eMedicine Specialties > Emergency Medicine > Genitourinary

Renal Failure, Acute: Follow-up

Author: Peter R Peacock Jr, MD, Director of Information and Systems, Department of Emergency Medicine, Kings County Hospital; Informatics Director, EM Physicians of Brooklyn
Coauthor(s): Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Contributor Information and Disclosures

Updated: Dec 8, 2009

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 acute renal failure (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

Overview: Renal Failure, Acute
Differential Diagnoses & Workup: Renal Failure, Acute
Treatment & Medication: Renal Failure, Acute
Follow-up: Renal Failure, Acute
References
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References

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Further Reading

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Keywords

acute renal failure, acute renal failure symptoms, acute renal failure causes, acute renal failure treatment, ARF, acute kidney failure, community-acquired ARF, hospital-acquired ARF, dialysis, prerenal ARF, acute tubular necrosis, acute glomerulonephritis

gastroenteritis, hemolytic uremic syndrome, HUS, microangiopathic anemia, acute poststreptococcal glomerulonephritis, cardiac failure, nephritic syndrome, bladder hematoma, bladder stone, neurogenic bladder, urinary obstruction

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Contributor Information and Disclosures

Author

Peter R Peacock Jr, MD, Director of Information and Systems, Department of Emergency Medicine, Kings County Hospital; Informatics Director, EM Physicians of Brooklyn
Peter R Peacock Jr, MD is a member of the following medical societies: American College of Emergency Physicians, Physicians for Social Responsibility, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Joseph A Salomone III, MD, EMS Medical Director, Kansas City, Missouri; Associate Professor and Staff Physician, Truman Medical Centers/UMKC School of Medicine
Joseph A Salomone III, MD is a member of the following medical societies: American Academy of Emergency Medicine, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH, Professor and Chair, Department of Emergency Medicine, University of Virginia Health System
Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

 
 
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