Acute renal failure with classification and management tailored to nursing

1. AKI (ARF)

2. • Acute kidney injury (AKI), formerly called acute renal failure (ARF), is
commonly defined as an abrupt decline in renal function, clinically
manifesting as a reversible acute increase in nitrogen waste products
(measured by blood urea nitrogen [BUN] and serum creatinine levels)
over the course of hours to weeks.

3. RIFLE classification
• The Acute Dialysis Quality Initiative (ADQI) group published the RIFLE
classification, which is based on changes from the patient's baseline
either in serum creatinine level, glomerular filtration rate (GFR), or
urine output (UO).

4. The RIFLE classification of AKI is as follows
• Risk (R) - Increase in serum creatinine level X 1.5 or decrease in GFR
by 25%, or UO < 0.5 mL/kg/hr for 6 hours
• Injury (I) - Increase in serum creatinine level X 2.0 or decrease in GFR
by 50%, or UO < 0.5 mL/kg/hr for 12 hours
• Failure (F) - Increase in serum creatinine level X 3.0, decrease in GFR
by 75%, or serum creatinine level ≥4 mg/dL with acute increase of
>0.5 mg/dL; UO < 0.3 mL/kg/h for 24 hours, or anuria for 12 hours
• Loss (L) - Persistent AKI, complete loss of kidney function >4 weeks
• End-stage kidney disease (E) - Loss of kidney function >3 months

5. The Acute Kidney Injury Network
(AKIN) has developed specific criteria for the diagnosis of AKI. The
AKIN defines AKI as abrupt (within 48 hours) reduction of kidney
function, manifested by any one of the following
• An absolute increase in serum creatinine of 0.3 mg/dL or greater
(≥26.4 µmol/L)
• A percentage increase in serum creatinine of 50% or greater (1.5-fold
from baseline)
• A reduction in urine output, defined as less than 0.5 mL/kg/h for
more than 6 hours

6. SOFA score
• Sequential Organ Failure Assessment [SOFA] score
• SOFA score is the most commonly used system to quantify renal
function at baseline or as a secondary outcome.

7. Signs and symptoms
1. Skin
• Livedo reticularis, digital ischemia, butterfly rash
• Palpable purpura: systemic vasculitis
• Maculopapular rash: Allergic interstitial nephritis
• Track marks (ie, intravenous drug abuse): Endocarditis

8. 2. Eyes
Keratitis, iritis, uveitis, dry conjunctivae: Autoimmune vasculitis
Jaundice: Liver diseases
Band keratopathy (ie, hypercalcemia): Multiple myeloma
Signs of diabetes mellitus
Signs of hypertension
Atheroemboli: Retinopathy (ie, Hollenhorst plaque in cholesterol
microembolism

9. 3. Ears
Hearing loss: Alport disease and aminoglycoside toxicity
Mucosal or cartilaginous ulcerations: Granulomatosis with polyangiitis
(Wegener granulomatosis)

10. 4. Cardiovascular system
Irregular rhythms (ie, atrial fibrillation): Thromboemboli
Murmurs: Endocarditis
Pericardial friction rub: Uremic pericarditis
Increased jugulovenous distention, rales, S3: Heart failure

11. 5. Abdomen
• Pulsatile mass or bruit: Atheroemboli
• Abdominal or costovertebral angle tenderness: Nephrolithiasis,
papillary necrosis, renal artery thrombosis, renal vein thrombosis
• Pelvic, rectal masses; prostatic hypertrophy; distended bladder:
Urinary obstruction
• Limb ischemia, edema: Rhabdomyolysis

12. 6. Pulmonary system
Rales: Pulmonary edema, infectious pulmonary process
Hemoptysis: ANCA (antineutrophilic cytoplasmic antibodies) vasculitis,
anti–glomerular basement membrane (anti-GBM, Goodpasture)
syndrome

13. Diagnostic testing
• RFTs: Increased levels of blood urea nitrogen (BUN) and creatinine are
the hallmarks of renal failure
• Complete blood count: infection; acute blood loss or chronic anemia
• Renal ultrasonography is useful for evaluating existing renal disease
and obstruction of the urinary collecting system.
• Aortorenal angiography: renal artery stenosis
• Renal biopsy

14. Management
• The current treatment for acute kidney injury is mainly supportive.
• providing an adequate airway and ventilation
• Correction of fluid overload with furosemide.
• Reversal of hypovolemia by rapid fluid infusion
• Correction of severe acidosis with bicarbonate administration, which can
be important as a bridge to dialysis.
• Correction of hyperkalemia.
• Correction of hematologic abnormalities (eg, anemia, uremic platelet
dysfunction) with measures such as transfusions and administration of
desmopressin or estrogens.
• Placement of a urinary catheter

15. Prognosis
• Because most cases of community-acquired acute kidney injury are
secondary to volume depletion, as many as 90% of cases are
estimated to have a potentially reversible cause.
• Hospital-acquired AKI often occurs in an ICU setting and is commonly
part of multiorgan failure with increased mortality rate, dialysis
requirements, and rates of progression to end-stage renal failure

16. Differential Diagnosis
• Alcoholic Ketoacidosis, Anemia, Sickle CellAneurysm,
AbdominalCongestive Heart Failure and Pulmonary EdemaDiabetic
KetoacidosisAcute GlomerulonephritisHemolytic Uremic
SyndromeHenoch-Schönlein
PurpuraHyperkalemiaHypermagnesemiaHypernatremiaHypertensive
EmergenciesMetabolic AcidosisPediatrics, DehydrationPediatrics,
Diabetic KetoacidosisPediatrics, Inborn Errors of
MetabolismPediatrics, Sickle Cell DiseasePediatrics, Urinary Tract
Infections and PyelonephritisRenal CalculiRenal Failure, Chronic and
Dialysis ComplicationsToxicity, AlcoholsUrinary ObstructionUrinary
Tract Infection in FemalesUrinary Tract Infection in Males