Acute renal failure causes and treatments

Acute renal failure causes and treatments

Acute renal failure (STC) is a condition of reduced glomerular filtration rate dramatically and quickly, within tuvai gioden few days, leading to disorders of water, electrolyte, acid-base balance and area tucac production products metabolism in cơthể. This condition is usually detected clinically when up substances containing nitrogen (urea, creatinine) and or expression oliguria or anuria.

So far the theologians the world has not come up with an agreed definition of diagnostic criteria for acute renal failure and is often based on the rate of increase in serum creatinine concentration than the background concentration of creatinine (baseline) of the patients for the diagnosis of acute renal failure.

Acute renal failure arises when:

- The rate of increase in serum creatinine of> 42.5 mmol / l for 24 to 48 hours compared to the creatinine concentration if the patient's background creatinine <221mmol / l or:

- The rate of increase in serum creatinine of> 20% within 24 to 48 hours compared to the creatinine if the background creatimn concentration of patients> 221mmol / l

Clinical fact not we ever know the exact blood creatinine concentration of patients without acute renal failure (creatinine background) so most clinicians are often based on the growth rate of creatinine serum in a specific time period for the diagnosis of acute renal failure as follows:

- When the speed increased serum creatinine concentration> 45mmol / l within 24-48 hours.

Besides relying on the increase in serum creatinine concentration clinicians need to rely on other clinical manifestations such as: pathogens, the sudden appearance of symptoms such as urinating less disabled to make the diagnosis timely diagnosis and management of suspected cases of acute renal failure.

I. Cause of acute renal failure

Acute renal failure due to many reasons, it can be difficult to interpret the mechanism of pathogenesis in a simple way. Can generally there are five factors that contribute to the pathogenesis of acute renal failure mechanism is as follows (see Figure 1):

1. Back diffusion of glomerular filtrate passing through the tubular membrane by tubular damage.

2. Tubular obstruction due to a pigment cells by, or protein products

3. Increased pressure in the organization of renal interstitial edema

4. Effective reduced blood flow in the renal cortex leads to reduced glomerular filtration rate acute.

5. Change the permeability of the membrane to the glomerular capillary

All of these factors contribute to more or less lead to anuria. Main factors, sub factors, depending on the etiology and evolution of the disease process.

II. CLINICAL MANIFESTATIONS AND ACCESS clinical course of acute renal failure:

1. The clinical signs

The majority of cases of acute renal failure onset with signs least urethra (<400ml/24h), but in some cases the urine still> 1l/24h (preserved urine).

In addition, depending on the cause of acute renal failure that clinical manifestations may vary:

Acute renal failure caused by renal ago:

Common symptoms of dehydration such as:

- Quick Circuit, HA HA, HA lag

- Skin, dry mucous membranes; reduce wrinkled skin stretch, neck veins collapse

- The number of urine descending

Acute renal failure due to causes in the kidney:

It is possible that one or more of the following signs:

- The risk factors: prolonged shock, drugs toxic to the kidney, dye; rhabdomyolysis, haemolysis

- Urine red or dark blood in the urine in acute glomerulonephritis, etc.

- Lower back pain due to kidney stones, ureter.

- Oliguria, edema, hypertension ...

- Fever muscle pain and itching, rash rash after taking the drug.

Acute renal failure acute tubular necrosis can

Heading of acute renal failure in kidney but can be split into a separate clinical.

Acute renal failure caused by renal

Common signs of urinary tract obstruction, such as:

- Pain of kidney or hurt them back or points ureter

- Kidney to due to fluid retention, accumulation of pus.

- The symptoms of bladder: bladder pain away, long cold, long drive ...

- Oliguria, anuria unknown.

- Rectal Visitors can see the prostate just to go with the previous urination disorder.

Normal renal function recovery after resolving the cause congestion as remove the stones, prostate removal ...

2. The clinical manifestations

- In all cases of acute renal failure that urea, blood creatinine increased daily, can increase very rapidly within a few hours.

- Blood potassium increased if acute renal failure is not timely and effective interventions.

- Heavy blood loss or anemia massive intravascular haemolysis.

- Also see: blood calcium decreased, sometimes increased blood calcium, blood phosphorus increased, metabolic acidosis manifested by decreased alkaline reserve, increased anion gap ...

3. Some subclinical exploration help diagnose the cause

3.1. Urinalysis

- Normal or low red or white blood cells found in: kidney failure caused by kidney, renal artery, renal vasculitis in front of, the syndrome of hemolysis increased blood urea or experience in micro-thrombosis syndrome rash and thrombocytopenia, the cause of acute renal failure after kidney stones, ureteral stones ...

- The crystals are met: by increasing urate acute, acyclovir poisoning, sulfonamides, the dye intravenously.

- Cylindrical particles in acute tubular necrosis, renal anemia and poisoning suggestions.

- Proteinuria trace or negative suggestions before or after renal causes, Meu protein on 1 gram per day and or red head: thus suggests glomerular disease.

- Head leukemia: kidney tissue infections such as acute kidney pyelonephritis, glomerulonephritis details.

- Leukocytes like acid: atopic renal interstitial tube institutions due to antibiotics, anti-inflammatory pain relievers non-steroids, pathological thrombosis due to atherosclerosis or some form of acute glomerulonephritis.

- Meu hemoglobin and myoglobin in the urine: hints haemolysis or rhabdomyolysis.

3.2. Blood tests

When there is increased attached, phosphate, uric acid and creatinine kinase (CK), blood creatinine increased, blood urea more suggestions rhabdomyolysis.

- Severe anemia without bleeding suggest hemolysis, multiple myeloma bone disease, IC thrombosis (thrombotic microangiopathy).

- Increased blood eosinophils suggests allergic interstitial nephritis, or inflammation of the artery around.

3.3. Diagnostic Imaging

- Take X.quang us unprepared to detect urinary stones dye;

- Capture the urinary system with dye injection intravenously or shooting pool kidney-ureter and down stream location detection obstruction causing acute renal failure but only when absolutely necessary and with mild renal impairment or on the basis of the ability to filter blood in the kidneys because intravenous dye will aggravate kidney failure.

- Radiation kidney when there are contraindications to use of intravenous dye, and especially acute renal failure before surgical removal of stones and gravel to evaluate kidney function and kidney stones without stones.

- Ultrasound: determine the size of the kidneys, the indirect signs of stones or other causes congestion, specifically exclude causes of acute renal failure after kidney.

- Renal artery Doppler can determine the cause of acute renal failure is caused by blood vessels: thrombosis, renal vein, renal parenchymal perfusion status as well as in renal vascular resistance.

- CT scanner, MRI can confirm the diagnosis easier in some cases did not find the cause of acute renal failure.

3.4. A renal biopsy

Indicated in some cases of acute renal failure due to glomerulonephritis, suspected renal system damage secondary to the purpose of:

+ Assessment of glomerular injury.

+ Renal interstitial pipe damage and glomerular injury classification.

+ When other measures no clear diagnosis, a renal biopsy is useful for treatment options and prognosis.

4. The clinical

Acute renal failure typically progress through four stages.

Acute tubular necrosis acute renal failure is a typical instance.

4.1. Onset

Onset, within 24 hours, the attack phase of the pathogen. Changes depending on the cause. In patients with poisoning, rapid evolution can lead to anuria now generally decreased urine output; if timely intervention can avoid the switch to stage 2.

4.2. Period from diabetes at anuria

Anuria may turn slowly, patients with diabetes less gradually and anuria, but anuria may also occur suddenly, as in the case of poisoning or mechanical causes. Less urine, anuria may last 1-2 days, 1-6 weeks, 7-14 days average patient will pee again.

- There may be consistent

- Urea, creatinine increased, water and electrolyte disorders, hyperkalaemia

- Metabolic acidosis

Blood uric acid increased

- The manifestations of cardiovascular, respiratory, neurological, gastrointestinal syndrome of high blood urea.

When speed increased urea, creatinine of blood as quickly as the more severe prognosis. Blood urea increased depending on the level of anuria, depending on the diet proteins, depending on the breakdown of proteins in the body. Blood creatinine, the final breakdown products of creatinine (mostly in), regardless of the diet, so it more accurately reflects renal function urea. As the urea concentration increases above 8 mmol/24 hours or creatinine increase on 90mmol/l/24gio, very bad prognosis.

4.3. Wet the back stage

- Lasts an average of 5-7 days

- Urine, start 200-300ml/24h, can pee 4-5lit/24h

- Still high risk: increased urea, creatinine; diabetes, dehydration, loss of electrolytes (potassium, low, low blood sodium).

4.4. Recovery period:

- Depending on the cause of acute renal failure and prolonged recovery time can vary, an average of 4 weeks.

- The biochemical disorder gradually returned to normal: urea, blood creatinine decreased. Urea, ascending urinary creatinine. However, the ability to concentrate the urine of renal tubular years to recover fully. Glomerular filtration rate faster recovery, usually after 2 months can return to normal.

III. Diagnosis of acute renal failure

1. Definitive diagnosis

Definitive diagnosis is based on:

- There are acute causes such as taking carp security, heavy potassium poisoning, diarrhea, dehydration, acute glomerulonephritis ...

+ Appearance: oliguria, anuria

+ Urea, blood creatinine increased within a few hours to several days (see the definition of acute renal failure)

+ K + blood increases.

+ Acid-base balance disorder may come, common metabolic acidosis.

2. Differential Diagnosis

2.1. A number of cases have increased creatinine or blood urea without acute renal failure

2.1.1. Urea increased by

- Increase in too much protein in the body: through eating, drinking, multiple amino acid transmission

- Gastrointestinal bleeding

- Increase the breakdown process

- Being used steroids

- Being used tetracycline

2.1.2 Increased blood creatinine concentration by:

- Increased release from

- Reduction in proximal tubular secretion by cimetidine, trimethoprim ...

2.2. Acute renal failure with acute attacks of chronic renal failure

- This means that acute renal failure occurred on the patients with chronic renal failure before that.

- It is worth noting that the differential diagnosis because we can only mistaken for chronic renal failure in patients with mild or moderate selection of renal replacement therapy method which in fact can only be treated conservation.

In chronic renal failure:

- History of kidney disease - urinary tract.

- Serum creatinine and urea increased in advance if you have been diagnosed and monitored.

- Anemia corresponding to the degree of renal impairment.

- High blood pressure, heart failure: usually more severe in patients with chronic renal failure.

- Ultrasound can see two small renal atrophy, renal parenchyma increases the negative resistance (reflecting the degree of renal parenchymal fibrosis) if due to chronic glomerulonephritis, or other causes of chronic renal failure, such as: coal cysts, kidney stones ...

Exacerbation of chronic renal failure:

- There are other causes that aggravates the level of CKD, such as: kidney poison, medicine men unidentified substance, dehydration due to vomiting, diarrhea, systemic infection or kidney infection drives , after a sudden kidney blockage.

- Severe renal impairment but not severe anemia if the cause of acute renal failure due to blood loss and patients not taking drugs to increase red blood cells before.

- On ultrasound: the size and nature of the renal parenchyma is not commensurate with the degree of renal impairment, severe renal impairment, but careful not to shrink and prevent sound much if the cause of chronic renal failure was chronic glomerulonephritis.

- Excluding the favorable cause of impaired renal function, the degree of renal failure will be reduced but never returns to normal.

2.3. Clinical distinction can

Acute renal failure due to causes before kidney with acute renal failure caused by kidney in acute tubular necrosis (Table 418).

3. Diagnose the cause

Acute renal failure due to many causes, can cause pre-renal, renal and post renal. Can be summarized by the following diagram:

Some indicators distinguish acute renal failure due to causes before kidney

with acute renal failure due to acute tubular necrosis in the kidneys causing

Diagnostic indicators

Causes before kidney

In kidney

Waste fractions Na


> 1

Urinary Na


> 20

Ucre / Pure

> 40


Uure / Pure

> 8


Proportion of urine

> 1018


Urinary osmotic pressure

> 500 mOsm / kg water

<250 mOsm / kg water

Pure / PCRE

> 20


Renal failure index


> 1

- Ucre = urinary creatinine concentration

- Uure = urinary urea concentration

- PCRE = serum creatinine concentration

- Pure = serum urea concentration

- Renal Index = urinary Na / Ucre / PCRE

- Glomerular filtration fraction =

3.1. Acute renal failure before kidney (about 55-60% of all cases of acute renal failure)

- Shock volume reduction: dehydration, blood loss.

- Cardiac shock.

- Septic shock.

- Anaphylactic shock.

- The cause of decreased circulating volume, such as: nephrotic syndrome, cirrhosis, minimum maintenance ... cause special proteins blood and reduction of albumin is severe anemia.

3.2. Acute renal failure in kidney (about 35-40% of all cases of acute renal failure)

3.2.1. The acute glomerulonephritis: about 3-12% of patients with acute renal failure.

Primary glomerular diseases: acute renal failure can be a complication of acute glomerulonephritis after a streptococcal infection.

Secondary glomerular diseases:

- Glomerulonephritis lupus in the acute phase progression.

Goodpasture's syndrome.

- Schonlein - Henoch kidney damage.

3.2.2. The acute renal interstitial tube

The cause of acute interstitial nephritis tube (also known as acute tubular necrosis):

- Acute poisoning: carbon tetrachlorua, glycol, carp bile, medicinal herbs contain ...

- Drugs: antibiotics aminosid, cephalosporin, cyclosporin A ...

- Other drugs: nonsteroidal anti-inflammatory analgesic (Glafenin, paracetamol, etc.), lithium, diuretics thiazide group, the anti-cancer drug, dye with iodine ...

- Tan acute blood: from the wrong ABO transfusion, infection, malaria, a blood-soluble drugs: quinine, rifampycin, anti-inflammatory analgesic.

- Acute rhabdomyolysis due to: physical trauma, ischemic, urea marriage lasts, seizures, heroin, antiepileptic drug abuse ...

- The state of shock: early acute kidney function, may lead to acute tubular necrosis.

- The causes of acute interstitial nephritis:

+ Due infections: sepsis, caused by Leptospira, Salmonella diseases, acute pyelonephritis kidney.

+ Through immune mechanisms cause allergies: Antibiotics: b lactamin, cephalosporin, rifampycin, sulfamid ... A nonsteroidal anti-inflammatory drugs such as painkillers, thiazide diuretics, anticonvulsants, alloprinol, cimetidine ...

- Metabolic disorders: increased blood uric acid.

- Some other cause: multiple myeloma bone (myeloma), lymph nodes (lymphoma) ...

3.2.3. The renal vascular lesions

- Blood Cryoglobulin.

- Inflammation of the artery around the button.

Urticarial Vasculitis.

- Granulomatous Disease Wegner.

Takayasu disease.

- Renal injury.

- Renal artery obstruction ...

3.3. Acute renal failure after kidney (less than 5% of all cases of acute renal failure)

Including the causes of obstructive urinary path:

- Gravel renal pelvis and ureter.

- U insert pressure, congestion urinary posts.

- Fiber causes inflammation, stricture: renal tuberculosis - urinary, syphilis.

- Retroperitoneal fibrosis ...

4. Diagnosis of complications

4.1. Heart

Excess weight along with high blood pressure can cause pulmonary edema, heart failure, cerebral edema, ... period oliguria / anuria. During this period also common situation hyperkalemia cause arrhythmias, if severe, can cause cardiac arrest. There may be pericardial effusion, pericarditis, myocardial infarction.

4.2. Nerves

- Increased blood urea syndrome not only met during the period of oliguria / anuria which can still be seen in patients with stage back or agency neuromuscular disorders, convulsions, coma.

4.3. Digestion

Gastrointestinal ulcers, pancreatitis, gastrointestinal hemorrhage is a severe complication and increases the risk of death.

4.4. Metabolism

- Patients who are prone to dehydration and electrolyte disorders such as hypercalcaemia, increased phosphorus, uric acid, increased blood magnesium. Decreased potassium, sodium blood during diabetes and can be fatal if not treated properly and monitored closely.

- Decrease insulin metabolism, increased parathyroid hormone and decreased thyroid hormone T3-T4

- Malnutrition

4.5. Infections

- The multiple lung infections, urinary tract, skin wounds, septicemia.

IV. CAN SOME OF CLINICAL acute renal failure

1. Acute renal failure in relation to the process of pregnancy and childbirth

The elements in the kidney plays a major role causing acute renal failure include:

+ Eclampsia and pre-eclampsia, anemia due to blood loss, vegetables, abruption, amniotic fluid embolism, renal failure after abortion ...

+ Postpartum acute renal failure may be due to the syndrome of hemolysis, thrombosis and thrombocytopenia ... IC May experience acute renal failure after kidney due to ureteral obstruction by the uterus to and cause acute pyelonephritis renal acute renal failure.

2. Acute renal failure in some liver disease (liver and kidney syndrome)

Occur in patients with severe liver disease at an early stage, the cause was attributed to renal vasoconstriction and reduced blood flow causing acute renal failure before kidney. Hypoalbuminemia is also a factor contributing to severe kidney failure.

- Some cases may be due to the loss of circulating volume is really due to gastrointestinal bleeding, diuretic abuse. Acute renal failure in liver and kidney syndrome, blood urea and creatinine levels did not reflect the true degree of renal impairment. Blood urea and creatinine did not increase too much, although severe renal impairment because of the reduced production of urea and creatinine.

- Liver syndrome should be distinguished from the kidney to renal injury by toxic substances in patients with impaired hepatic function such as hepatitis, drug-induced interstitial nephritis organization or bacteria or inflammation circuit damage liver.

3. Acute renal failure and lung disease (pulmonary renal syndrome)

- Typically, Goodpasture syndrome, disease u particles Weneger and a few other vascular inflammation. The presence of such antibodies: anti-glomerular membrane antibody, antibodies against the cytoplasm of neutrophils or white blood complement reduction in the blood to help confirm the diagnosis.

- A few cases of acute renal failure may occur in patients with renal mass circulation and pulmonary edema, or severe lung disease causing decreased cardiac output and renal acute renal failure before.

4. Acute renal failure due to rhabdomyolysis (Rhabdomyolysis)

- In the clinical encounter, this is the kidney of acute renal failure in myoglobin. Have increased creatine phosphokinase, phosphate, uric acid, potassium and creatinine levels. Featured here is blood creatinine increased rapidly compared with other clinical forms of acute renal failure. The ratio of urea / creatinine blood usually <10 and hyperkalemia common and occurs early.

- Symptoms of hypocalcaemia is very common due to increased blood phosphorus and calcium deposition in muscle, blood calcium will rise again in the early stages of recovery. About the treatment of attention when urine should increase the amount of fluids and alkali purpose of diluting urine and increases the excretion of pigment.

5. Acute renal failure in the nephrotic syndrome

Some causes of acute renal failure before kidney: decreased effective circulating volume due to diuretic use, due to low blood albumin, drain out about interstitial cause of blood condensed state. So, we return duct pressure plays an important role in the treatment of acute renal failure.

- Acute renal failure in kidney may be due to: a manifestation of primary glomerular disease, interstitial nephritis due to anti-inflammatory non-steroids, rifampin, interferon alfa male drug is toxic to the kidney, by static rules renal artery, consistent heavy interstitial held ...

- The majority of cases of acute renal failure in the nephrotic syndrome in renal function recovered well after treatment with steroids, diuretic and albumin compensation.

V. Treatment of acute renal failure

To effective treatment and bring good prognosis timely diagnosis of acute renal failure in the early stages. The blood urea and creatinine and urine volume sometimes is not good signs of acute renal failure, need to pay attention to the indicators of metabolic and biochemical analysis of urine to diagnose causes and discrimination.

1. Principles of treatment

- Quickly remove even can cause renal (kidney, after kidney): stop using the drugs toxic to the kidney or cause allergies.

- Try to recover the amount of urine.

- Conservation Treatment: water balance, electrolytes, nitrogen sources (proteins, amino acids) in and out, to ensure proper nutrition, medication adjustment, closely monitor patients to prevent and detect timely management of complications.

- Treatment to suit each stage of the disease, choosing the right time and right method of renal replacement therapy or timely transfer of patients there are qualified to diagnose and treat.

2. Specific treatment

2.1. Acute renal failure before renal

- When there are signs of dehydration most circulating blood volume to compensate (intravenous NaCl 0.9%; colloid, plasma, albumin, blood)

- If no lack of service and the risk of lagging HA can vasoactive medications and refer patients to the facility fully equipped to monitor and treat the state of shock.

2.2. Acute renal failure after kidney

- Eliminate bottlenecks (in combination therapy symptoms,): if there is need to place the catheter and bladder to find the cause of lower urinary obstruction (at the neck of the bladder, prostate, urethra). In case of high urinary obstruction (in the ureter, renal pelvis) should be considered for surgery (obtain tumor and gravel) or lithotripsy when indicated. It is possible to set up a temporary optical film pyelonephritis.

- If patients with diabetes after the cause of rules that have to be addressed cause dehydration and electrolyte needs rehydration and electrolytes.

2.3. Acute renal failure in kidneys (loss)

For acute kidney injury requiring treatment cause kidney damage and coordinate symptomatic treatment and support and monitor the progression of acute renal failure.

2.3.1. Urinating less anuria stage

The basic purpose of treatment at this stage is:

- Reduce homeostasis.

- Limit hyperkalemia.

- Limit increased blood non-protein nitrogen.


- In patients with anuria ensure balanced sound, meaning less.

- Keep in mind the amount of water lost due to vomiting, diarrhea. To calculate the amount of water generated by metabolism (about 300 ml per day). The amount of water lost through sweating, breathing about 600 ml / 24 hours.

Diuretics: furosemide group, loop diuretics to eliminate water and electrolytes, particularly potassium, only when there is no cause kidney blockage after.

- Dosage: dose must, can 200-500mg/24 hours or more depending on the level of response of the urethra. Regular starting dose is 40-80 mg. Dose high 1000mg/24 hours can be specified. Note on toxic effects on hearing of high-dose furosemide.

Can be used of dopamine dose use intravenous 1-3mg/kg/phut with the diuretic effect (but no clear evidence about the effect of reducing the time renal failure).

When hyperkalemia

- The stage renal entity must ensure that water and electrolyte balance, especially hyperkalemia condition. Select one or more treatment hypokalemia based on severity, mild hyperkalemia status.

- Restrict to potassium: potassium vegetables, medicines, fluids with potassium

- Remove the drive necrosis, infection control.

Measures can treat hyperkalemia in emergency situations including:

- Calcium (gluconate or chloride) should be used as soon as the severe manifestations of cardiovascular disorders (slow circuit, QRS widening) slow injection 0.5-2g TM in 5-10 minutes, a rapid but short . The shot can be repeated 30 minutes / time consumption depends on blood potassium levels.

Hypertonic glucose (20%, 30%, 50%) 250-500ml combine with Insulin 10 - transmission 20ui TM: start work after 15 - 30 minutes, reduce serum potassium 0.5 - 1.5 mmol / liter.

- Communication natribicarbonat: when there is a certain amount of urine (300 - 500ml/24gio), the infusion easier: You can transfer sodium bicarbonate 1.4% or 4.2% or intravenous sodium bicarbonate 8, 4% if you want to limit the amount of water added. Clearing sodium bicarbonate to help improve blood acidosis, through which K ions from the cell outside the cell. Use dose 1mEq/kg, a slow TM (works well in the case of acidosis).

- Resin ion exchange drinking: polystyrene sulfonate (Kayexalate), Resin Calcio, drinking every 15g coordinate with sorbitol can be reduced to 0.5 mmol / l. Can be diluted in 100 ml isotonic anal enema, less effect than orally applied to a number of cases where the patient is not able to drink or vomit more. Drug will work after about 1 hour.

- Continue diuretic in case of patients with diabetes, without urinary obstruction and circulatory volume reduction

- Hemodialysis: artificial kidney or peritoneal filter when persistent hyperkalemia or less responsive to the above measures

Treatment of electrolyte disorders:

- Sodium and chlorine: sodium lowering blood due to fluid retention. It is best to water restrictions. When blood potassium dropped significantly, patients with nausea, need to compensate sodium.

- Blood Calcium: rarely have hypocalcaemia. If there appears tetani by low blood calcium to calcium gluconate or calcium chloride.

Limit the increase in non-protein nitrogen of blood: mainly limited to increased blood urea:

- Diet: protein 0.4 g/kg/24gio first, enough calories least 35kcal/kg weight body enough vitamins.

- Removing of infection, avoid antibiotics toxic to the kidney (eg, aminoglycoside group), dose adjustment according to the level of glomerular as well as infection and the elimination of the drug.

Treatment of hypertension:

- High blood pressure is often caused by excess circulating volume or glomerular disease: combined dialysis, diuretics with other antihypertensive drug classes. When antihypertensive drug classes, note choices, depending on the cause of renal failure.

- When hyperkalemia using angiotensin converting enzyme inhibitors, angiotensin receptor agents resistance and the sympathetic beta-blockers, as these drugs may worsen the condition hyperkalemia.

Specify dialysis:

Should specify dialysis soon in one of the following signs:

- Persistent Hyperkalemia is not relieved by the medical treatment or serum potassium> 6.5 mmol / l.

- There are severe metabolic acidosis did not improve by the alkaline method.

- TT (hypervolemia) threatening cardiovascular complications.

- The expression brain (encelophathy) as a mental disorder caused by high blood urea syndrome, inflammation and foreign interest ceremony.

2.3.2. Management in the long term return

- At this stage, pee a lot but has not recovered renal function. These days many blood urea and creatinine in the urine is still increasing. Diabetes can cause dehydration, electrolyte loss.

- Further restrictions proteins in the food, only increases proteins when blood urea fell to safe levels (<10 mmol / 1). Only vegetables without the risk of hyperkalemia.

- Infusion or drink to prevent dehydration and electrolyte loss.

+ In the case of wet medium, just compensated by drink oresol (2 to 2.51 / 24 hours).

- When urine> 3 liters, should be compensated by the intravenous line. Transmission, depending on the quantity of urine.

+ However, if after 5-7 days have diabetes should limit the amount of fluids and monitor the patient's condition, urine output 24 hours to make appropriate service attitude because the kidneys can start rehabilitation concentrated.

- Need to closely monitor blood electrolytes, particularly sodium and potassium.

2.3.3. Management in the recovery phase

- Health patients are recovering. When blood urea returned to normal, the need to increase proteins in the diet and ensure enough calories and vitamins.

- Should pay close attention to the work of nursing care from the beginning to anti-ulcer, anti-multiple infections by lying for a long time. Medium after 4 weeks of treatment, renal function began to recover well and the patient can leave the hospital.

- Subscribe to monthly until renal function recovered completely. For the disease can become chronic (glomerular disease, interstitial nephritis caused by drugs or infection) should be examined periodically for long-term patients.

- Continue treatment causes: obstruction, primary glomerular disease, systemic disease (lupus, myelome ...)

3. The method of renal replacement therapy in acute renal failure

- The continuous dialysis techniques used to remove fluid and toxic solvents, especially in patients with acute renal failure due to poisoning that unstable hemodynamic status, increased catabolism much.

- Daily intermittent Hemodialysis can use alternative to continuous dialysis for patients with increased catabolism hemodynamic status is relatively stable.

- Dialysis interrupt routine work to remove soluble and toxic substances, is indicated for patients with no disorder of blood circulation and help prepare for the surgery address the causes of kidney failure after kidney.

- Filter peritoneum can be applied to cases of acute renal failure due to poisoning, unstable hemodynamic status, severe heart failure, and is applied to the base without dialysis conditions.

- Super slow filter can be applied to patients with excess is mainly which does not have many metabolic disorders.

- Plasma Filter (plasma exchange) applies to patients with infections, poisoning, or some autoimmune diseases causing acute renal failure, have the effect of removing the antigen-antibody complexes, antibodies saved blood, cytokines and chemical intermediates.

4. Nutrition for patients with acute renal failure

- Oral nutrition Priority if the patient can eat and drink or patients without vomiting status. Depending on each case and at each stage of acute renal failure will apply different diets. However, it should provide a diet as follows:

- Limit salt intake should be limited to 2 - 4 g Na / day, including the amount of salt in the fluid.

- Provide enough power: 30 - 50 kcal / kg / day

- Minimize the amount of potassium is usually <40 mEq / day

- Protein <0.6 g / kg / day

And Lipid 2 - 2.5 g / kg / day

- Carbs: 100g/ngay

- In the case of dialysis is not limited to nutrition, particularly when applied to continuous dialysis techniques


Of glomerular injury, renal interstitial tube depends heavily on the cause of acute renal failure and management, the vulnerability of the structure and function may include:

1. The glomerular changes

- Thickness of the membrane glomerular capillary

- The glomeruli may be hyaline or fibrosis

- Reduced glomerular filtration rate

- Increase in glomerular filtration by the glomerular healing

- Reduced clearance of inulin

- Increased blood creatinine concentration

- Reduce the urea clearance

- Increase the filtration fraction

2. The changes of renal interstitial tube

- Tubular atrophy

- Renal interstitial fibrosis

- Reduced excretion phenolsulfonphtalein

- Reduced ability to concentrate urine

3. A few other changes

- Prolonged proteinuria

- Reduce the size of the kidney

- Acute renal failure continues to evolve heavier

- Evolution of chronic renal failure in a few cases

VII. Wage

Since the 1960s, the prognosis has changed for the better, thanks to the contributions of modern resuscitation techniques. However, mortality rates remain high, in the center of artificial kidney dialysis or peritoneal filter, the mortality rate is still 20 - 40%, depending on the patient group. For patients with acute renal failure after major surgery, trauma, burns, infection of the uterus after delivery, severe poisoning potassium, very bad prognosis.

Cause of death may be due to disease, a bacterial infection, high blood urea syndrome, high blood potassium. The prognosis depends on the primary disease, resuscitation techniques, the work of nurses and other measures to prevent multiple infections especially multiple infections and lung infections from wounds, ulcers.


- Minimize the use of these drugs can be toxic to the kidneys, dose adjustment based on glomerular filtration rate

- Maintain adequate circulatory volume, cause increased urinary articles in a number of specific cases (such as heart surgery, trauma, rhabdomyolysis, haemolysis in the circuit, using the contrast dye is static line circuits, etc.).

- Resuscitation positive for the disease to trauma, early compensate enough to prevent acute renal failure before kidney.

- Addressing immediate cause of urinary obstruction is detected in order to prevent complications of acute renal failure.


- Acute renal failure is a syndrome of severe but reversible. Need for early detection of acute renal failure as the cause of acute renal failure.

- The diagnosis is mainly based on diabetes at anuria, blood urea, blood potassium increased gradually.

- Monitor urine output continuously for hours and the clinical and other tests to evaluate the daily or even hourly as: creatinine, urea, potassium, acid-base balance status.

- Treatment depends on the cause and stage, monitored and treated in time the unrest on the patient can be saved completely.

- The case of urea, potassium increased at and respond to dialysis treatment is not necessary. If blood urea increased, blood potassium or other serious complications, need time to put dialysis patients quickly from the critically contribute to reduce mortality in patients with acute renal failure.