Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation ...
Transcript of Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation ...
![Page 1: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/1.jpg)
Acute Renal Failure
Dr Gerrard Uy
![Page 2: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/2.jpg)
Overview
Definitions Classification and causes Presentation Treatment
![Page 3: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/3.jpg)
Definition Acute Renal failure (ARF)
Inability of kidney to maintain homeostasis leading to a buildup of nitrogenous wastes
Different to renal insufficiency where kidney function is deranged but can still support life
Characterized by a rapid decline in glomerular filtration rate (GFR)
![Page 4: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/4.jpg)
ARF
Occurs over hours/days Usually asymptomatic Lab definition
Increase in baseline creatinine of more than 50%
Decrease in creatinine clearance of more than 50%
Deterioration in renal function requiring dialysis
![Page 5: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/5.jpg)
ARF definitions
Anuria – no urine output or less than 100mls/24 hours
Oliguria - <500mls urine output/24 hours or <20mls/hour
Polyuria - >2.5L/24 hours
![Page 6: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/6.jpg)
ARF
Pre renal (functional)
Renal-intrinsic (structural)
Post renal (obstruction)
![Page 7: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/7.jpg)
ARF Pirouz Daeihagh, M.D.Internal medicine/Nephrology Wake Forest University School of Medicine. Downloaded 4.6.09
![Page 8: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/8.jpg)
Causes of ARF Pre-renal:
Inadequate perfusion check volume status
Renal: ARF despite perfusion & excretion check urinalysis, FBC & autoimmune
screen Post-renal:
Blocked outflow check bladder, catheter & ultrasound
![Page 9: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/9.jpg)
Causes of ARF
Pre-renal Renal Post-renalAbsolutehypovolaemia
Glomerular(RPGN)
Pelvi-calyceal
Relativehypovolaemia
Tubular(ATN)
Ureteric
Reducedcardiac output
Interstitial(AIN)
VUJ-bladder
Reno-vascularocclusion
Vascular(atheroemboli)
Bladder neck-urethra
![Page 10: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/10.jpg)
ARF Pre renal
Most common form of ARF Decreased renal perfusion without
cellular injury 70% of community acquired cases 40% hospital acquired cases
![Page 11: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/11.jpg)
ARF Pre renal
Hepatorenal syndrome Unique form of prerenal ARF Frequently complicates advanced cirrhosis Kidneys are structurally normal but fail
due to splanchnic vasodilation and arteriovenous shunting
2 types: Type 1 HRS – more aggressive Type 2 HRS
![Page 12: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/12.jpg)
ARF Intrinsic Acute tubular necrosis (ATN)
Ischaemia Toxin Tubular factors
Acute interstitial Necrosis (AIN) Inflammation oedema
Glomerulonephritis (GN) Damage to filtering mechanisms Multiple causes as per previous presentation
![Page 13: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/13.jpg)
ARF Post renal
Post renal obstruction Obstruction to the urinary outflow
tract Bladder neck obstruction – most common
cause of post renal ARF Prostatic hypertrophy
Blocked catheter Malignancy
![Page 14: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/14.jpg)
Prerenal Failure 1
•Often rapidly reversible if we can identify this early.
•The elderly at high risk because of their predisposition to hypovolemia and renal atherosclerotic disease.
•This is by definition rapidly reversible upon the restoration of renal blood flow and glomerular perfusion pressure.
•THE KIDNEYS ARE NORMAL.
•This will accompany any disease that involves hypovolemia, low cardiac output, systemic dilation, or selective intrarenal vasoconstriction.
ARF Anthony Mato MD Downloaded 5.8.09
![Page 15: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/15.jpg)
Differential Diagnosis 2 Hypovolemia
GI loss: Nausea, vomiting, diarrhea (hyponatraemia)
Renal loss: diuresis, hypo adrenalism, osmotic diuresis (DM)
Sequestration: pancreatitis, peritonitis,trauma, low albumin (third spacing).
Hemorrhage, burns, dehydration (intravascular loss).
ARF Anthony Mato MD Downloaded 5.8.09
![Page 16: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/16.jpg)
Differential Diagnosis 3 Renal vasoconstriction: hypercalcaemia,
adrenaline/noradrenaline, cyclosporin, tacrolimus, amphotericin B.
Systemic vasodilation: sepsis, medications, anesthesia, anaphylaxis.
Cirrhosis with ascites Hepato-renal syndrome Impairment of autoregulation: NSAIDs, ACE,
ARBs. Hyperviscosity syndromes: Multiple
Myeloma, Polycyaemia rubra vera
![Page 17: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/17.jpg)
Differential Diagnosis 4
Low CO Myocardial diseases Valvular heart disease Pericardial disease Tamponade Pulmonary artery hypertension Pulmonary Embolus Positive pressure mechanical ventilation
![Page 18: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/18.jpg)
The only organ with entry and exit arteries
![Page 19: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/19.jpg)
Glomerular blood flow
Afferent arteriole Efferent art
GlomerularCapillaries &Mesangium
Constrictors: endothelin, catecholamines, thromboxane
CompensatoryConstrictor: Angiotensin II
Blocker:ACE-I
CompensatoryDilators:Prostacyclin, NO
Blocker:NSAID
![Page 20: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/20.jpg)
Acute Tubular Necrosis (ATN)Classification
Ischemic Nephrotoxic
![Page 21: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/21.jpg)
ATN
![Page 22: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/22.jpg)
ATN
![Page 23: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/23.jpg)
Acute Renal FailureNephrotoxic ATN
Endogenous Toxins Heme pigments (myoglobin, hemoglobin) Myeloma light chains
Exogenous Toxins Antibiotics (e.g., aminoglycosides, amphotericin
B) Radiocontrast agents Heavy metals (e.g., cis-platinum, mercury) Poisons (e.g., ethylene glycol)
![Page 24: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/24.jpg)
Acute Interstitial NephritisCauses
Allergic interstitial nephritis Drugs
Infections Bacterial Viral
Sarcoidosis
![Page 25: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/25.jpg)
Allergic Interstitial Nephritis(AIN)Clinical Characteristics
Fever Rash Arthralgias Eosinophilia Urinalysis
Microscopic hematuria Sterile pyuria Eosinophiluria
![Page 26: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/26.jpg)
AIN
![Page 27: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/27.jpg)
Contrast-Induced ARFPrevalence
Less than 1% in patients with normal renal function
Increases significantly with renal insufficiency
![Page 28: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/28.jpg)
Contrast-Induced ARFRisk Factors
Renal insufficiency Diabetes mellitus Multiple myeloma High osmolar (ionic) contrast media Contrast medium volume
![Page 29: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/29.jpg)
Contrast-induced ARFClinical Characteristics
Onset - 24 to 48 hrs after exposure Duration - 5 to 7 days Non-oliguric (majority) Dialysis - rarely needed Urinary sediment - variable Low fractional excretion of Na
![Page 30: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/30.jpg)
Pre-Procedure Prophylaxis1. IV Fluid (N/S)1-1.5 ml/kg/hour x12 hours prior to procedure and 6-12
hours after2. Mucomyst (N-acetylcysteine)Free radical scavenger; prevents oxidative tissue
damage 600mg po bd x 4 doses (2 before procedure, 2 after)
3. Bicarbonate (JAMA 2004)Alkalinizing urine should reduce renal medullary damage5% dextrose with 3 amps HCO3; bolus 3.5 mL/kg 1
hour preprocedure, then 1mL/kg/hour for 6 hours postprocedure
4. Possibly helpful? Fenoldopam, Dopamine 5. Not helpful! Diuretics, Mannitol
![Page 31: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/31.jpg)
Contrast-induced ARFProphylactic Strategies
Use I.V. contrast only when necessary Hydration Minimize contrast volume Low-osmolar (nonionic) contrast
media N-acetylcysteine, fenoldopam
![Page 32: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/32.jpg)
ARF Post-renal Causes 1
Intra-renal Obstruction Acute uric acid nephropathy Drugs (e.g., acyclovir)
Extra-renal Obstruction Renal pelvis or ureter (e.g., stones,
clots, tumors, papillary necrosis, retroperitoneal fibrosis)
Bladder (e.g., BPH, neuropathic bladder)
Urethra (e.g., stricture)
![Page 33: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/33.jpg)
Acute Renal FailureDiagnostic Tools
Urinary sediment Urinary indices
Urine volume Urine electrolytes
Radiologic studies
![Page 34: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/34.jpg)
Urinary Sediment (1)
Bland Pre-renal azotaemia Urinary outlet obstruction
![Page 35: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/35.jpg)
Urinary Sediment (2)
RBC casts or dysmorphic RBCs Acute glomerulonephritis Small vessel vasculitis
![Page 36: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/36.jpg)
Red Blood Cell Cast
![Page 37: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/37.jpg)
Red Blood Cells
Monomorphic Dysmorphic
![Page 38: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/38.jpg)
Dysmorphic Red Blood Cells
![Page 39: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/39.jpg)
Dysmorphic Red Blood Cells
![Page 40: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/40.jpg)
Urinary Sediment (3)
WBC Cells and WBC Casts Acute interstitial nephritis Acute pyelonephritis
![Page 41: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/41.jpg)
White Blood Cells
![Page 42: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/42.jpg)
White Blood Cell Cast
![Page 43: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/43.jpg)
Urinary Sediment (4)
Renal Tubular Epithelial (RTE) cells, RTE cell casts, pigmented granular (“muddy brown”) casts Acute tubular necrosis
![Page 44: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/44.jpg)
Renal Tubular Epithelial Cell Cast
![Page 45: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/45.jpg)
Pigmented Granular Casts
![Page 46: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/46.jpg)
Acute Renal FailureUrine Volume (1)
Anuria (< 100 ml/24h) Acute bilateral arterial or venous
occlusion Bilateral cortical necrosis Acute necrotizing glomerulonephritis Obstruction (complete) ATN (very rare)
![Page 47: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/47.jpg)
Acute Renal FailureUrine Volume (2)
Oliguria (<100 ml/24h) Pre-renal azotemia ATN
Non-Oliguria (> 500 ml/24h) ATN Obstruction (partial)
![Page 48: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/48.jpg)
Clinical Assessment
Thirst and orthostatic dizziness Orthostatic hypotension Tachycardia Reduced JVP Decreased skin turgor Dry mucous membranes
![Page 49: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/49.jpg)
ARF-Signs and Symptoms
Weight gain Peripheral oedema Hypertension
![Page 50: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/50.jpg)
ARF Signs and Symptoms
Hyperkalemia Nausea/Vomiting Pulmonary edema Ascites Asterixis Encephalopathy
![Page 51: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/51.jpg)
Lab findings Prerenal ARF
Sediment is characteristically acellular Contains transparent hyaline cast
Intrinsic renal ARF Urine sediment contains a variety of casts
RBC cast – glomerulonephritis WBC cast – interstitial nephritis Broad granular cast - CKD
Post renal ARF Commonly presents with hematuria and pyuria
![Page 52: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/52.jpg)
Lab findings
Rising creatinine and urea Rising potassium Decreasing Hb Acidosis Hyponatraemia Hypocalcaemia
![Page 53: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/53.jpg)
Mx ARF Immediate treatment of pulmonary edema and
hyperkalaemia Remove offending cause or treat offending cause Dialysis as needed to control hyperkalaemia,
pulmonary edema, metabolic acidosis, and uremic symptoms
Adjustment of drug regimen Usually restriction of water, Na, and K intake, but
provision of adequate protein Possibly phosphate binders and Na polystyrene
sulfonate
![Page 54: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/54.jpg)
Recognise the at-risk patient
Reduced renal reserve: Pre-existing CRF, age > 60, hypertension, diabetes
Reduced intra-vascular volume:Diuretics, sepsis, cirrhosis, nephrosis
Reduced renal compensation:ACE-I’s (ATII), NSAID’s (PG’s), CyA
![Page 55: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/55.jpg)
Acute Tubular NecrosisClinical Characteristics
Characteristic Oliguric ATN Non-Oliguric ATN
Incidence 41% 59%
Toxin-induced 8% 30%
UV (ml/24h) < 400 1,280 + 75
UNa (mEq/L) 68 + 6 50 + 5
FENa (%) 6.8 + 1.4 3.1 + 0.5
Dialysis required 84% 26%
Mortality 50% 25%
![Page 56: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/56.jpg)
![Page 57: Acute Renal Failure Dr Gerrard Uy. Overview Definitions Classification and causes Presentation Treatment.](https://reader033.fdocuments.us/reader033/viewer/2022042718/56649f055503460f94c19fc6/html5/thumbnails/57.jpg)
Conclusion
Think about who might be vulnerable to acute renal failure
Think twice before initiating therapy that may cause ARF