ACUTE RENAL FAILURE

LEARNING OBJECTIVES:

KNOWLEDGE - Students should be able to describe the:

1. Compare and contrast the distinction between the three major pathophysiologic etiologies for acute renal failure (ARF) based on history, urinalysis, urine studies, and radiologic imaging:
   1. Decreased renal perfusion (prerenal)
      1. Hypovolemia
      2. Decreased cardiac output
      3. Systemic vasodilation
      4. Renal vasoconstriction
   2. Intrinsic renal disease (renal)
      1. Vascular lesions
      2. Glomerular lesions
      3. Interstitial nephritis
      4. Intra-tubule depositions/obstruction
      5. Acute tubular necrosis (ATN)
   3. Acute renal obstruction (postrenal)
      1. Urethral (e.g. tumors, calculi, clot, sloughed papillae, retroperitoneal fibrosis, lymphadenopathy)
      2. Bladder neck (e.g. tumors, calculi, prostatic hypertrophy or carcinoma, neurogenic)
      3. Urethral (e.g. stricture, tumors, obstructed indwelling catheters)
2. Describe the metabolic consequences of significant reductions in renal function.
3. Describe the indications for dialysis.
4. Calculate fractional excretion of sodium and apply it to distinguish between pre-renal and intrinsic renal disease.
5. Develop appropriate initial management plan for acute renal failure including volume management, dietary recommendations, drug dosage alterations, electrolyte monitoring, and indications for dialysis.
6. Interpret a urinalysis, including microscoipc examination for casts, red blood cells, white blood cells, and crystals (note overlap with Renal Tests).
7. Calculate the anion gap and generate a differential diagnosis for metabolic acidosis (note overlap with acid base disorders).
8. Identify risk factors for contrast-induced nephropathy and recommend steps to prevent this complication.

PATIENT CARE SKILLS:

1. History:   Students should be able to assess:

• baseline renal functional status
• family history of renal disease
• potential nephrotoxin exposure
• for co-morbid conditions which may cause renal disease

2. Physical exam:   Students should be able to evaluate:
   • volume status
   • effective arterial circulating volume
   • clinical signs and symptoms of uremia
     
3. Differential Diagnosis:   Students should be able to differentiate:

• acute vs chronic renal failure
• prerenal vs parenchymal vs post renal obstruction

4. Laboratory Findings:   Students should be able to interpret:

• urine lytes
• creatinine clearance
• spot urine protein: creatinine ratio
• urinalysis
• renal ultrasound
• renal biopsy

5. Communication Skills:   Students should be able to:

• provide patient education
• discuss end of life issues
• take into consideration each patient's psychosocial status
• develop effective doctor-patient communication skills

6. Procedure Skills:    Students should become proficient at:

• IV placement
• arterial blood gas
• Foley placement

7. Management Skills: - Students should be able to manage:

• drug dosing adjustments
• renal dietary restriction
• volume states
• electrolyte imbalance
• acid-base disturbances
• intoxications

 

ATTITUDES AND PROFESSIONAL BEHAVIORS :

1. Demonstrate respect for the patient.
2. Attend to and advocate for the patient's interests and needs in a manner appropriate to the student's role.
3. Recognize the importance of allowing terminally ill patients to die with comfort and dignity.

REFERENCES:

1. Albright, R.   Acute Renal Failure:   A Practical Update.   Mayo Clniic Proceedings.   Vol 76(1).   Jan 2001.   pp67-74