Acute Renal Failure
Prerequisites
Prior knowledge and skills during the preclinical years should include:
- Knowledge of drugs that can have adverse effect on renal function.
- ability to interpret an urinalysis.
Knowledge
Students should be able to:
- define and describe Acute Renal Failure (ARF) and be able to distinguish between the three major pathophysiologic etiologies for ARF:
- decreased renal perfusion (pre-renal)
- intrinsic renal disease (renal)
- acute renal obstruction (post-renal)
- bladder outlet obstruction (prostatic hypertrophy)
- stone, thrombus or tumor in ureter
- distinguish major pathophysiologic etiologies of “pre-renal” ARF, including:
- hypovolemia
- decreased cardiac output (CHF, tamponade)
- systemic vasodilation (sepsis)
- renal vasoconstriction
- distinguish major pathophysiologic etiologies of intrinsic “renal” ARF, including:
- vascular lesions
- TTP
- Hemolytic-Uremic Syndrome
- DIC
- Malignant hypertension
- Renal vein thrombosis
- glomerular lesions
- interstitial nephritis
- drugs, infection
- intra-tubule deposition/obstruction
- crystals, protein
- actue tubular necrosis
- ischemia (severe ? RBF)
- toxins (dye, aminoglycosides, amphotericin B, metals, acetaminophen, platinum)
- pigments
- discuss the natural history, initial evaluation and treatment and complications of ARF.
Skills
Students should demonstrate specific skills, including:
- History-Taking Skills: By the end of the clerkship students should be able to obtain, document, and present an age-appropriate history, that distinguishes among the three major reasons for ARF (pre-renal, renal, post-renal), including:
- pre-disposing conditions
- nephrotoxic drugs or agents
- systemic disease
- Physical Exam Skills: Students should be able to perform a physical examination to aid in the diagnosis and etiology of ARF, including:
- the determination of a patient’s volume status through estimation of the central venous pressure using the height of jugular venous distention and measurement of pulse and blood pressure in the standing position
- palpation and percussion of the bladder to recognize bladder distention
- palpation of the prostate
- examination for evidence of systemic disease, including:
- skin, joints and nails
- Laboratory Interpretation: Students should be able to perform and interpret a urinalysis, including:
- the recognition of casts, red blood cells, white blood cells and crystals
- calculate fractional excretion of sodium and appreciate its usefulness in distinguishing between pre-renal and intrinsic renal disease
- calculate creatinine clearance
- interpret the results of renal ultrasonography
Students should be able to recommend when each of these tests should be ordered.
- Management Skills: Students should be able to design an appropriate management plan for initial management of ARF, including:
- discontinuing renal toxins
- volume management
- dietary recommendations
- drug dosage alterations
- electrolyte monitoring
- indications for acute dialysis (fluid overload, hyperkalemia, acidosis, complications of uremia – altered mental status, bleeding, pericarditis, myopathy)
Resources
- Internal Medicine Clerkship Guide, Paauw, et al, Mosby 2003, 388-395
- Clerkship Seminar, “Acute Renal Failure”, Lawrence Smith, MD
- “Acute Oliguria”, Saulo Klahr, MD and Steven B. Miller, MD, The New England Journal of Medicine, 1998, Volume 338, Number 10, 671-675 (Clerkship Website Weekly Articles, Week 6)
- "Diagnosis and Treatment of Acute Tubular Necrosis", Matthew L. Esson, MD, and Robert W. Schrier, MD, Ann Intern Med. 2002;137:744-752
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