Kidney Failure

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What is Kidney Failure?

Kidney Failure, also known as Renal Failure, is a condition in which the kidneys are functioning less than 10-15% of their normal capacity. It is a stage of kidney disease in which the kidneys can no longer function either without dialysis or the individual requires a kidney transplant. This can be rapidly progressive or may occur over time and is usually secondary to other underlying medical conditions.

Alternate names

  • End-Stage Kidney Disease
  • End-Stage Renal Disease

Is the Kidney Failure condition a Medical emergency?

Kidney Failure is a medical emergency and requires prompt medical attention.

Types

Kidney Failure may be classified as,

  • Acute Kidney Failure: It is rapidly progressive and can be further classified as
    • Pre-Renal - it is caused by conditions that lead to a decrease in the blood flow to the kidneys.
    • Intrinsic or Renal- it is caused by conditions that directly damage the kidneys.
    • Post-Renal- it is caused by conditions that cause an obstruction to the flow of urine from the kidneys.
  • Chronic Kidney Failure: It progresses slowly over time, and may not show any symptoms initially
  • Acute on Chronic Kidney Failure: This can occur over pre-existing chronic kidney failure

Causes

Kidney Failure is caused when the kidneys are damaged due to underlying medical conditions or other environmental or genetic factors. Some of these include:

  • Acute Kidney Failure:
    • Causes of Pre-Renal Acute Renal Failure:
      • Low blood volume - dehydration, diuretics, burns, vomiting and diarrhea, bleeding, major surgery, pancreatitis
      • Cardiac Disease - Heart attack, heart failure, severe heart valve disease, low blood pressure
      • Infections - Sepsis
      • Medication & Drugs - Anesthetics, NSAIDs, radio-contrast agents, amphotericin B, norepinephrine, calcineurin inhibitors
      • Allergic reactions - Anaphylaxis
      • Organ failure - liver failure, heart failure
      • Vascular - Renal artery stenosis, renal vein thrombosis
    • Causes of Intrinsic Acute Renal Failure:
      • Vascular - plaques and clots in renal arteries and veins, Disseminated Intravascular coagulation
      • Infections - Pyelonephritis, viral nephritis, sepsis
      • Drugs - Penicillin, NSAIDs, cephalosporins, chemotherapeutic agents, sulfonamides, rifampicin, radio-contrast agents, proton pump inhibitors, etc
      • Glomerular disease - glomerulonephritis
      • Heme Pigment buildup - Muscle tissue breakdown (rhabdomyolysis), intravascular hemolysis, hemolytic uremic syndrome
      • Crystal deposit and buildup - tumor lysis syndrome (seen in some cancers)
      • Poisoning - Alcohol poisoning, vitamin C overdose, heavy metal poisoning
      • Systemic disease - Sjogren’s syndrome, Sarcoidosis, Lupus, lymphoma, leukemia, scleroderma
    • Causes of Post-Renal Acute Renal Failure:
      • Ureteric obstruction - Stone disease, tumor, fibrosis, ligation during pelvic surgery
      • Bladder neck obstruction - Benign prostatic hypertrophy (BPH), cancer of the prostate, neurogenic bladder, drugs such as tricyclic anti-depressants, bladder tumor, and stones
      • Urethral obstruction - Strictures, tumor, phimosis
      • Renal vein thrombosis
  • Chronic Kidney Failure:
    • Diabetes mellitus
    • Long term uncontrolled hypertension
    • Polycystic kidney disease
    • Medications – such as ibuprofen, paracetamol
    • Infections with Hantavirus

Risk factors

The risk factors for developing Kidney Failure include the following:

  • Serious medical conditions that require hospitalization and intensive care
  • Elderly age group
  • Peripheral artery disease
  • Diabetes
  • High blood pressure
  • Heart failure and severe heart valve disease
  • Kidney diseases
  • Liver diseases
  • Certain cancers and chemotherapy

Symptoms & signs

The signs and symptoms of Kidney Failure may present rapidly as in acute kidney failure or may present slowly over time as in chronic kidney failure. They may include:

  • Nausea and vomiting
  • Loss of appetite and weight loss
  • Tiredness
  • Increased frequency of urination and increased urination at night
  • Either low urine output or excessive urine output
  • Blood in urine
  • Frothy urine
  • Itching
  • Muscle cramps
  • Back pain
  • Swelling of the hands, legs, ankles, feet, and face
  • Shortness of breath
  • Abnormal heart rhythms
  • Low blood pressure
  • Muscle paralysis
  • Dizziness
  • Seizures
  • Loss of concentration and memory loss
  • Disturbed sleep

Investigations

Some investigations that are advised for the evaluation of Kidney Failure include:

  • Measurement of urine output - the amount of urine passed in 24 hours is measured
  • Complete urine examination - a complete examination of the urine including cells, albumin/protein, sugars, blood, etc is done
  • Blood tests and Renal function tests- to measure the levels of urea, nitrogen, Creatinine, and eGFR
  • Imaging tests - ultrasound and CT scan of the abdomen may be required
  • Kidney biopsy - biopsy to obtain a sample of kidney tissue may be required in some cases

Diagnosis

A diagnosis of Kidney Failure is established based on medical history, clinical evaluation, and results of investigations done.

Course & Stages

Acute Kidney Failure can progress very rapidly and is staged as follows:

  • Risk - If the Serum Creatinine levels have increased by 1.5 times, or the eGFR has dropped by 25%, or the urine output is less than 0.5ml/kg/hour for 6 hours
  • Injury - If the Serum Creatinine levels have increased by 2 times, or the eGFR has dropped by 50%, or the urine output is less than 0.5ml/kg/hour for 12 hours
  • Failure - If the Serum Creatinine levels have increased by 3 times, or the eGFR has dropped by 75%, or the urine output is less than 0.3ml/kg/hour for 24 hours, or anuria (no urine output) for 12 hours
  • Loss - No kidney function for 4 weeks, and requiring renal replacement therapy
  • End-Stage Kidney Disease - Complete loss of kidney function and requiring renal replacement therapy for 3 months

Chronic Kidney Failure progresses slowly and is staged as follows:

  • Stage I – mildly reduced kidney function with no apparent symptoms and eGFR over 90
  • Stage II – mild kidney damage with minimal symptoms, and eGFR between 60-89
  • Stage III – moderate damage to kidney and eGFR between 30-59
    • Stage IIIa – eGFR between 45-59
    • Stage IIIb – eGFR between 30-44
  • Stage IV – moderate to severe damage to kidney function, and eGFR is between 15-29
  • Stage V – there is severe loss of kidney function, or the kidneys have already failed, and eGFR is less than 15

Treatment options

The treatment of Kidney Failure depends on identifying the underlying cause of Kidney Failure as well as the type and stage of Kidney Failure and aims at restoring the function of the kidneys at the earliest and preventing further kidney damage.

Medical management

The medical management of Kidney Failure depends on the cause and may include the following:

  • Replacement of fluids - IV administration of fluids is done as long as there is no fluid overload
  • Diuretics - such as furosemide may be administered either to help with low blood pressure or to remove excess fluid from the body,
  • Polystyrene Sulfonate - may be administered to control the levels of potassium, as high levels may cause irregular heartbeats and muscle spasms
  • Calcium Infusion - IV calcium infusion may be done if the serum calcium levels are low

In addition, stopping medication or drugs that are causing kidney damage, and starting medications or drugs such as steroids or cyclophosphamide to help with the management of vasculitis or glomerulonephritis may also be done.

Interventional including surgery and indications for surgery

The following interventional procedures may be done:

  • Placement of a central venous catheter - a central venous catheter may be placed to assess the volume status of body fluids, to avoid over or under replacement
  • Dialysis or Renal Replacement Therapy - may be required to remove the excess fluid, toxins, or potassium from the body. This may be done either intermittently or continuously until the kidney function improves.
  • Catheterization - A catheter may need to be put in place if the cause of failure is due to an obstruction or if the bladder function is affected
  • Kidney transplantation – is the last resort when all other measures fail to improve kidney function

In addition, if the cause of failure is due to an obstruction to the outflow of urine, and surgical intervention is required to remove the obstruction then surgical procedures such as a nephrostomy may be done.

Role of diet/ Exercise/ Lifestyle changes/ Preventive measures

Eating a healthy diet and maintaining a healthy lifestyle are important in the prevention of kidney disease. The following may help to reduce the risk of Kidney Failure:

  • Keeping diabetes and high blood pressure under control
  • Eating a diet that is low fat and low salt
  • Exercising and maintaining an ideal body weight
  • Avoiding unnecessary and unadvised use of painkillers and over the counter medications for pain relief
  • Moderating the intake of alcohol

Complications

The complications of Kidney Failure may include:

  • Fluid overload and Fluid build-up - fluid accumulation in the lungs can occur leading to pulmonary edema and shortness of breath
  • Chest pain and discomfort
  • Muscular weakness - the altered electrolyte and fluid imbalance can lead to extreme muscular weakness
  • Metabolic acidosis
  • Permanent Kidney damage

Prognosis

The prognosis for Kidney Failure depends on the underlying cause and the type of Kidney Failure that is present. Early identification, management, and prevention can help to improve the prognosis in chronic kidney failure. The prognosis for acute renal failure is poor, and the death rate is very high, especially in individuals who develop it after major surgeries on the heart or abdomen. Permanent kidney damage is also very high after acute kidney failure and a lot of individuals would require lifelong renal replacement therapy or dialysis, thus affecting their quality of life.

When to contact the doctor or hospital? / How to identify the emergency or complications?

Acute renal failure is a condition that requires immediate medical attention, it is therefore very important to contact a doctor as soon as the symptoms and signs of acute kidney failure are seen, especially reduced urine output, shortness of breath, irregular heartbeat, confusion, and weakness.

Indications for hospitalization if required

Depending on the type of Kidney Failure that is present, hospitalization may be required. Acute kidney failure almost always requires hospitalization.

Suggested clinical specialist/ Department to consult for this condition

  • Nephrology
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