14 Ri Acute Nonoliguric Renal Failure

1. Acute nonoliguric renal Acute nonoliguric renal
failurefailure
Ri Ri 黃正憲黃正憲
2003/10/272003/10/27

2. Acute Renal FailureAcute Renal Failure
Definitions:Definitions:
An increase in the An increase in the serum creatinine of serum creatinine of ³³ 0.5 0.5
mg/dl over baseline valuemg/dl over baseline value
An increase in the serum creatinine of more An increase in the serum creatinine of more
than 50% over base line valuethan 50% over base line value
A reduction in the calculated creatinine A reduction in the calculated creatinine
clearance of 50%clearance of 50%
A decrease in the renal function that results in A decrease in the renal function that results in
the need for dialysisthe need for dialysis

3. Category Category
1. urine output1. urine output
Anuric: <100 mL/dAnuric: <100 mL/d
Oliguric: 100-500 mL/dOliguric: 100-500 mL/d
Nonoliguric: >500 mL/d
2. the more common 2. the more common
Pre-renalPre-renal
IntrinsicIntrinsic
Post-renalPost-renal

4. Acute Renal FailureAcute Renal Failure
Pre Renal CausesPre Renal Causes
- Intravascular volume depletion from vomiting - Intravascular volume depletion from vomiting
diarrhea, diarrhea,
poor fluid intake, fever, use of diureticspoor fluid intake, fever, use of diuretics
- Decreased glomerular perfusion in the setting of - Decreased glomerular perfusion in the setting of
renal artery atherosclerotic disease with decreased renal artery atherosclerotic disease with decreased
systolic head of BP, use of ACE inhibitors or NSAIDSsystolic head of BP, use of ACE inhibitors or NSAIDS
- Decreased effective arterial blood volume in CHF, - Decreased effective arterial blood volume in CHF,
liver dysfunction, septic shock, anesthesialiver dysfunction, septic shock, anesthesia

5. Acute Renal FailureAcute Renal Failure
Pre Renal CausesPre Renal Causes

Post Renal CausesPost Renal Causes
- External compression to the outflow tract from tumors, - External compression to the outflow tract from tumors,
increased intra abdominal pressure, retroperitoneal fibrosisincreased intra abdominal pressure, retroperitoneal fibrosis
- Intrinsic blockage from tumor, calculi, blood clots, - Intrinsic blockage from tumor, calculi, blood clots,
papillary necrosispapillary necrosis
- Intratubular obstruction from crystals and myeloma chains- Intratubular obstruction from crystals and myeloma chains
- Blocked Foley catheter- Blocked Foley catheter

6. Acute Renal FailureAcute Renal Failure
Pre Renal CausesPre Renal Causes

Post Renal CausesPost Renal Causes

Intrinsic causesIntrinsic causes
Tubulo- Glomerular VascularTubulo- Glomerular Vascular
InterstitialInterstitial

7. Acute Renal FailureAcute Renal Failure
Pre Renal CausesPre Renal Causes

Post Renal CausesPost Renal Causes

Intrinsic causesIntrinsic causes
Tubular Interstitial AcuteTubular Interstitial Acute
necrosis nephritis necrosis nephritis
glomerulonephritisglomerulonephritis
(10% of cases) (5% of cases)(10% of cases) (5% of cases)
Ischemia ToxinsIschemia Toxins
(50% of cases) (35% of cases)(50% of cases) (35% of cases)

8. Ischemic Acute Renal FailureIschemic Acute Renal Failure
Intravascular volume depletion and hypotension
Gastrointestinal, renal, dermal losses, hemorrhage, shock
Generalized
or localized reduction in
renal blood flow
IschemicIschemic
Acute Renal FailureAcute Renal Failure
Decreased effective
intravascular volume: CHF,
cirrhosis, nephrosis, peritonitis
Medications: ACE
inhibitors, NSAIDS,
radiocontrast agents,
Ampho B, Cyclosporin
Hepatorenal syndrome
Large vessel renal vascular disease:
Renal artery thrombosis or embolism,
operative arterial cross clamping, renal
artery stenosis
Small vessel renal vascular disease:
Atheroembolism, vasculitis, malignant
hypertension, hypercalcemia,
transplant rejection
SepsisSepsis

9. Toxin induced Acute Renal FailureToxin induced Acute Renal Failure
Reduction in renal perfusion Reduction in renal perfusion
through alteration of intra renal through alteration of intra renal
hemodynamicshemodynamics
Direct tubular injuryDirect tubular injury
Heme pigment induced ARFHeme pigment induced ARF
Intratubular obstructionIntratubular obstruction
Allergic Interstitial NephritisAllergic Interstitial Nephritis
Hemolytic Uremic SyndromeHemolytic Uremic Syndrome
NSAIDs, ACE inhibitors, NSAIDs, ACE inhibitors,
Cyclosporin, Tacrolimus, IV Cyclosporin, Tacrolimus, IV
contrast, Ampho Bcontrast, Ampho B
Aminoglycosides, IV contrast, Aminoglycosides, IV contrast,
Cyclosporin, Cisplatin, Ampho B, Cyclosporin, Cisplatin, Ampho B,
Heavy metals, IV immunoglobulinsHeavy metals, IV immunoglobulins
Rhabdomyolysis, Hemolysis, Rhabdomyolysis, Hemolysis,
Cocaine, Ethanol, StatinsCocaine, Ethanol, Statins
Acyclovir, Sulfonamides, Ethylene Acyclovir, Sulfonamides, Ethylene
glycol, myoglobinglycol, myoglobin
Penicillins, Cephalosporins, Penicillins, Cephalosporins,
Sulfonamides, Rifampin, Cipro, Sulfonamides, Rifampin, Cipro,
NSAIDs, Thiazides, Cimetidine, NSAIDs, Thiazides, Cimetidine,
AllopurinolAllopurinol
Cyclosporin, Cocaine, Mitomycin, Cyclosporin, Cocaine, Mitomycin,
QuinineQuinine

10. Categories of anuria, oliguria, and nonoliguria Categories of anuria, oliguria, and nonoliguria may may
bebe useful in differential diagnosis of ARF. useful in differential diagnosis of ARF.
AnuriaAnuria - Urinary tract obstruction, renal artery - Urinary tract obstruction, renal artery
obstruction, RPGN, bilateral diffuse renal cortical obstruction, RPGN, bilateral diffuse renal cortical
necrosisnecrosis
OliguriaOliguria - Prerenal failure, hepatorenal syndrome - Prerenal failure, hepatorenal syndrome
Nonoliguria Nonoliguria – AIN, AGN, partial obstructive – AIN, AGN, partial obstructive
nephropathy, nephrotoxic and ischemic ATN, nephropathy, nephrotoxic and ischemic ATN,
radiocontrast-induced ARF, and rhabdomyolysisradiocontrast-induced ARF, and rhabdomyolysis

11. Nonoliguric ARFNonoliguric ARF
Oliguria is a frequent but not invariable Oliguria is a frequent but not invariable
clinical feature (~50%). clinical feature (~50%).
Harrison’s 15ed

12. Nonoliguric ARFNonoliguric ARF
ATN: aminoglycoside, streptomycin, polymyxin ATN: aminoglycoside, streptomycin, polymyxin
B, lithium, or cisplatin nephrotoxicity.B, lithium, or cisplatin nephrotoxicity.
Case report:Case report:
Celecoxib-induced Celecoxib-induced nonoliguric acute renal failure
Annals of Pharmacotherapy. 36(1):52-4, 2002 Jan.Annals of Pharmacotherapy. 36(1):52-4, 2002 Jan.
Lupus nephritisLupus nephritis
American Journal of the Medical Sciences. 321(6):381-7, 2001 Jun.American Journal of the Medical Sciences. 321(6):381-7, 2001 Jun.
Isoniazid-induced Isoniazid-induced crescentic glomerulonephritis
Omeprazole-induced Omeprazole-induced acute interstitial nephritis..
…………..

13. Nonoliguric ARFNonoliguric ARF
Glomerular alterations in experimental oliguric and
nonoliguric acute renal failure.
tubular damage was more pronounced in was more pronounced in
oliguric kidneys…. There was oliguric kidneys…. There was no significant
difference in these glomerular changes in these glomerular changes
between oliguric and nonoliguric kidneys. between oliguric and nonoliguric kidneys.
The findings suggest that less reduction in the The findings suggest that less reduction in the
whole-kidney GFR in nonoliguric ARF kidneys whole-kidney GFR in nonoliguric ARF kidneys
is ascribed largely to is ascribed largely to less pronounced tubular
damage rather than to less severe glomerular
morphologic alterations.
Renal Failure. 15(2):215-24, 1993.

14. Nonoliguric ARFNonoliguric ARF
Acute renal failure: clinical outcome and causes of Acute renal failure: clinical outcome and causes of
death.death.
Higher mortalityHigher mortality was observed in was observed in oliguric oliguric
patientspatients (62.9%) than nonoliguric (34.5%) (p < (62.9%) than nonoliguric (34.5%) (p <
0.05) and in 0.05) and in ischemic renal failureischemic renal failure (56.7%) (56.7%)
when compared to nephrotoxic renal failure when compared to nephrotoxic renal failure
(14.7%) (p < 0.05).(14.7%) (p < 0.05).
Renal Failure. 19(2):253-7, 1997 Mar

15. Nonoliguric ARFNonoliguric ARF
Acute renal failure in a teaching hospital.
…Compared with nonoliguric patients, oliguric
patients had higher mortality (56.3% vs
18.9%, p < 0.01), and needed dialysis more
frequently (43.8% vs 12.9%, p < 0.01)
Singapore Medical Journal. 36(3):278-81, 1995 Jun.

16. Conclusion Conclusion
Nonoliguric acute renal failure
Although the causes of nonoliguric renal failure Although the causes of nonoliguric renal failure
varied, varied, nephrotoxic failure occurred more occurred more
frequently in nonoliguric than in oliguric subjects frequently in nonoliguric than in oliguric subjects
(P <0.01). (P <0.01).
As compared to oliguric patients, those without As compared to oliguric patients, those without
oliguria had significantly lower urinary sodium oliguria had significantly lower urinary sodium
concentrations (P<0.05) and FENa (P < 0.02), concentrations (P<0.05) and FENa (P < 0.02),
had shorter hospital stay (P < 0.01), had fewer had shorter hospital stay (P < 0.01), had fewer
septic episodes, neurologic abnormalities, septic episodes, neurologic abnormalities,
gastrointestinal bleeding and acidemia, required gastrointestinal bleeding and acidemia, required
dialysis less frequently (P < 0.001) and had dialysis less frequently (P < 0.001) and had
lower mortality rate (P < 0.05). lower mortality rate (P < 0.05).
NEJM. 296(20):1134-38,1977 May

17. Management of acute renal Management of acute renal
failure failure
Management of volume homeostasisManagement of volume homeostasis
Management of electrolyte homeostasisManagement of electrolyte homeostasis
Management of acid- base homeostasisManagement of acid- base homeostasis
Management of uremia Management of uremia
Nutritional management in acute renal Nutritional management in acute renal
failure failure
Dialysis in acute renal failure Dialysis in acute renal failure

18. Management of volume Management of volume
homeostasishomeostasis
Record I/O Record I/O
Physical examination Physical examination
Fluid = urine output + 300-500Fluid = urine output + 300-500
Sodium intake<2 g/daySodium intake<2 g/day
DiureticsDiuretics
Low dose dopamin ( 0.3 ug/kg/min)Low dose dopamin ( 0.3 ug/kg/min)
CVP or pulmonary capillary wedge CVP or pulmonary capillary wedge
pressure pressure

19. Management of electrolyte Management of electrolyte
homeostais homeostais
Hypernatremia and hyponatremiaHypernatremia and hyponatremia
HyperkalemiaHyperkalemia
Hypocalcemia Hypocalcemia
Hypomagnesemia Hypomagnesemia
Hyperphosphatemia Hyperphosphatemia

20. Management of acid- base Management of acid- base
homeostasishomeostasis
Dietary protein restriction 0.8-1.0g/kg of Dietary protein restriction 0.8-1.0g/kg of
body weight 30 kcal /kg/day ( except body weight 30 kcal /kg/day ( except
hypercatabolism )hypercatabolism )
Look for cause of acidosis Look for cause of acidosis
Sodium bicarbonate Sodium bicarbonate
Dialysis Dialysis

21. Management of uremiaManagement of uremia
Fatigue, lethargy, mental dullness, norexia Fatigue, lethargy, mental dullness, norexia
and nausea and nausea
More serious– myoclonus, confusion, More serious– myoclonus, confusion,
delirium or coma, seizure and pericarditis delirium or coma, seizure and pericarditis
Diet protein controlDiet protein control
Check GI bleeding Check GI bleeding
Hemodialysis Hemodialysis

22. Nutritional management in Nutritional management in
acute renal failure acute renal failure
Minimal recommand protein Minimal recommand protein
intake0.6-0.8g/kg/dayintake0.6-0.8g/kg/day
Carbohydrate and lipid should maximal Carbohydrate and lipid should maximal
with a target of providing 30-65kcal with a target of providing 30-65kcal
/kg/day/kg/day
Limit fluid volume potassium , magnesium, Limit fluid volume potassium , magnesium,
and phosphorus should avoid.and phosphorus should avoid.

23. Indications for dialysisIndications for dialysis
Absolute indicationsAbsolute indications
uremic symptomsuremic symptoms
uremic pericarditisuremic pericarditis
Relative indicationsRelative indications
volume overlosdvolume overlosd
hyperkalemiahyperkalemia
metabolic acidosismetabolic acidosis
Other electrolyte abnormalitiesOther electrolyte abnormalities

24. Drug management in acute Drug management in acute
renal failure renal failure
Stop nephrotoxic drugsStop nephrotoxic drugs
Adjust medication doseAdjust medication dose
Check drug level Check drug level

25. Thanks for your attentionThanks for your attention