eMedicine Specialties > Emergency Medicine > Genitourinary
Renal Failure, Acute: Follow-up
Updated: Aug 8, 2008
Follow-up
Further Inpatient Care
- Patients with acute renal failure (ARF) should generally be admitted to an inpatient setting; intensive care will be appropriate for many of them.
Transfer
- Transfer patients with significant ARF to a facility with capability for hemodialysis on a 24-hour basis.
Deterrence/Prevention
- It is important to recognize renal failure early as well as risk factors for renal injury and to avoid interventions that may iatrogenically induce renal failure.
Complications
- A vast array of fluid and electrolyte abnormalities can be seen with ARF. Refer to the appropriate articles for a more complete discussion of these disorders (see Hypercalcemia and Hyperkalemia).
- Cardiovascular complications (eg, CHF, myocardial infarction, arrhythmias, cardiac arrest) have been observed in as many as 35% of patients with ARF. Fluid overload secondary to oliguric ARF is a particular risk for elderly patients with little cardiac reserve.
- Pericarditis is a relatively rare complication of ARF. When pericarditis complicates ARF, consider additional diagnoses, such as SLE and hepatorenal syndrome.
- ARF also can be a complication of cardiac diseases, such as endocarditis, worsening CHF, or atrial fibrillation with emboli.
- Cardiac arrest in a patient with ARF always should arouse suspicion of hyperkalemia. Many authors recommend a trial of intravenous calcium chloride (or gluconate) in all patients with ARF who experience cardiac arrest.
- Pulmonary complications have been reported in approximately 54% of patients with ARF. Pulmonary complications are the single most significant risk factor for death in patients with ARF.
- Several diseases exist that commonly present with simultaneous pulmonary and renal involvement, including pulmonary/renal syndromes (eg, Goodpasture syndrome, Wegener granulomatosis, polyarteritis nodosa, cryoglobulinemia, sarcoidosis).
- Hypoxia commonly occurs during hemodialysis and can be particularly significant in the patient with pulmonary disease. This dialysis-related hypoxia is thought to occur secondary to WBC lung sequestration and alveolar hypoventilation.
- GI symptoms of nausea, vomiting, and anorexia are frequent complications of ARF and represent one of the cardinal signs of uremia.
- GI bleeding occurs in approximately one third of patients with ARF. Most episodes are mild, but GI bleeding accounts for 3-8% of deaths in patients with ARF.
- Mild hyperamylasemia (2-3 times controls) commonly is seen in ARF. Elevation of baseline amylase can complicate diagnosis of pancreatitis in patients with ARF.
- Lipase, which commonly is not elevated in ARF, often is necessary to make the diagnosis of pancreatitis. Pancreatitis has been reported as a concurrent illness with ARF in patients with atheroemboli, vasculitis, and sepsis from ascending cholangitis.
- Jaundice has been reported to complicate ARF in approximately 43% of cases. Etiologies of jaundice with ARF include hepatic congestion, blood transfusions, and sepsis.
- Hepatitis occurring concurrently with ARF should prompt the differential diagnosis of common bile duct obstruction, fulminant hepatitis B, leptospirosis, acetaminophen toxicity, and Amanita phalloides toxin.
- Infections commonly complicate the course of ARF and have been reported to occur in as many as 33% of patients with ARF. Most common sites are pulmonary and urinary tracts. Infections are the leading cause of morbidity and death in patients with ARF. Various studies have reported mortality rates of 11-72% in infections complicating ARF.
- Neurologic signs of uremia are a common complication of ARF and have been reported in approximately 38% of patients with ARF.
- Neurologic sequelae include lethargy, somnolence, reversal of the sleep-wake cycle, and cognitive or memory deficits.
- Focal neurologic deficits rarely are due solely to uremia and should remain a diagnosis of exclusion in patients with ARF.
- Pathophysiology of neurologic symptoms is still unknown but they do not correlate well to levels of BUN or creatinine. A number of diseases express themselves with concurrent neurologic and renal manifestations (eg, SLE, TTP, HUS, endocarditis, malignant hypertension).
Prognosis
- Mortality rates from ARF remain 50%, despite the institution of effective renal replacement therapies.
- Deaths from ARF are related directly to the patient's underlying disease process (eg, sepsis, CHF).
- Mortality rates in patients older than 80 years are approximately 40%, very similar to those in younger patients. Age should not be a determining factor in instituting renal replacement therapy.
- Approximately 20–60% of patients experiencing ARF require dialysis during their hospital stay. The majority of these patients recover, with only 25% requiring long-term renal replacement therapy.
Patient Education
- Stress to patients that progressive renal failure is a silent disease. Symptoms of uremia occur only with advanced, generally irreversible renal failure. The only way for patients to reliably follow the course of their disease is by regular checkups with their physicians.
- For excellent patient education resources, see eMedicine's Diabetes Center. Also, visit eMedicine's patient education article, Acute Kidney Failure.
Miscellaneous
Medicolegal Pitfalls
- Failing to consider ARF: Normal-range BUN and creatinine levels do not reliably rule out the diagnosis of ARF. Patients with low muscle mass and/or vegetarians may have significant decreases in GFR and still remain in normal ranges for BUN and creatinine. Comparison with baseline values and trends are more important than absolute numerical values.
- Most cases of ARF in inpatients are secondary to iatrogenic causes. Be especially careful in prescribing potential nephrotoxins (eg, radiocontrast agents, aminoglycosides, NSAIDs) to patients predisposed to ARF (eg, dehydration, CHF, diabetes mellitus, chronic renal failure, elderly patients).
More on Renal Failure, Acute |
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| Treatment & Medication: Renal Failure, Acute |
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| References |
| « Previous Page |
References
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Further Reading
Keywords
ARF, acute kidney failure, renal failure, decrease in glomerular filtration rate, decrease in GFR, community-acquired ARF, hospital-acquired ARF, dialysis, oliguric ARF, nonoliguric ARF, prerenal ARF, newborn respiratory distress syndrome, intrinsic ARF, acute tubular necrosis, ATN, acute glomerulonephritis, postrenal ARF, hypovolemia, gastroenteritis, hemolyticuremicsyndrome, HUS, O157:H7, microangiopathic anemia, acute poststreptococcal glomerulonephritis, cardiac failure, nephritic syndrome, nephrotoxins, rhabdomyolysis
allergic interstitial nephritis, prostatic obstruction, diabetes mellitus, hypertension, Goodpasture syndrome, Wegener granulomatosis, renal arterial stenosis, systemic lupus erythematosus, SLE, sarcoidosis, lymphoma
Legionnaire disease, hantavirus, polyarteritis nodosa, retroperitoneal fibrosis, benign prostatic hypertrophy, colorectal carcinoma, bladder hematoma, bladder stone, neurogenic bladder, urinary obstruction
