Decisions For Nutrition In Patients With Acute Renal Failure

Decisions dependent on Patients ability to resume oral diet (within 5 days ) Nutritional status Underlying illness degree of associated hypercatabolism 1. What patient with acute renal failure needs nutritional support 2. When should nutritional support be initiated 3. At what degree of impairment in renal function should the nutritional regimen be adapted for renal failure 4. In a patient with multiple organ dysfunction, which organ determines the type of nutritional support 5. Is enteral or...

Causes of Acute Renal Failure

Sudden causes Induce Called Sudden causes Induce Called Characteristics of acute renal failure. Acute renal failure is a syndrome characterized by a sudden decrease of the glomerular filtration rate (GFR) and consequently an increase in blood nitrogen products (blood urea nitrogen and creatinine). It is associated with oliguria in about two thirds of cases. Depending on the localization or the nature of the renal insult, ARF is classified as prerenal, parenchymatous, or obstructive (postrenal)....

Relationship Between The Clinical And Cellular Phases Of Ischemic Acute Renal Failure

Repair, migration, apoptosis, proliferation induced by ischemia can be mimicked by F-actin disassembly mediated by cytochalasin D 11 . Although these correlations are highly suggestive of a central role for actin alterations in the pathophysiology of ischemia-induced surface membrane damage they fall short in providing mechanistic data that directly relate actin cytoskeletal changes to cell injury. Proximal tubule cell injury during ischemia is also known to be principally responsible for the...

Amino Acid Solutions For The Treatment Of Acute Renal Failure Nephro Solutions

* Glycine is a componenet of the dipeptide. t Tyrosine is included as dipeptide (glycyl-L-tyrosine). Amino acid (AA) solutions for parenteral nutrition in acute renal failure (ARF). The most controversial choice regards the type of amino acid solution to be used either essential amino acids (EAAs) exclusively, solutions of EAA plus nonessential amino acids (NEAAs), or specially designed nephro solutions of different proportions of EAA and specific NEAA that might become conditionally essential...

Mechanisms of Cell Death Necrosis and Apoptosis

Apoptosis and necrosis two distinct morphologic forms of cell death. A, Necrosis. Cells undergoing necrosis become swollen and enlarged. The mitochondria become markedly abnormal. The main morphoplogic features of mitochondrial injury include swelling and flattening of the folds of the inner mitochondrial membrane (the christae). The cell plasma membrane loses its integrity and allows the escape of cytosolic contents including lyzoso-mal proteases that cause injury and inflammation of the...

Comparison Of Dialysis Prescription And Dose Delivered In Crrt And

* Reflects doses for continuous venovenous hemofiltration with ultrafiltration rate of 20 to 30 mL min. * Reflects doses for continuous venovenous hemofiltration with ultrafiltration rate of 20 to 30 mL min. Comparison of dialysis prescription and dose delivered in continuous renal replacement (CRRT) and intermittent hemodialysis (IHD). The ability of each modality to achieve a particular clearance is influenced by the dialysis prescription and the operational characteristics however, it must...

Gastrointestinal Absorption of Magnesium

Gastrointestinal absorption of dietary magnesium (Mg) Gastrointestinal absorption of dietary magnesium (Mg) *Normal dietary Mg intake 300 mg (12.5 mmol) per day *Normal dietary Mg intake 300 mg (12.5 mmol) per day Gastrointestinal absorption of dietary intake of magnesium (Mg). The normal adult dietary intake of Mg is 300 to 360 mg d (12.5-15 mmol d). A Mg intake of about 3.6 mg kg d is necessary to maintain Mg balance. Foods high in Mg content include green leafy vegetables (rich in...

Contributing Factors To Protein Catabolism In Acute Renal Failure

Impairment of metabolic functions by uremia toxins Endocrine factors Insulin resistance Increased secretion of catabolic hormones (catecholamines, glucagon, glucocorticoids) Hyperparathyroidism Suppression of release or resistance to growth factors Acidosis Systemic inflammatory response syndrome (activation of cytokine network) Release of proteases Inadequate supply of nutritional substrates Loss of nutritional substrates (renal replacement therapy) Protein catabolism in acute renal failure...

Causes Of Electrolyte Derangements In Acute Renal Failure

Electrolytes in acute renal failure (ARF) causes of hyperkalemia and hyperphosphatemia. ARF frequently is associated with hyper-kalemia and hyperphosphatemia. Causes are not only impaired renal excretion of electrolytes but release during catabolism, altered distribution in intracellular and extracellular spaces, impaired cellular uptake, and acidosis. Thus, the type of underlying disease and degree of hypercatabolism also determine the occurrence and severity of electrolyte abnormalities....

Indications And Timing Of Dialysis For Acute Renal Failure Renal Replacement Versus Renal Support

Timing of intervention Indications for dialysis Dialysis dose Based on level of biochemical markers Support other organs Based on individualized need Broad Dialysis intervention in acute renal failure (ARF) renal replacement versus renal support. An important consideration in the management of ARF is defining the goals of therapy. Several issues must be considered, including the timing of the intervention, the amount and frequency of dialysis, and the duration of therapy. In practice, these...

Metabolic Effects Of Continuous Renal Replacement Therapy

Amelioration of uremia intoxication (renal replacement) Plus Heat loss Excessive load of substrates (eg, lactate, glucose) Loss of nutrients (eg, amino acids, vitamins) Elimination of short-chain proteins (hormones, mediators ) Induction or activation of mediator cascades Stimulation of protein catabolism Metabolic impact of extracorporeal therapy. The impact of hemodialysis therapy on metabolism is multifactorial. Amino acid and protein metabolism are altered not only by substrate losses but...

Actions Of Growth Factors In Acute Renal Failure

Selected actions of growth factors in the setting of acute renal failure (ARF). After an acute renal injury, a spectrum of molecular responses occur involving the local expression of growth factors and their receptors. In addition, there is considerable variation in the mechanisms by which the growth factors are beneficial for ARF. After an Rationale for the use of insulin-like growth factor IGF-I in the setting of acute renal failure (ARF). Of the growth factors that have been demonstrated to...

Epidemiology of Acute Renal Failure

Prospective epidemiologic studies of acute renal failure (ARF) in large populations have not often been published . The first study reported by Eliahou and colleagues 4 was developed in Israel in the 1960s and included only Jewish patients. This summary of available data suggests a progressive increase in ARF incidence that at present seems to have stabilized around 200 cases per million population per year (pmp y). No data about ARF incidence are available from undeveloped...

Metabolic Alterations in Acute Renal Failure

Energy metabolism in acute renal failure (ARF). In experimental animals ARF decreases oxygen consumption even when hypothermia and acidosis are corrected (uremic hypometabolism) 3 . In contrast, in the clinical setting oxygen consumption of patients with various form of renal failure is remarkably little changed 4 . In subjects with chronic renal failure (CRF), advanced uremia (UA), patients on regular hemodialysis therapy (HD) but also in patients with uncomplicated ARF (ARFNS) resting energy...

Renal Tubular Phosphate Reabsorption

Renal tubular reabsorption of phosphorus. Most of the inorganic phosphorus in serum is ultrafilterable at the level of the glomerulus. At physiologic levels of serum phosphorus and during a normal dietary phosphorus intake, most of the filtered phosphorous is reabsorbed in the proximal convoluted tubule (PCT) and proximal straight tubule (PST). A significant amount of filtered phosphorus is also reabsorbed in distal segments of the nephron 7,9,10 . CCT cortical collecting tubule IMCD inner...

Stepwise Approach To Diagnosis Of Acute Renal Failure

(if oligoanuric) Urinalysis (see Fig. 12-15) evaluation to exclude urinary tract obstruction Consider need for more data to assess intravascular volume or cardiac output status Consider need for additional blood tests Consider need for evaluation of renal vascular status Stepwise approach to diagnosis of acute renal failure (ARF). The multiple causes, predisposing factors, and clinical settings demand a logical, sequential approach to each case of ARF. This figure presents a four-step approach...

General Nephrotoxic Factors

ACE inhibitors NSAIDs ( ) Aminoglycosides Important blood flow (1 4 cardiac output) Largest endothelial surface by weight Multiple enzyme systems Transcellular transport Concentration of substances Protein unbinding High O2 consumption delivery ratio in outer medulla Sites of renal damage, including factors that contribute to the kidney's susceptibility to damage. ACE angiotensin-converting enzyme NSAID nonsteroidal anti-inflammatory drugs HgCl2 mercuric chloride. DRUGS AND CHEMICALS...

Lorraine C Racusen Cynthia C Nast

Causes of acute renal failure can be divided into three categories 1) prerenal, due to inadequate perfusion 2) postrenal, due to obstruction of outflow and 3) intrinsic, due to injury to renal parenchyma. Among the latter, diseases of, or injury to, glomeruli, vessels, interstitium, or tubules may lead to a decrease in glomerular filtration rate (GFR). Glomerular diseases that lead to acute renal failure are the proliferative glomerulonephritides, including postinfectious and...

Michael S Goligorsky Wilfred Lieberthal

Acute renal failure (ARF) is a syndrome characterized by an abrupt and reversible kidney dysfunction. The spectrum of inciting factors is broad from ischemic and nephrotoxic agents to a variety of endotoxemic states and syndrome of multiple organ failure. The pathophysiology of ARF includes vascular, glomerular and tubular dysfunction which, depending on the actual offending stimulus, vary in the severity and time of appearance. Hemodynamic compromise prevails in cases when noxious stimuli are...

Dialysis Modalities For Acute Renal Failure

Several methods of dialysis are available for renal replacement therapy. While most of these have been adapted from dialysis procedures developed for end-stage renal disease several variations are available specifically for ARF patients 1 . Of the intermittent procedures, intermittent hemodialysis (IHD) is currently the standard form of therapy worldwide for treatment of ARF in both intensive care unit (ICU) and non-ICU settings. The vast majority of IHD is performed using single-pass systems...

Figure 113

The countercurrent mechanism of the kidneys in concert with the hypothalamic osmoreceptors via antidiuretic hormone (ADH) secretion maintain a very finely tuned balance of water (H2O). A defect in the urine-diluting capacity with continued H2O intake results in hyponatremia. Conversely, a defect in urine concentration with inadequate H2O intake culminates in hypernatremia. Hyponatremia reflects a disturbance in homeostatic mechanisms characterized by excess total...

References

Druml W Nutritional support in acute renal failure. In Nutrition and the Kidney. Edited by Mitch WE, Klahr S. Philadelphia LippincottRaven, 1998. Druml W, Mitch WE Metabolism in acute renal failure. Sem Dial 1996, 9 484-490. Om P, Hohenegger M Energy metabolism in acute uremic rats. Nephron 1980, 25 249-253. Schneeweiss B, Graninger W, Stockenhuber F, et al. Energy metabolism in acute and chronic renal failure. Am J Clin Nutr 1990, 52 596-601. Soop M, Forsberg E, Th'rne A, Alvestrand A Energy...

Nonsteroidal Antiinflammatory Drugs

Patients at risk for NSAID-induced acute renal failure TRenin-angiotensin axis TAngiotensin II T Adrenergic nervous system TCatecholamines Renal vasoconstriction Renal function Normalized renal function yL .I Inhibition L k by NSAID p- Compensatory vasodilation induced by renal prostaglandin synthesis Mechanism by which nonsteroidal anti-inflammatory drugs (NSAIDs) disrupt the compensatory vasodilatation response of renal prostaglandins to vasoconstrictor hormones in patients with prerenal...

Moshe Levi Mordecai Popovtzer

The physiologic concentration of serum phosphorus (phosphate) in normal adults ranges from 2.5 to 4.5 mg dL (0.80-1.44 mmol L). A diurnal variation occurs in serum phosphorus of 0.6 to 1.0 mg dL, the lowest concentration occurring between 8 AM and 11 AM. A seasonal variation also occurs the highest serum phosphorus concentration is in the summer and the lowest in the winter. Serum phosphorus concentration is markedly higher in growing children and adolescents than in adults, and it is also...

Lithium Induced Acute Renal Failure

Salt depletion strongly impairs renal elimination of lithium. Salt loading increases absolute and fractional lithium clearance. Increased plasma lithium level due to decreased Usually no change in plasma lithium level may be used to treat lithium-induced polyuria Increased plasma lithium level due to decreased renal lithium clearance (exceptions are aspirin Decreased plasma lithium level due to increased Drug interactions with lithium 24 . Acute renal failure, with or without oliguria, can be...

Hypophosphatemia Hyperphosphatemia

Major causes of hypophosphatemia. (From Angus 1 with permission.) during refeeding Acute respiratory alkalosis Hungry bone syndrome Inadequate intake Antacids containing aluminum or magnesium Steatorrhea and chronic diarrhea Primary and secondary hyperparathyroidism Vitamin D deficiency or resistance Fanconi's syndrome Miscellaneous osmotic diuresis, proximally acting diuretics, acute volume expansion Pseudohypophosphatemia Mannitol Bilirubin Acute leukemia Decreased dietary intake Decreased...

Blood Urea Nitrogen Buncreatinine Ratio

The blood urea nitrogen (BUN)-creatinine ratio. Based on the information in Figure 12-3, the BUN-creatinine ratio often deviates from the usual value of about 10 1. These deviations may have modest diagnostic implications. As an example, for reasons as yet unclear, tubular reabsorption of urea nitrogen is enhanced in low-urine flow states. Thus, a high BUN-creatinine ratio often occurs in prerenal and postrenal (see Fig. 12-6) forms of renal failure. Similarly, enhanced delivery of amino acids...

Growth Factor Production

Production of epidermal growth factor (EGF), insulin-like growth factor (IGF-I), and hepatocyte growth factor (HGF) by various tissues. EGF, IGF-I, and HGF have all been demonstrated to improve outcomes in various animal models of acute renal failure (ARF). All three growth-promoting factors are produced in the kidneys and in a variety of other organs. The local production is probably most important for recovery from an acute renal insult. The influence of production in other organs in the...

Extracellular Fluid Volume Homeostasis in Chronic Renal Failure

One Time Urine Sodium

Relation between glomerular filtration rate (GFR) and fractional sodium (Na) excretion (FENa). The normal FENa is less than 1 . Adaptations in chronic renal failure maintain urinary Na excretion equal to dietary intake until end-stage renal disease is reached. To achieve this, the FENa must increase as the GFR decreases. -- Normal --Mild CRF ' Severe CRF 15 14 13 12 11 10 -9 8 7 6 5 4 3 2 1 Effects of dietary sodium (Na) intake on extracellular fluid (ECF) volume in chronic renal failure (CRF)...

Exogenous And Endogenous Chemicals That Cause Acute Renal Failure

Aminoglycosides gentamicin, tobramycin, Ionic eg, diatrizoate, iothalamate Exogenous and endogenous chemicals that cause acute renal failure. Renal vessels NSAIDs ACE inhibitors Cyclosporin A Proximal convoluted tubule S1 S2 segments Aminoglycosides Cephaloridine Cadmium chloride Potassium dichromate Renal vessels NSAIDs ACE inhibitors Cyclosporin A Proximal straight tubule S3 segment Cisplatin Mercuric chloride Dichlorovinyl-L-cysteine Nephrotoxicants may act at different sites in the kidney,...

Determinants Of Solute Removal In Dialysis Techniques For Acute Renal Failure

Determinants of solute removal in dialysis techniques for acute renal failure. Solute removal in these techniques is achieved by convection, diffusion, or a combination of these two. Convective techniques include ultrafiltration UF and hemofiltration H and they depend on solute removal by solvent drag 6 . As solute removal is solely dependent on convective clearance it can be enhanced only by increasing the volume of ultrafiltrate produced. While ultrafiltration requires fluid removal only, to...

Causes Of The Syndrome Of Inappropriate Diuretic Hormone Secretion

Deamino-D-arginine vasopressin DDAVP Drugs that enhance release of antidiuretic hormone Meningitis viral, bacterial, tuberculous, Drugs that potentiate renal action of antidiuretic hormone Nonsteroidal anti-inflammatory drugs Drugs that cause hyponatremia by unknown mechanisms

Figure

Potassium Reabsorption Nephron

More than half of filtered potassium is passively reabsorbed by the end of the proximal convolted tubule PCT . Potassium is then added to tubular fluid in the descending limb of Henle's loop see below . The major site of active potassium reabsorption is the thick ascending limb of the loop of Henle TAL , so that, by the end of the distal convoluted tubule DCT , only 10 to 15 of filtered potassium remains in the tubule lumen. Potassium is secreted mainly by the...

Operational Characteristics

Trisodium Citrate Mechanism Crrt

Pathways of thrombogenesis in extracorporeal circuits. Modified from Lindhout 8 with permission. n ,.1 in-, 1 Membrane Patient I Dialyzer J Uremia gt C J Geometry Drug therapy -V Manufacture Dialyzer preparation Anticoagulation Blood flow access Dialyzer preparation Anticoagulation Blood flow access Factors influencing dialysis-related thrombogenicity. One of the major determinants of the efficacy of any dialysis procedure in acute renal failure ARF is the ability to maintain a functioning...

Hypokalemia Treatment

Hypokalemia Deficit

Treatment of hypokalemia estimation of potassium deficit. In the absence of stimuli that alter intracellular-extracellular potassium distribution, a decrease in the serum potassium concentration from 3.5 to 3.0 mEq L corresponds to a 5 reduction 175 mEq in total body potassium stores. A decline from 3.0 to 2.0 mEq L signifies an additional 200 to 400-mEq deficit. Factors such as the rapidity of the fall in serum potassium and the presence or absence of symptoms dictate the aggressiveness of...

Hypokalemia Diagnostic Approach

Approach Hypokalemia

Overview of diagnostic approach to hypokalemia hypokalemia without total body potassium depletion. Hypokalemia can result from transcellular shifts of potassium into cells without total body potassium depletion or from decreases in total body potassium. Perhaps the most dramatic examples occur in catecholamine excess states, as after administration of l adreneric receptor P2AR agonists or during stress. It is important to note that, during some conditions eg, ketoaci-dosis , transcellular...

Gastrointestinal Absorption of Calcium

Gastrointestinal absorption of dietary calcium Ca Gastrointestinal absorption of dietary calcium Ca Normal dietary Ca intake 1000 mg 25 mmol per day Normal dietary Ca intake 1000 mg 25 mmol per day Gastrointestinal absorption of dietary calcium Ca . The normal recommended dietary intake of Ca for an adult is 800 to 1200 mg d 20-30 mmol d . Foods high in Ca content include milk, dairy products, meat, fish with bones, oysters, and many leafy green vegetables eg, spinach and collard greens ....

Ravindra L Mehta

Over the last decade, significant advances have been made in the availability of different dialysis methods for replacement of renal function. Although the majority of these have been developed for patients with end-stage renal disease, more and more they are being applied for the treatment of acute renal failure ARF . The treatment of ARF, with renal replacement therapy RRT , has the following goals 1 to maintain fluid and electrolyte, acid-base, and solute homeostasis 2 to prevent further...

Acute Rejection

DIAGNOSTIC POSSIBILITIES IN TRANSPLANT-RELATED ACUTE RENAL FAILURE Diagnostic possibilities in transplant-related acute renal failure. 1. Acute cell-mediated rejection 2. Delayed-appearing antibody-mediated rejection 4. Cyclosporine or FK506 toxicity 8. Post-transplant lymphoproliferative disorder Diagnosis of rejection in the Banff classification makes use of two basic lesions, tubulitis and intimal arteritis. The 1993-1995 Banff classification depicted in this figure is the standard in use in...

Composition Of Replacement Fluid And Dialysate For Crrt

Composition of dialysate and replacement fluids used for continuous renal replacement therapy CRRT . One of the key features of any dialysis method is the manipulation of metabolic balance. In general, this is achieved by altering composition of dialysate or replacement fluid . Most commercially available dialysate and replacement solutions have lactate as the base however, bicarbonate-based solutions are being utilized more and more 17,18 . Replacement 17 mL min Prefilter Prefilter Effect of...

Rick G Schnellmann Katrina J Kelly

Humans are exposed intentionally and unintentionally to a variety of diverse chemicals that harm the kidney. As the list of drugs, natural products, industrial chemicals and environmental pollutants that cause nephrotoxicity has increased, it has become clear that chemicals with very diverse chemical structures produce nephrotoxicity. For example, the heavy metal HgCl2, the myco-toxin fumonisin B1, the immunosuppresant cyclosporin A, and the aminoglycoside antibiotics all produce acute renal...

Ischemia Induced Proximal Tubule Cell Alterations

Ischemia induced proximal tubule cell alterations. 1. Microvilli fusion, internalization, fragmentation and luminal shedding resulting in loss of surface membrane area and tubular obstruction 2. Loss of surface membrane polarity for lipids and proteins 3. Junctional complex dissociation with unregulated paracellular permeability backleak 1. Polymerization of actin throughout the cell cytosol 2. Disruption and delocalization of F-actin structures including stress fibers, cortical actin 3....

Renal Handling of Calcium

Renal Handling Calcium

Glomerular filtration of calcium Ca . Total serum Ca consists of ionized, protein bound, and complexed fractions 47.5 , 46.0 , and 6.5 , respectively . The complexed Ca is bound to molecules such as phosphate and citrate. The ultrafilterable Ca equals the total of the ionized and complexed fractions. Normal total serum Ca is approximately 8.9 to 10.1 mg dL about 2.2-2.5 mmol L . Ca can be bound to albumin and globulins. For each 1.0 gm dL decrease in serum albumin, total serum Ca decreases by...

Renal Handling of Magnesium

Renal Handling Citrat

The glomerular filtration of magnesium Mg . Total serum Mg consists of ionized, complexed, and protein bound fractions, 60 , 7 , and 33 of total, respectively. The complexed Mg is bound to molecules such as citrate, oxalate, and phosphate. The ultrafil-terable Mg is the total of the ionized and complexed fractions. Normal total serum Mg is approximately 1.7 to 2.1 mg dL about 0.70-0.90 mmol L 1,2,7-9,11,12 . The renal handling of magnesium Mg2 . Mg is filtered at the glomerulus, with the...

Hyperkalemia Diagnostic Approach

Hyperkalemia Common Causes

Approach to hyperkalemia hyperkalemia without total body potassium excess. Spurious hyperkalemia is suggested by the absence of electrocardiographic ECG findings in patients with elevated serum potassium. The most common cause of spurious hyperkalemia is hemolysis, which may be apparent on visual inspection of serum. For patients with extreme leukocytosis or thrombocytosis, potassium levels should be measured in plasma samples that have been promptly separated from the cellular components since...

Acute Renal Failure Cellular Features of Injury and Repair

Bush Hiroyuki Sakurai Tatsuo Tsukamoto Sanjay K. Nigam Although ischemic acute renal failure ARF is likely the result of many different factors, much tubule injury can be traced back to a number of specific lesions that occur at the cellular level in ischemic polarized epithelial cells. At the onset of an ischemic insult, rapid and dramatic biochemical changes in the cellular environment occur, most notably perturbation of the intracellular levels of ATP and free calcium and increases...

Of Acute Renal Failure

Urine diagnostic indices see Fig. 12-16 Consider need for further evaluation for obstruction Ultrasonography, computed tomography, or magnetic resonance imaging Consider need for additional blood tests Vasculitis glomerulopathy human immunodeficiency virus infections, antineu-trophilic cytoplasmic antibodies, antinuclear antibodies, serologic tests for hepatitis, systemic bacterial endocarditis and streptococcal infections, rheumatoid factor, complement, cryoglobins Plasma cell disorders urine...

Recommendation For Initial Dialysis Modality For Acute Renal Failure

Recommendation for initial dialysis modality for acute renal failure ARF . Patients with multiple organ failure MOF and ARF can be treated with various continuous therapies or IHD. Continuous therapies provide better hemodynamic stability however, if not monitored carefully they can lead to significant volume depletion. In general, hemodynami-cally unstable, catabolic, and fluid-overloaded patients are best treated with continuous therapies, whereas IHD is better suited for patients who require...

Categorization of Causes of Acute Renal Failure

This figure depicts the most commonly used schema to classify and diagnostically approach the patient with ARF 1, 6, 9 . The most common general cause of ARF 60 to 70 of cases is prerenal factors. Prerenal causes include those secondary to renal hypoperfusion, which occurs in the setting of extracellular fluid loss eg, with vomiting, nasogastric suctioning, gastrointestinal hemorrhage, diarrhea, burns, heat stroke, diuretics, glucosuria , sequestration of extracellular...