Acute Kidney Failure

Acute kidney failure occurs when illness, infection, or injury damages the kidneys. Temporarily, the kidneys cannot adequately remove fluids and wastes from the body or maintain the proper level of certain kidney-regulated chemicals in the bloodstream.

Description

The kidneys are the body's natural filtration system. They perform the critical task of processing approximately 200 quarts of fluid in the bloodstream every 24 hours. Waste products like urea and toxins, along with excess fluids, are removed from the bloodstream in the form of urine. Kidney (or renal) failure occurs when kidney functioning becomes impaired. Fluids and toxins begin to accumulate in the bloodstream. As fluids build up in the bloodstream, the patient with acute kidney failure may become puffy and swollen (edematous) in the face, hands, and feet. Their blood pressure typically begins to rise, and they may experience fatigue and nausea.

Unlike chronic kidney failure, which is long term and irreversible, acute kidney failure is a temporary condition. With proper and timely treatment, it can typically be reversed. Often there is no permanent damage to the kidneys. Acute kidney failure appears most frequently as a complication of serious illness, like heart failure,liver failure, dehydration, severe burns, and excessive bleeding (hemorrhage). It may also be caused by an obstruction to the urinary tract or as a direct result of kidney disease, injury, or an adverse reaction to a medicine.

Causes and symptoms

Acute kidney failure can be caused by many different illnesses, injuries, and infections. These conditions fall into three main categories: prerenal, postrenal, and intrarenal conditions.

Prerenal conditions do not damage the kidney, but can cause diminished kidney function. They are the most common cause of acute renal failure, and include:

• dehydration
• hemorrhage
• septicemia, or sepsis
• heart failure
• liver failure
• burns

Postrenal conditions cause kidney failure by obstructing the urinary tract. These conditions include:

• inflammation of the prostate gland in men (prostatitis)
• enlargement of the prostate gland (benign prostatic hypertrophy)
• bladder or pelvic tumors
• kidney stones (calculi)

Intrarenal conditions involve kidney disease or direct injury to the kidneys. These conditions include:

• lack of blood supply to the kidneys (ischemia)
• use of radiocontrast agents in patients with kidney problems
• drug abuse or overdose
• long-term use of nephrotoxic medications, like certain pain medicines
• acute inflammation of the glomeruli, or filters, of the kidney (glomerulonephritis)
• kidney infections (pyelitis or pyelonephritis)

Common symptoms of acute kidney failure include:

• anemia. The kidneys are responsible for producing erythropoietin (EPO), a hormone that stimulates red blood cell production. If kidney disease causes shrinking of the kidney, red blood cell production is reduced, leading to anemia.
• bad breath or bad taste in mouth. Urea in the saliva may cause an ammonia-like taste in the mouth.
• bone and joint problems. The kidneys produce vitamin D, which helps the body absorb calcium and keeps bones strong. For patients with kidney failure, bones may become brittle. In children, normal growth may be stunted. Joint pain may also occur as a result of high phosphate levels in the blood. Retention of uric acid may cause gout.
• edema. Puffiness or swelling in the arms, hands, feet, and around the eyes.
• frequent urination.
• foamy or bloody urine. Protein in the urine may cause it to foam significantly. Blood in the urine may indicate bleeding from diseased or obstructed kidneys, bladder, or ureters.
• headaches. High blood pressure may trigger headaches.
• hypertension, or high blood pressure. The retention of fluids and wastes causes blood volume to increase. This makes blood pressure rise.
• increased fatigue. Toxic substances in the blood and the presence of anemia may cause the patient to feel exhausted.
• itching. Phosphorus, normally eliminated in the urine, accumulates in the blood of patients with kidney failure. An increased phosphorus level may cause the skin to itch.
• lower back pain. Patients suffering from certain kidney problems (like kidney stones and other obstructions) may have pain where the kidneys are located, in the small of the back below the ribs.
• nausea. Urea in the gastric juices may cause upset stomach.

Diagnosis

Kidney failure is diagnosed by a doctor. A nephrologist, a doctor that specializes in the kidney, may be consulted to confirm the diagnosis and recommend treatment options. The patient that is suspected of having acute kidney failure will have blood and urine tests to determine the level of kidney function. A blood test will assess the levels of creatinine, blood urea nitrogen (BUN), uric acid, phosphate, sodium, and potassium. The kidney regulates these agents in the blood. Urine samples will also be collected, usually over a 24-hour period, to assess protein loss and/or creatinine clearance.

Determining the cause of kidney failure is critical to proper treatment. A full assessment of the kidneys is necessary to determine if the underlying disease is treatable and if the kidney failure is chronic or acute. X rays, magnetic resonance imaging (MRI), computed tomography scan (CT), ultrasound, renal biopsy, and/or arteriogram of the kidneys may be used to determine the cause of kidney failure and level of remaining kidney function. X rays and ultrasound of the bladder and/or ureters may also be needed.

Treatment

Treatment for acute kidney failure varies. Treatment is directed to the underlying, primary medical condition that has triggered kidney failure. Prerenal conditions may be treated with replacement fluids given through a vein, diuretics, blood transfusion, or medications. Postrenal conditions and intrarenal conditions may require surgery and/or medication.

Frequently, patients in acute kidney failure require hemodialysis, hemofiltration, or peritoneal dialysis to filter fluids and wastes from the bloodstream until the primary medical condition can be controlled.

Hemodialysis

Hemodialysis involves circulating the patient's blood outside of the body through an extracorporeal circuit (ECC), or dialysis circuit. The ECC is made up of plastic blood tubing, a filter known as a dialyzer (or artificial kidney), and a dialysis machine that monitors and maintains blood flow and administers dialysate. Dialysate is a sterile chemical solution that is used to draw waste products out of the blood. The patient's blood leaves the body through the vein and travels through the ECC and the dialyzer, where fluid removal takes place.

During dialysis, waste products in the bloodstream are carried out of the body. At the same time, electrolytes and other chemicals are added to the blood. The purified, chemically-balanced blood is then returned to the body.

A dialysis "run" typically lasts three to four hours, depending on the type of dialyzer used and the physical condition of the patient. Dialysis is used several times a week until acute kidney failure is reversed.

Blood pressure changes associated with hemodialysis may pose a risk for patients with heart problems. Peritoneal dialysis may be the preferred treatment option in these cases.

Hemofiltration

Hemofiltration, also called continuous renal replacement therapy (CRRT), is a slow, continuous blood filtration therapy used to control acute kidney failure in critically ill patients. These patients are typically very sick and may have heart problems or circulatory problems. They cannot handle the rapid filtration rates of hemodialysis. They also frequently need antibiotics, nutrition, vasopressors, and other fluids given through a vein to treat their primary condition. Because hemofiltration is continuous, prescription fluids can be given to patients in kidney failure without the risk of fluid overload.

Like hemodialysis, hemofiltration uses an ECC. A hollow fiber hemofilter is used instead of a dialyzer to remove fluids and toxins. Instead of a dialysis machine, a blood pump makes the blood flow through the ECC. The volume of blood circulating through the ECC in hemofiltration is less than that in hemodialysis. Filtration rates are slower and gentler on the circulatory system. Hemofiltration treatment will generally be used until kidney failure is reversed.

Peritoneal dialysis

Peritoneal dialysis may be used if an acute kidney failure patient is stable and not in immediate crisis. In peritoneal dialysis (PD), the lining of the patient's abdomen, the peritoneum, acts as a blood filter. A flexible tube-like instrument (catheter) is surgically inserted into the patient's abdomen. During treatment, the catheter is used to fill the abdominal cavity with dialysate. Waste products and excess fluids move from the patient's bloodstream into the dialysate solution. After a certain time period, the waste-filled dialysate is drained from the abdomen, and replaced with clean dialysate. There are three type of peritoneal dialysis, which vary according to treatment time and administration method.

Peritoneal dialysis is often the best treatment option for infants and children. Their small size can make vein access difficult to maintain. It is not recommended for patients with abdominal adhesions or other abdominal defects (like a hernia) that might reduce the efficiency of the treatment. It is also not recommended for patients who suffer frequent bouts of an inflammation of the small pouches in the intestinal tract (diverticulitis).

Prognosis

Because many of the illnesses and underlying conditions that often trigger acute kidney failure are critical, the prognosis for these patients many times is not good. Studies have estimated overall death rates for acute kidney failure at 42-88%. Many people, however, die because of the primary disease that has caused the kidney failure. These figures may also be misleading because patients who experience kidney failure as a result of less serious illnesses (like kidney stones or dehydration) have an excellent chance of complete recovery. Early recognition and prompt, appropriate treatment are key to patient recovery.

Up to 10% of patients who experience acute kidney failure will suffer irreversible kidney damage. They will eventually go on to develop chronic kidney failure or end-stage renal disease. These patients will require longterm dialysis or kidney transplantation to replace their lost renal functioning.

Prevention

Since acute kidney failure can be caused by many things, prevention is difficult. Medications that may impair kidney function should be given cautiously. Patients with pre-existing kidney conditions who are hospitalized for other illnesses or injuries should be carefully monitored for kidney failure complications. Treatments and procedures that may put them at risk for kidney failure (like diagnostic tests requiring radiocontrast agents or dyes) should be used with extreme caution.