments in the ideal,
balanced state.
Homer Smith from Fish to Philosopher
Medical therapy of acute kidney
injury
Today Tomorrow
 Loop diuretics  Fenoldapam
 dopamine  ANP
furosemide

 Decreased activity of the ascending loop of


Henle decreases renal oxygen demand by the
kidney
 Better align demand and supply in ischemia
Mehta’s trial of furosemide in arf

 Retrospective review of
ICU patients
 Diuretic responsiveness
determined survival

Mehta, R. L. et al. JAMA 2002;288:2547-2553.


furosemide the rct

 338 with dialysis dependent ARF


 Randomized to high dose furosemide (2,000
mg/day) vs placebo
 End-point length of dialysis
 No improvement of survival, length of
dialysis, number of dialysis sessions
 Shorter time to 2 liters/day of urine output

Cantarovich F, Rangoonwala B, Et al. Am J Kidney Dis 2004; 44: 402-9.


dopamine: still doesn’t work

 In healthy volunteers low


dose dopamine increases
renal blood flow and
induces diuresis Increased RBF

 Patients in the intensive


care unit do not respond
this way.

Increased urine
dopamine: still doesn’t work

 In healthy volunteers low


dose dopamine increases
renal blood flow and
induces diuresis
 Patients in the intensive
care unit do not respond
this way.
 RCT of 380 ICU patients
with early renal failure

ANZICS Clinical Trials Group. Lancet 2000;356:2139-47.


Kellum JA, Decker JM.Crit Care 2001; 29:1526-31.
dopamine: still doesn’t work

 In healthy volunteers low


dose dopamine increases
renal blood flow and
induces diuresis
 Patients in the intensive
care unit do not respond
this way.
 RCT of 380 ICU patients
with early renal failure
 Meta-analysis of 58 studies
and 2,149 patients

ANZICS Clinical Trials Group. Lancet 2000;356:2139-47.


Kellum JA, Decker JM.Crit Care 2001; 29:1526-31.
 Dopamine increases cortical blood flow more
than medullary blood flow
 Cortical blood flow increases GFR
 Cortical blood flow increases renal oxygen demand
dopamine 2.0: fenoldapam

 Isolated DA-1 activity


 Licensed as an IV anti-hypertensive
 Increases medullary blood flow more than
cortical blood flow
 Improved oxygenation
 Does not increase renal work
RCT of fenoldapam

 155 patients randomized within 24 hours of


50% increase in Cr
 Primary end-point incidence of need-for-
dialysis and/or survival at 21 days
 Fenoldapam or half normal saline for 72
hours
 Protocolized definition of need-for-dialysis

Tumlin JA, Finkel KW, Murray PT, Et al. Am J Kidney Dis. 2005; 46:26-34.
P=0.235 P=0.163 P=0.068
40 38.7
35
Frequency (%) 30 27.5
25.3 25.3
25
20 Fenoldapam
16.25
15 13.8 Placebo

10
5
0
Dialysis or Death Dialysis Death

Non-Diabetics Cardiac Surgery

44.2 38.9 38.9


45 40
40 P=0.048 P=0.015 35
35 32.7 30 P=0.036 P=0.022
Frequency (%)

Frequency (%)
30
25.9 25
25
20 17.6
20
13 15
15
10 8.8
10
5 5
0 0
Dialysis or Death Dialysis Dialysis or Death Dialysis

Tumlin JA, Finkel KW, Murray PT, Et al. Am J Kidney Dis. 2005; 46:26-34.
Tumlin JA, Finkel KW, Murray PT, Et al. Am J Kidney Dis. 2005; 46:26-34.
prophylactic fenoldapam in sepsis

 300 patients with sepsis and no signs of AKI


 Non-oliguric
 Cr < 1.7
 Randomized to prophylactic fenoldapam vs
placebo
Prophylaxis is a way to get around
the problem of late diagnosis due
to the lack of an established
biomarker.
P=0.006

35 34

30
Frequency (%)

25
20 19.3 P=0.056

15 14 Fenoldapam

10 6.6
Placebo
5
0
Cr > 1.7 Cr > 3.5

Fenoldapam Placebo
atrial natriuretic peptide

 Recombinant Anaritide is therapeutic form


 Dilates afferent arterioles
 Improves GFR and urine output in animal
models of ATN
 Three high profile studies looked at using
ANP in human AKI.
radiocontrast nephropathy

 30 minutes of ANP
before contrast
 30 minutes of ANP after
contrast
 Cr > 1.8
 Randomized to placebo
or 1 of 3 doses of
anaritide
 Creatinine increase of
0.5 or 25% defined RCN

Kurnik B, Allgren RL, Genter FC. Am J Kid Dis 1998; 31: 674-80.
50 47
45 43
 504 critically ill patients

Dialysis-free Survival (%)


40
 Creatinine at randomization 35
30
was 4.6
25
 75% had a normal BL 20
creatinine 15
10
 24-hour infusion of Anaritide 5
0
Placebo Anaritide

50
45
40

Hypotension (%)
35
30
p=0.008 25
20
15
10
5
0
Placebo Anaritide

Allgren R, Manbury T, Rahman SN. N Eng J Med 1997; 336: 828-34.


oliguric follow-up. strict EBM.

 222 oliguric patients  24-hour infusion of ANP

21 day dialysis free survival 60 day mortality SBP < 90 mmHg

97
100 100 100
90 90 P=0.51 90 P<0.001
80 80 80

Frequency (%)
Frequency (%)

Frequency (%)

70 70 70
56 60 58
60 60 60
50
P=0.22 50 50
40 40 40
30 21 30 30
20 15 20 20
10 10 10
0 0 0
Placebo Anaritide Placebo Anaritide Placebo Anaritide

Lewis J, Salem M, Chertow G. Am J Kid Dis 2000; 36: 767-74.


fixing everything that was wrong

 Early treatment
 50% increase in creatinine
 Low dose anaritide
 50 ng/kg/min vs 200 ng/kg/min
 Anaritide run continuously until renal recovery or
dialysis.
 Previous studies used 24 hour infusion
 Protocol defined indication for dialysis
 UO < 0.5 cc/kg/hr  Pulmonary edema and
for 3 hours FiO2 >0.8
 Cr > 4.5  K>6.0

Swärd K, Valsson F, Odencrants P, Et al. Crit Care Med 2004; 32: 1310-5.
 N=61
 Average Cr 2.3

100
90
80

Hypotension (%)
70
59
60 52
50
40
30
20
10
0
Placebo Anaritide

Swärd K, Valsson F, Odencrants P, Et al. Crit Care Med 2004; 32: 1310-5.
summary

 Prognosis is grim
 We now have a validated, consensus definition
 R isk
 I njury
 F ailure
 L oss of function
 E srd
 Outpatient and inpatient acquired ARF differ in
etiology
 Hospital acquired disease is your fault
summary

 FE of Urea is a validated way to separate pre-renal


from AKI even in the presence of diuretics
 Use of high dose dialysis regardless of methodology
offers no survival benefit
 Do not fluid overload your patient
 Dopamine doesn’t work
 Fenoldapam and anaritide may have a role in
reducing mortality from ARF.
Done

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