SIU School of Medicine

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Department of Internal Medicine

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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