1	Acute Renal Failure
2	Approach to ARF Usually detected by rise in creatinine Oliguria is not life-threatening Diuretics are not a treatment for ARF Urine output poor correlate of GFR Meticulous review of medications Assess fluid balance (don’t let edema fool you) Focused physical exam
3	Evaluation of ARF
4	Hospital Acquired ARF
5	Urinalysis in ARF
6	Liquid Biopsy
7	Urine Electrolytes From 1978 Limited patient populations Numerous exclusion criteria Numerous exceptions to the rule No recent validation May have poor predictive value
8	Prerenal Azotemia Don’t confuse edema with fluid overload May be unable to correct Avoid NSAID and ACE-I/ARB Stop aggressive diuresis Colloid vs. crystalloids unsettled controversy May require dialysis or ultrafiltration
9	Obstruction Intra-renal & extra-renal forms Abrupt onset/anuria “Cured” intra-abdominal disease or history of radiation Bland urinary sediment Hyperkalemia with acidosis (type IV) Ultrasound 90% sensitive Relieve the obstruction
10	Clinical Pearls in ARF Rhabdomyolysis Urine heme positive No RBCs on micro Myeloma Negative protein on dipstick Proteinuria with collected urine Pregnancy HELLP HUS Drugs ACE-I/ARB NSAIDS Altered sensorium HUS/TTP Cholesterol emboli Rash/purpura Eosinophilia ANCA disease Systemic symptoms Subacute illness Pulmonary-renal Obstruction Hyperkalemia Bland sediment anuria
11	ATN Background
12	Mortality in ATN
13	Definition of ATN
14	Pitfalls of Serum Creatinine Creatinine is filtered and secreted Normal value dependent on age, gender, and muscle mass Creatinine rise is a LATE consequence of renal failure
15	ADQI Increased sensitivity Uniform approach to clinical research Likely correlated with underlying physiology Requires new mind set
16	ATN After Cardiac Bypass
17	Acute Kidney Injury and Mortality 19,982 adults Absolute and relative increases in SCr Multivariable analysis Mortality Length of stay Cost
18	Diagnostic Criteria for AKI An abrupt (within 48 hours) reduction in kidney function defined as an absolute increase in serum creatinine of either ≥0.3 mg/dL or a percentage increase of ≥50% (1.5-fold from baseline) OR a reduction in urine output (documented oliguria of <0.5 mL/kg/h for >6 hours). In the context of the clinical presentation and following adequate fluid resuscitation as appropriate
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21	AKI and ARDS Ischemic AKI in rats Increased vascular permeability in lungs Pulmonary interstitial edema and alveolar hemorrhage Blocked by macrophage inhibitor (CNI-1493)
22	Distant Effects in Ischemic AKI Systemic increase in TNF-α and IL-1 after renal ischemia Increased TNF-α,IL-1 and ICAM-1 in heart Increased leukocytes in heart Decreased LV function by Echo Blocked by anti-ICAM
23	Therapy of AKI Prevention is key! Most therapies have failed in humans No appropriate animal models We start too late Timing is (may be) critical Need better markers of ATN
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36	Complications of ARF Death Infection Anemia Uremia* Pericarditis* Fluid overload* Metabolic acidosis* Non-anion gap early Anion gap late Hyperphosphatemia/hypocalcemia* Bleeding*
37	Cleveland Clinic ATN Data
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39	Frequency of Hemodialysis in ATN
40	Frequency of Hemodialysis in ATN
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43	"Immune Modulation" Immune Modulation Host defense system ü Antigen presentation ü Cytokine production ü Metabolic/endocrine functions Hormone production ü Vitamin production ü Ca, Phos homeostasis ü
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