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Kidney: acute renal failure
Introduction
- Syndrome with abrupt deterioration in renal function.
- Cause: toxins/drugs, infection, renal ischemia.
- Signs: uremia, oliguria (in most cases), anuria or polyuria (less commonly), dehydration, lethargy.
- Treatment: prompt treatment to limit renal damage.
- Prognosis: guarded, depending on unerlying cause; mortality may be high and extensive renal damage may result in chronic renal failure.
Presenting signs
- Acute uremia Uremia:
- Vomiting.
- Diarrhea.
- Anorexia.
- Lethargy.
- Oliguria (<0.5 ml/kg/h).
- Oral ulceration, appears in 3-5 days.
- Anuria.
- Polyuria (>2 ml/kg/h) in mild cases or in recovery phase.
- Abdominal pain in sublumbar region (depending on etiology).
- Uremic encephalopathy (seizures) in very advanced cases.
- Uremic pneumonitis (respiratory distress).
Acute presentation
- Anuria.
- Uremic crisis.
Geographic incidence
- Leptospirosis is a cause of acute renal failure which has a geographical influence, eg Long Island of New York state in America.
- Ethylene glycol toxicity Ethylene glycol poisoning more common in colder climates.
Cost considerations
- If the owner can afford hemodialysis, it may improve survival and recovery rate. It is very expensive.
- Intensive fluid therapy and monitoring is moderate to expensive.
- Acute renal failure is rarely responsive to inexpensive therapy.
Special risks
Anesthesia
- Hyperkalemia Hyperkalemia and metabolic acidosis (pH <7.1) Acid base imbalance can cause severe cardiac problems and exacerbate neurological signs.
- Overdosage of drugs, since most drugs have some degree of renal clearance.
Pathogenesis
Etiology
Acute tubular necrosis
- Toxins:
- Ethylene glycol Ethylene glycol poisoning .
- Antibiotics:aminoglycosides (neomycin Neomycin, gentamycin Gentamicin), polymixin B Polymyxin B, sulfonamides Trimethoprim, tetracycline Tetracycline.
- Amphotericin B Amphotericin B.
- Mercury.
- NSAIDs (especially in dehydrated animal) Analgesia: NSAID.
- Doxorubicin Doxorubicin.
- Plants Poisonous Plants: lilies Lilies (Lilium and Hemerocallis species) (easter lily, day lily, tiger lily, Japanese show lily and rubrum lily); night blooming jessamine, Solanum malacoxylon.
- Grapes, raisins.
- Infection:
- Bacterial (pyelonephritis) Pyelonephritis.
- Viral (FIP Feline immunodeficiency virus disease).
- Endotoxemia, eg E coli infection.
- Acute glomerulonephritis Glomerulonephritis.
- Renal lymphoma Kidney: neoplasia.
Pre-renal ARF
- Renal ischemia:
- Prolonged dehydration.
- Hypovolemic shock.
- Hemorrhage/trauma.
- Renal vessel thromboembolism Thromboembolism: aorta.
- Anesthesia/surgery.
- Diuretics/vasodilators.
- Hemoglobinuria/myoglobinuria.
- Vasculitis.
- Pancreatitis Pancreatitis or other causes of systemic inflammatory response syndrome Systemic inflammatory response syndrome (SIRS).
Post-renal ARF
- Urolithiasis Urolithiasis.
- Neoplasia Urethra: neoplasia.
- Feline lower urinary tract disease Feline lower urinary tract disease (FLUTD).
- Ureteric ligation.
Predisposing factors
General
- Pre-existing renal damage with additional insult, eg reduced renal perfusion.
- Any cause of reduced renal blood flow.
Specific
- Anesthesia, especially without appropriate blood pressure monitoring and IV fluid support.
- Chemotherapy with cisplatin.
- Access to antifreeze (ethylene glycol).
- Misuse of NSAIDs, aminoglycosides, diuretics or vasodilators.
Pathophysiology
Four phases
- Initiation phase (renal insult resulting in damage to renal parenchyma; injury potentially reversible at this stage; hours to 1-2 days).
- Extension phase (ongoing cellular injury progressing to cell death, with progressive decline in GFR and loss of urine concentrating ability).
- Maintenance phase (elimination of inciting factors at this stage does not alter existing damage or rate of recovery; signs of uremia may be present; a prolonged maintenance phase is associated with slower recovery and increased likelihood of permanently reduced renal function).
- Recovery phase (progressive return of renal function).
- Reduced renal blood flow → reduced oxygen and energy transport to cells → cell swelling and membrane damage → vasoconstriction and inflammatory mediator release → further vasoconstriction.
- Nephrons are damaged at different sites (glomerulus, tubular cell, intercellular junction, basement membrane) depending on etiology → acute decline in glomerular filtration rate → increased urea/creatinine, decrease in urine specific gravity → uremic signs, oliguria (sometimes anuria or polyuria), fluid and electrolyte imbalances, acidosis.
Timecourse
- Animals may die acutely, especially if underlying cause is not detected and treated or if oliguric phase persists.
- If treated appropriately, animals may recover, but recovery phase can take >3 weeks of intensive care.
Diagnosis
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Treatment
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Prevention
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Outcomes
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Further Reading
Publications
Refereed papers
- Recent references from PubMed and VetMedResource.
- Dorval P & Boysen S R (2009) Management of acute renal failure in cats using peritoneal dialysis: a retrospective study of six cases (2003-2007). J Feline Med Surg 11 (2), 107-115 PubMed.
- Worwag S & Langston C E (2008) Acute intrinsic renal failure in cats: 32 cases (1997-2004). JAVMA 232 (5), 728-732 PubMed.
- Sigrist N E (2007) Use of dopamine in acute renal failure. J Vet Emerg Crit Care 17 (2), 117-126 VetMedResource.
- Stokes J E & Forrester S D (2004) New and unusual causes of acute renal failure in dogs and cats. Vet Clin North Am Small Anim Pract 34 (4), 909-922 PubMed.
- Grauer G F (1998) Fluid therapy in acute and chronic renal failure. Vet Clin North Am Small Anim Pract 28 (3), 609-622 PubMed.
- Grauer G F (1996) Prevention of acute renal failure. Vet Clin North Am Small Anim Pract 26 (6), 1447-1459 PubMed.
- Ohashi F, Awaji T, Shimada T et al (1995) Plasma methylguanidine and creatinine concentrations in cats with experimentally induced acute renal failure. J Vet Med Sci 57 (5), 965-966 PubMed.
- Mealey K L, Boothe D M (1994) Nephrotoxicosis associated with topical administration of gentamicin in a cat. JAVMA 204 (12) 1919-1921 PubMed.
Other sources of information
- Langston C (2010) Acute Uraemia. In:T extbook of Veterinary Internal Medicine7th edn. Ettinger S J & Feldman E C (eds). W B Saunders, pp 1969-1985.
- Chew D J & Gieg J A (2006) Fluid therapy during intrinsic renal failure. In: Fluid, Electrolyte and Acid-base Disorders in Small Animals. Di Bartola S P (ed). W B Saunders, pp 518-540.
- Frenier S L & Dhein C R (1991) Diagnosis and management of acute renal failure. In: Consultations in feline internal medicine 1. (ed) J R August. W B Saunders. pp 281-288.