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Advances in Acute renal failure Acute renal failure first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease1951

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Page 1: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Advances in Acute renal failure

Acute renal failure first proposed by Homer Smith

Text book: ‘The Kidney Structure and Function in Health and Disease1951

Page 2: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

35 definitions in literature(Kellum et al. Curr Opin Crit Care 2002;8:509-514)

Page 3: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

35 definitions in literature(Kellum et al. Curr Opin Crit Care 2002;8:509-514)

Prevalence: 1 to 25% in ICUMortality: 15 to 60% Prevalence: 1 to 25% in ICUMortality: 15 to 60%

Page 4: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Why ‘RIFLE’ Criteria

ARDS & Sepsis: Definitions not perfect; but found to be useful

Need to classify the severity of syndrome; rather than only severest form

ARF= Dialysis dependence

Lack of single definition Held ARF research 20 years back

(Bellomo R et al. Intensive Care Med. 2001 Nov;27(11):1685-8)

Page 5: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Citated till now in 546 articles

Page 6: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Severity classes

Outcome classes

Oliguria/ARF

Page 7: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Decline in GFR Abrupt; 1 to 7 daysAt all levels Both UOP & S. Cr Change sustained for >24

hours.

Relationship between S. Cr & GFR Depends on the phase of recovering renal failure

Certainly steady state often not reached

Both S. Cr & GFR changes Always be considered in terms of the baseline

When baseline is unknown or confronted with a patient who has elevated S.Cr ??? Suggestion MDRD formula

Oliguria insensitive marker: many patients remain non-oliguric

Page 8: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Conventional definitionRapid decline hours to weeks

Decline in GFRRetention of nitrogenous waste products

1. Fails to describe dynamic process initiation, maintenance & recovery2. Emphasis on overt failure of kidneys; belies that mild decrement of renal function A/w cardiac eventsHoste et al. : Only 14% of patients of ‘F’ Received dialysis;

but 5 times hospital mortality (Crit Care 2006; 10: R73)

AKI Incidence by RIFLE : 2-10 times higher than conventional definition

Page 9: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

No AKI Risk Injury Failure5.5% 8.8% 11.4% 26.3%

Page 10: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Relationship: RIFLE class V/s Outcome Six studies

Hoste EA Curr Opin Crit Care 2006; 12; 531-537

Mortality

Page 11: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Limitations of RIFLEUrine output

Diuretic use: sensitivity & specifictyFor accurate measurement: requires catheter

Hoste (Crit Care 2006:10:R73) Uchino (Crit Care Med 2006:34:1913-1917)

S. Cr + UOP S.CrMortality: 8.8%, 11.4%; 26.3% 15.1%; 29.2%; 41.1%

Need to know baseline S.CrNot always known

RIFLE advises to use MDRD; MDRD for CKD

Page 12: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

RIFLE Version 1.2 or AKIN Stages

Stages 1,2 and 3 instead of R. I and F Bagshaw et al. **Increase in S. Cr at least 0.3 mg/dL even if it does not reach 50% threshold

Increase in sensitivity by 1%

A 48 hour window on first documentation of any criteria

Caution: May exclude patients that should be included in AKI diagnosis

Use of RRT, classifies patient to ‘F’ regardless of S.Cr or UOP

-

NDT 2008; 23 (5);1564-1579

**

Page 13: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

JAMA 2005;294:813-818

29,269 patients in ICUs Largest prospective study

Period prevalence 5.7% (1.4 to 25.9%)

Median age 67 years

Contributing factors Septic shock (47.5%)Major surgery, Cardiogenic shock

Mortality 60.3%

Septic patients 70.2%

Page 14: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

618 patients in ICUs

Mean age 59.5 years

Co-morbidities CKD 30%CAD 37%DM 29%

In-hospital mortality 37%

AKI superimposed on CKD lower mortality than AKI

Page 15: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Nature Reviews Nephrology 2006, 2 (7) 364

Page 16: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Nature Reviews Nephrology 2006, 2 (7) 364

Hospital incidence

Page 17: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Nature Reviews Nephrology 2006, 2 (7) 364

Page 18: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Disease Percentage

Pre-renal azotemia caused by acute renal hypoperfusion

55-60

Intrinsic renal azotemiaDiseases of large vessels, small vessela, glomeruli, interstititum & Tubules**ATN

35-40

Post renal azotemia due to obstruction

<5

** Accounts for 90% of intrinsic renal category

Disease categories of AKI

Page 19: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Diagnosis of ARFOften diagnosed Increase in S. Cr & Urea

BUN to S. Cr ratio = 15 : 1

Schrier Kid Int 1979 ; 15: 205-216

Hypercatabolic ARF Hypercatabolic ARF

Page 20: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease
Page 21: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

LR: Likelihood ratio

Page 22: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Renal biopsy in ARFIndications Oliguria > 2 weeks Schrier

> 6 weeksOTCN

Anuria Flawed Patchy necrosis Angiogram to know perfusion of cortices

Systemic disease Heavy proteinuria &

haematuria Marked hypertensionNo circulatory disturbance

to account for ATN

Gomez. CJASN 3; 674: 2008

Largest registry 2281 ARF biopsies

AKI as an indication 16%

Most commonly Elderly; 32%>60y

ATN Only 5%; Intense selection bias:

Only those not presumed to be ATN clinically biopsied

What is not clarified

Initially thought to be ATN finally biopsied

Page 23: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Gomez. CJASN 3; 674: 2008

Page 24: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Modified Colapinto aspiration needle

Sheath

Protective cover

Needle

Needle + Specimen

Past = Contraindications

Page 25: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Interventional radiologist

25 high risk patients21 (84%) tissue adequate

17Perforation of renal capsule

6 of them coil embolization1 RVT after one week

Feasibility of transjugular biopsy well documented

Clinical benefit to be established

Page 26: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Previous criteria: Early v/s Late; QualitativeProposed: Quantitative; Based on RIFLE criteria

CJASN 3; 876-880; 2008

Page 27: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

RRT: Early versus LateTiming

Page 28: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

V. Seabra et al, AJKD, 52: 272-284; 2008Mortality

Page 29: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

V. Seabra et al, AJKD, 52: 272-284; 2008Renal recovery

Page 30: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

V. Seabra et al, AJKD, 52: 272-284; 2008

Page 31: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

160 patients Randomized to daily HD v/s Alternate day HDAlt day HD Daily HD

Duration of HD (hr) 3.4 ± 0.5 3.3 ± 0.4 Kt/v (delivered) 0.94 ± 0.11 0.91 ± 0.12Mortality 46% 28%Resolution of ARF (days) 16 ± 6 9 ± 2

??? A case of inadequate dialysisMean time averaged BUN (mg/dL)

104 ± 18 60 ± 20

Mean time averaged S.Cr (mg/dL)

9.5 ± 1.2 5.3 ±1.2

Dosing

Page 32: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Optimal dose is 35 ml/kg/hr = 50.4 L/d

Survival rate 41% 57%** 58%**

Dosing

Page 33: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Intensive treatment Less Intensive treatment

IHD &/ or SLED: Six times a week

Thrice a week

CVVH: 35 ml/kg/hr 20 ml/kg/hr

Allowed patient transition from one mode to another as long as they stayed within the intensive or less intensive

groups

Palevsky et al.Dosing

Page 34: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Dosing

Page 35: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

1. 6 days delay in initiation of treatment2. 219 protocol deviations Isolated UF in less

intensive group3. SLED more in intensive group4. Treatment for 28 d only. Mortality At 60 d; 10%

of patients received extra dialysis

CORRESPONDENCE

Dosing

Page 36: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

1508 patients randomized CVVHDF 40 ml/kg/hour 25 ml/kg/hour

Deaths at 90 d 44.7% 44.7%RRT dependence

at 90 d6.8% 4.4%

Hypophosph-otemia

65%** 54%

Bellomo et al.

Dosing

Page 37: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Bellomo et al.Dosing

Page 38: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Mortality: No difference 2010 Vol. 38, No.5; 1360

Page 39: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease
Page 40: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

RecommendationsDialysis dose: Kt/V: 1.4 & effluent volume

25 to 30 ml/kg/hourDaily monitoring of delivered dose

Nutrition & drug dosing monitored

Eight RCTs in last decadeAt present Four discussed

Page 41: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Steep correlation bet the dose & survival

Plateau: no further benefit

Page 42: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

What is unknown even after VA/NIH ATN?1.Breaking point2.BP for diff modes of dialysis

What is gainedVA/NIH ATN1.Not to risk under dialysis2.Dialysis dose monitoring

Page 43: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

CRRT v/s IHD: Six RCTs Last 10 years; In Europe & US

CRRT IHD

John S et al. NDT 16; 320-327, 2001

No difference in mortality 70% in both

Mehta et al. KI 60; 1154-1163; 2001

MortalityICU: 59%Hospital: 65%

41%47%After covariate adjustment:

No differenceAugustine JJ AJKD 2004; 44: 1000-1007 No difference in mortality

Greater haemodynamic stability in CRRT

Uhelinger DE et al.NDT 2005; 20:1630-1637

Mortality: 34% 38% p= NS

Gasporvic et al.Renal fail 25; 855-866;2003

No difference in mortality

Hemodiafe studyVinsonneau et al, Lancet, 368, 379-385, 2006

No difference in mortality

Page 44: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Continuous versus intermittent renal replacement therapy for critically ill patients with acute kidney injury: A meta-analysisBagshaw, Sean M. MD, MSc; Berthiaume, Luc R. MD; Delaney, Anthony MBBS, MSc; Bellomo, Rinaldo MD

Crit Care Med, 36: 610-617; 2008CRRT v/s IHD

Page 45: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Continuous versus intermittent renal replacement therapy for critically ill patients with acute kidney injury: A meta-analysisBagshaw, Sean M. MD, MSc; Berthiaume, Luc R. MD; Delaney, Anthony MBBS, MSc; Bellomo, Rinaldo MD

Crit Care Med, 36: 610-617; 2008

There was suggestion that continuous RRT had fewer episodes of hemodynamic instability and

better control of fluid balance.

In the context of these limitations, the initial RRT modality did not seem to affect mortality or

recovery to RRT independence

CRRT v/s IHD

Page 46: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Death Renal recovery

Page 47: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Intermittent, continuous and hybrid techniques offer specific advantages

All are part of a medley race in dialysis of critically ill

Page 48: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Prospective RCT Hypercatabolic patients87 patientsCEPD & TPD cross over trail 12 hour wash out after initial dialysis Baxter dialysate bags & Cycler machines

CEPD TPDWeekly Kt/V 1.80 ± 0.32 2.43 ± 0.87

“Just fell short of dialysis adequacy”

Higher clearances Less expensive (Rs.7165)

Both Reasonable options for the treatment of ARF

Page 49: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

NEJM 347; 12: 895; 2004

Hemofiltration versus Acute PD78 patients48 Malaria; 22 Sepsis

MortalityAcute PD : 47%Haemofiltration: 15%

Page 50: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

John T Daugirdas

1.Predominance of malaria2.Comparison of state of art CVVH with

rustic PD3.CVVH was low intensity; still

patients recovered fast

Page 51: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Kid Int 2008; 73: 587- 593

120 patients randomized HVPD Tenckhoff catheter placed by a nephrologist

7 days a week Dianeal solutionHome choice (Baxter)Weekly Kt/V= 3.6 ± 0.6

DHD 3 hour session6 days a week Weekly Kt/V= 4.7 ± 0.6

Page 52: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Kid Int 2008; 73: 587- 593

Page 53: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

SummaryRIFLE Criteria Single standard definition

Severity of class MortalityAKIN criteria Impact not yet knownEpidemiology Incidence of ARF

Mortality relatively static>6 RTEC & GC LR of ATN highTransjugular biopsy Possible to do; Utility unknownEarly dialysis EffectiveIntense dialysis No effective;

Not to risk under dialysisDose Kt/V=1.4; CRRT 25-30 ml/kg/hr

Daily monitoringCRRT v/s HD No differencePD Reasonable option

Page 54: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Biomarkers

Qualities

Accurate, reliable

Relatively non-invasive/acceptable to patients

Rapidly measurable, standardized assay

Sensitive/specific with reproducible cutoff values

Page 55: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Neutrophil gelatinase assosciated lipocalin (NGAL)25 kDa, proteinExpressed in neutrophilsKidney, lungs, trachea, stomach, colonIncreased in PT—after injury

KIM-1First novel renal biomarker discovered (Han WK et al. Kid Int. 2002; 62: 237–44)

A transmembrane protein in PT

IL-18Role in inflammation, Activating macrophagesMediates ischemic renal injury

Cystatin CNon-glycosylated LMW(13.4 kDa) cystine proteaseSynthesized at constant rate by all nucleated cells (Grubb AO Adv. Clin. Chem. 2000; 35: 63–99.)

Freely filtered glomerulusCompletely reabsorbed PTReadily assayed Automated immunonephelometric (Herget-Rosenthal S Clin. Nephrol. 2005; 64: 41–6)

As a GFR measurementrobust than S Cr

Page 56: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease
Page 57: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease
Page 58: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease
Page 59: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Urine

Page 60: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Urine

Page 61: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Biomarker Sample Source

Cardiac surgery

CIN Sepsis RT

NGAL Plasma Early Early Early Early

NGAL Urine Early Early Early Early

Cystatin C Plasma Intermediate Intermediate Intermediate Intermediate

IL-18* Urine Intermediate Absent Intermediate Intermediate

KIM-1* Urine Intermediate Not tested Not tested Not tested

* Commercial test not yet available

Current status of AKI biomarkers

Devarajan P Contrib Nephrol 2007, 156, 203-212

Page 62: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Acute versus ChronicHistoryVague ill healthNocturiaPruritusSkin pigmentation‘Bit of protein’ in urine‘Bit of problem in kidneys’

Suggests chronicity

Kidney sizes USG standardSize: 3.7 ± 0.4 cm times of L2 VB

Broad waxy casts Chronic renal failure or rapidly progressive; never ARF

Carbamylated Hb (expressed as µg carbamyl valine per gram (CV/g) Hb)

CRF: 129.0 ±8.1ARF: 55.6±6.2Normal: 31.6±1.3 **

Anemia, Hypocal, Hyperphos, Hyperuricemia

Present in both

** Alian Wynckel Nephrol Dial Transplant (2000) 15: 1183-1188

Page 63: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Fractional Excretion of Sodium (Fe Na)

Pre-renal azotemia ATN

Na+Reabsorbed avidlyD/t Suppression of ANPActivation of R-AT-Aldo

Na+ Reabsorption is inhibited as tubule is damaged

Creatinine reabsorption smaller extent than Cr in both conditions

<1% >1%

Ratio of Na+ clearance to the Cr. ClearanceUNa+ / PNa+ X PCr / UCr X 100

FeNA > 1.0 in pre-renal azotemia

FeNa < 1.0 in ATN

Diuretics Milder form of ATNs intermediate syndrome

Underlying salt losing nephropathy

Damage only to cortico medullary junction; preservation of LOH

Adrenal insuffficiency Ischemia, Rhabdomyolysis, AGs, RCA, HRS

Espinel JAMA 236; 579-581, 1976

Page 64: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Pre-renal azotemia with FeNA >1 d/t diuretic use

Fractional excretion of Lithium & UA remains low

PrognosisOliguric patients with

ARF with Fe Na <1%High likelihood of response to diuretics

Page 65: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Pre renal azotemia ATNFeNa (%) <1 >1Renal failure index UNa/Ucr/Pcr <1 >1Urinary Na+ concentration (mEq/L) <10 >20Plasma BUN/creatinine ratio >20 <10–15Fe UA (%) <7 >15Fe Lithium (%) <7 >20Urinary creatinine/plasma creatinine ratio >40 <20

Urinary urea nitrogen/plasma urea nitrogen ratio

>8 <3

Urine specific gravity >1.018 <1.012Urine osmolality (mOsm/kg H2O) >500 <250Urine sediment Hyaline casts RTECs & casts,

Muddy brown granular casts

Renal failure indices

Treatment Usually started on same lines whether it is pre-renal azotemia or ATN

Page 66: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

DOSINGMEHTA R., McDONALD KI 2001166 patients randomized84 to CRRT, 82 to IHDPatients with Mean Arterial Pressure (MAP) < 70 mm Hg

excluded

Mortality CRRT IHD P ICUpatients 59% 41% Significant

Hospital patients 65% 47% Significant

The mortality was worse in CRRT group, but on subgroup analysis the renal recovery was better on CRRTCriticism: Patients with MAP < 70 mm Hg have been excluded

Page 67: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease
Page 68: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease
Page 69: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease
Page 70: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease
Page 71: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease
Page 72: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease
Page 73: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease
Page 74: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Percentage 1965 to 1974 1981 to 1986Diarrhoeal diseases

23 10

Sepsis & drugs 37 50Obstretic 22 9Surgical causes 11 31 d/t ↑

obstructive uropathy

Changing Trends in Acute Renal Failure in Third-world Countries — Chandigarh Study

K. S. Chugh et al. Q J M 1989; 73:1117-1123

Page 75: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Epidemiologic Trend Changes in Acute Renal Failure—A Tertiary Center Experience from South India M. Jayakumar, Renal failure, (5 ) 2006 , 405 - 410

Number of patients 1112 between 1994 to 2004 Mean age 37.08 ± 3.4 yrsMales 669 (60.1%) MedicalObstetric Surgical

87.6 %8.9% 3.4 %

Most common medical cause

Diarrhoeal disease

Other causes Lepto, Malaria, DrugsRRT 69%Mortality 19.6%Dialysis depedence 8.18%

Page 76: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

RIFLE3 Severity classes 2 Outcome classes

Risk

Injury

Failure

Loss

End stage kidney disease

Based on changes in S.Cr or UOP Worst of each criteria to be used

Duration of loss of kidney function

Hoste et al. : Only 14% of patients of ‘F’ Received dialysis; but 5 times hospital

mortality (Crit Care 2006; 10: R73)

Page 77: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease

Optimal dose is 35 ml/kg/hr = 50.4 L/d

Survival rate 41% 57%** 58%**

Page 78: Advances in Acute renal failure Acute renal failure  first proposed by Homer Smith Text book: ‘The Kidney Structure and Function in Health and Disease