ARF AND HYPERKALEMIA

 Acute Renal failure (AFR)

AFR is defined as sudden reduction of urine output leading to renal function impairment in a person whose renal function was previously normal .

When your kidneys stop working suddenly, over a very short period of time (usually two days or less), it is called acute kidney injury (AKI). AKI is sometimes called acute kidney failure or acute renal failure. It is very serious and requires immediate treatment.

Causes :

Pre-renal causes 

1. Pump failure 

* Myocardial infarction 

* Pulmonary embolism

* Cardiac arrhythmia 

* Cardiac failure 

* Dissecting aneurysm of aorta

2. Hypovolemia  

* Fluid loss - Diarrhoea , vomiting 

* Blood loss

* Inadequate intake 

* Collection of fluid in 3 rd space 

3. Loss of peripheral resistance 

* Anaphylactic shock 

* Septicemia 

* Use of anti hypertensive 

* General anesthesia 

4. Intrarenal haemodhynamic alteration

* ACE inhibitors 

* NSAIDs

* Hepato- renal syndrome 

Post-renal 

1. Extra renal obstruction :

* Upper urinary tract obstruction . - stone , tumour 

* Lower urinary tract obstruction 

* Urethral stricture , Enlarged prostate 

* Bladder tumour , Bladder stone 

* Uterine prolapse 

2. Intrarenal obstruction 

* crystals - uric acid

- sulfonamide

* Pigment 

- Haemoglobin

* Light than protein : multiple myeloma 

Renal causes 

* Acute tubular Necrosis 

        Ischemic necrosis 

        Necrosis due to toxins

* Cortical necrosis 

        Ischaemia

        Sepsis 

* Immunological 

        Glomerulonephritis 

        Multi system disease : Systemic lupas  erythematosus ( SLE)

* Infiltration 

       Lymphoma 

       Leukemia

* Intra - renal intra - vascular coagulation 

- Accelerated phase of hypertension 

- Pre - eclampsia , eclampsia 

- Haemolytic uraemic  syndrome ( HUS)

Clinical features of acute renal failure 

Symptoms of uraemia 

* Anorexia 

* Weight loss 

* Dyspepsia 

* Sleep and task disturbances 

* Confusion

* Fatigue

Signs :

* Hypertension 

* Edema 

* Cardiac arrhythmias 

* Asterixis

* Raised jugular venous pressure ( ⬆️ JVP)

* Acidotic breathing 

* Decreased urine output 

Investigations 

1. To detect life threatening conditions :

- serum electrolytes : hyperkalaemia

- X - ray chest : pulmonary edema

- ABG : Acidosis 

- ECG : MI , arrhythmias

2. To exclusion of pre - renal and renal causes of acute renal failure .

3. Exclusion of post - Renal failure 

- X- ray KUB

- USG abdomen 

- Intravenous urography

4. To define disease process 

      a. Urine examination 

* RBC casts 

* Dysmorphic RBC

* Tubular cells 

* Tubular casts

* Hemoglobinuria - Haemolysis

* Myoglobinuria - Rhabdomyolysis  

 

    b. Haematological 

* TC, DC , Hb, ESR : infection 

* BT CT , platelets 

* Fibrinogen level

* Fibrin degrade products 

C. Immunological 

* ANA 

* LE cells

* Anti DNA antibody 

* Serum complement level 

Treatment 

Aim of treatment:

* To treat life threatening complications 

* To reserve metabolic acidosis 

* To maintain fluid and electrolyte balance 

* To remove the precipitating factor .

* To allow time for the kidneys to recover 

1. Treatment of life threatening complications:

* Threat hyperkalaemia

* Treat pulmonary edema 

* Correct acidosis

2. Support renal function / Maintain fluid and electrolytes

* Volume replacement in hypovolemia

* Stop nephrotoxic 

* Maintain strict fluid and electrolyte balance

1. Remove precipitation factors

* Treat infection 

* Renal obstruction in post renal causes.

Treatment of post renal failure 

   Relief of obstruction will improve urine output and urea and creatinine level will gradually come down to normal.

Treatment of established ATN

a. Inj . Frusemide 500 mg + 200ml of normal saline or dextrose over 24 hours 

b. Fluid balance:

   In the presence of edema, Input = output 

After edema , subside : 500ml + 24 hr output 

C .Diet 

    Protein 20-30 gm/ Day , high carbohydrates diet (. 2000- 2500 kcal / Day )

A. Hyperkalaemia 

* Avoid high potassium containing foods including beans, dark leafy greens, potatoes , fish , squash , mushrooms, Avocados and bananas .

* Avoiding potassium sparing diuretics ( spironolactone , amiloride ) and ACE inhibitors drugs 

* Give ion exchange resins ( sodium polystyrene sulfonate ) oral or rectal yo remove potassium from GI tract . Before giving his drug, patient bowel habit should be normal . Avoid in constipation and altered bowel habits.

* Glucose + soluble insulin ( 20 Unit + 50 ml 50%Glucose IV)

    -  500 ml of 5 % dextrose + 6 units insulin IV over 4-5 hr .

* 10 ml calcium gluconate 10 over 10 min iv . repeat as necessary if severe ECG changes 

* Salbutamol nebulization or iv 

* Correction of acidosis by iv.NaHCO3

B. Pulmonary edema 

* High - flow O2 inhalation 

* Furosemide 40-80 mg IV . Slowly 

       Large dose : 250mg in 50ml of normal saline over one hour.

* Diamorphine 2.5- 5 mg IV slowly 

* Dialysis if patient not responding with medications.

Treatment of infections

Common organism pseudomonas , E . Coli , proteus , bacteus, bacteroid.

Infection should be treated with following antibiotics.

- Gentamicin 

- Cefotaxime

- Ceftriaxone

- Metronidazole 

              Avoid Nephrotoxic drugs 

               - Terracyclines

              -  1 st generation cephalosporin 

              - NSAIDS

Replacement therapy 

* Haemodialysis

* Peritoneal dialysis 

Indications for dialysis 

Clinical :

- Fluid overload 

- Pericarditis 

- Drowsiness 

- Muscle twitching 

Biochemical :

- Blood urea > 35 mmol

- Serum creatinine > 700mmol /l

- Serum potassium > 6.5 mmol / l

- Arterial pH < 7.2 

# some questions are 

1. How long can someone live with acute renal failure?

Ans: People with kidney failure may survive days to weeks without dialysis, depending on the amount of kidney function they have, how severe their symptoms are, and their overall medical condition.

2.acute kidney failure?

Treatments that help prevent complications include:

Ans :Treatments to balance the amount of fluids in your blood. ... 

Medications to control blood potassium. ... 

Medications to restore blood calcium levels. ... 

Dialysis to remove toxins from your  blood .

3. What questions should I ask about dialysis?

Ans :Questions to ask your in-center dialysis nurse :

- What can I do to get the most out of my dialysis treatments?

-How should I expect to feel after dialysis?

Is there anything I may experience that I should contact you about?

-What do I need to know about taking my prescribed medications?

- How are my fluids?

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