This document summarizes a study that assessed reversible risk factors for acute-on-chronic renal failure. The study evaluated 100 patients admitted to a tertiary hospital over one year. Majority of patients had more than one reversible risk factor, most commonly urinary tract infection and sepsis. Conservative management and treatment of reversible factors resulted in significant improvement in renal function for most patients. Maximum reversibility was seen in patients with GFR between 15-29 ml/min, and least reversibility in those under 5 ml/min. The study concluded that identifying and treating reversible risk factors can help restore renal function and delay the need for renal replacement therapy in many patients experiencing acute decline on top of chronic kidney disease.

1. Assessment of reversible risk factors
causing
acute-on-chronic renal failure
N Nand*, M Shrama**, H Kumar***
Prity Mehta****
PGIMS, Rohtak - 124 001,
Haryana.
Journal, Indian Academy of Clinical Medicine l Vol. 13, No. 3 l July-September, 2012
By
………. RAMESH NAYAK……… 28/03/2014
for dept of physiology JNMC @ aditya

2. Contents:
1.Introduction
2.Objectives
3.Material And Methods
4.Results
5.Discussion
6.Conclusion
7.Critical Appraisal
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3. Functions of kidney
1. Excretory function
2. Regulatory function
3.Endocrine function
4.Metabolic function
H
O
M
E
O
S
T
A
S
I
S
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4. Renal failure
a)Acute b)Chronic
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5. a. Acute Renal Failure
- abrupt in onset and reversible
- AZOTEMIA most common
. indicator
- Depending upon the cause
. 3 types:
Prerenal
Postrenal
Renal
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6. b. Chronic Renal Failure
- progressive and represents irreversible kidney structural damage.
- signs and symptoms occur gradually
kidney has amazing compensatory ability.
- characterized by GFR reduction, reflects
reduction in the number of functional nephrons.
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7. Stages of progression of CRF:
1. Diminished Renal
Reserve
2. Renal Insufficiency
3. Renal Failure and
4. End-Stage Renal
Disease(ESRD)
CKD
STAGE 1
CKD
STAGE 2
CKD
STAGE 3
CKD
STAGE 4
eGFR
mL/min ≤50% ≤(50-20)% ≤20% ≤5%
serum BUN &
creatinine levels
still normal.
No symptoms
seen.
earliest
symptom
isosthenuria
azotemia,
anemia &
hypertension
begin to
appear.
kidneys cannot
regulate volume &
solute composition
 edema, metabolic
acidosis &
hyperkalemia develop.
 uremia may ensue
with neurologic,
GI and CV
manifestation
Histologically
reduction in
renal
capillaries.
 Atrophy and
fibrosis in
tubules.
 kidney mass
usually reduced.
TO,1. Diminished Renal
Reserve
2. Renal Insufficiency
3. Renal Failure and
4. End-Stage Renal
Disease(ESRD)
CKD
STAGE 1
≤50%
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8. Manifestations of CRF:
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9. for dept of physiology JNMC @ aditya 9

10. ACUTE-ON-CHRONIC RENAL FAILURE
 Any sudden decline in renal functions in patients with known chronic kidney
disease
 Each episode of acute attack - can be attributed to - one or more reversible risk
factors.
 Various reversible risk factor contributing to acute-on-chronic renal failure are:
Volume depletion
Urinary tract obstruction
Infection
Hypotension
Electrolyte imbalance
Accelerated hypertension
Nephrotoxic drugs
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11. Renal function tests:
1. Urine analysis
(physical, chemical and microscopic examination)
2. Blood analysis
(blood urea, plasma creatinine, serum protein, cholesterol and
. electrolyte)
3. Renal clearance tests
(to measure GFR and RBF)
4. Radiology and renal imaging
5. Renal biopsy
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12. Management of renal failure:
1) Conservative management
- preventing deterioration of remaining renal function and
- helps the body in compensating for the existing impairment.
2) Renal replacement therapy
- Dialysis and
- Renal transplantation
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13. Dialysis.
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14. Assessment of reversible risk factors causing
acute-on-chronic renal failure
1.PREVALENCE:
 ESRD reached epidemic proportions – treatment becoming an
unbearable health care burden.
 conservative estimate of ESRD burden - population of 1.1 billion - around
1,650,000 people develop ESRD in india annually.
 Taking conservative approach, if all patients were to be treated - cost
burden over $6.5 billion annually - health care budget for all of India $3.5
billion.
QUEST india | DaVita’s Clinical Journal for Nephrologists July 2007 Issue 9 By H. Sudarshan Ballal, M.D.
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15. 2.Introduction
 Any sudden decline in renal functions in patients with
known chronic kidney disease (CKD)
 Each episode of acute attack can be attributed to one or
more reversible risk factors.
 Timely management - renal function brought back to basal
level- preventing from ESRD - reducing the cost of renal
replacement therapy.
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16. 3.OBJECTIVE:
- Evaluate risk factors - their degree of reversibility - in cases
of acute-on-chronic renal failure
admitted to a tertiary care hospital, over a period of one
year, i.e., from November, 2006 to October, 2007.
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17. 4.MATERIAL AND METHODS:
MATERIAL:
 The study included 100 cases of acute-on-chronic renal failure
mean age of (48.69 ± 16.02) years.
62 men and 38 women.
 The diagnosis of acute-on-chronic renal failure was based on , patients with CRD
- presenting with sign and symptoms of acute renal failure or
- who presented with
0.5 mg/dl, if baseline serum creatinine was < 3 mg/dl
rise in serum creatinine of
1 mg/dl, if baseline was > 3 mg/dl with in one week period.
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18. METHODS:
 admitted in the ward - average period of 14.62 days (range: 9 to 24 days)
. - managed conservatively following thorough
clinical evaluation and investigations.
 Specific management of reversible factor(s) and haemodialysis, whereever
needed was also done.
 Observations of various parameters were recorded at baseline and subsequently
at 1 week and 2 week periods which included 24-hour
urine volume, blood urea, serum creatinine, and creatinine clearance.
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19.  To compare the degree of reversibility, the patients were divided into 4
groups
depending upon their GFR;
GFR (30 - 59 )ml/min group 3
GFR (15 - 29 )ml/min group 4
GFR (5 – 15) ml/min group 5a and
GFR < 5 ml/min group 5b.
 Reversibility of these parameters was then statistically analysed.
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20. 5.RESULTS :
 Majority of patients were found to
have more than one reversible risk
factor
Average being 2.62 (ranging
. from 1to 4)
 however, only one factor was
taken as the major factor depending
upon the clinical situation.
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21.  Table II depicts degree of reversibility in patients having specific
aggravating factors
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22. Maximum reversibility was found in patients in stage 4 and
least in stage 5b .
GFR (30 - 59 )ml/min group 3
GFR (15 - 29 )ml/min group 4
GFR (5 – 15) ml/min group 5a
GFR < 5 ml/min group 5b.
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23. 6.DISCUSSION:
 Patients presenting in severe uraemic state - not suffering from end-stage renal
. disease; rather – had significant degree of reversibility of renal function .
study showed, majority of patients were having more than one reversible
risk factor (average 2.62).
 Conservative management + haemodialysis and correction of reversible
risk factor(s) , resulted in significant improvement in mean creatinine clearance
after 2 weeks of follow-up.
proved better chances of reversibility even in patient with stage 3 and
. stage 4 of CRF.
 However, in the earlier studies, the net degree of reversibility was found to be low –
probably because the patients included were of advanced renal
failure (creatinine clearance < 15 ml/min)
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24. a)Sepsis
 Most common and major factor infecting urinary tract,
identified in the present study.
 Established that patients with CKD - increased risk of sepsis - causes
acute deterioration of renal function.
(which is due to renal vasoconstriction caused by endothelin )
 However the most common site of infection in previous studies was found
to be different by different investigators.
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25. b)Accelerated Hypertension
 Found to be major factor in 19 patients and had lower degree of
reversibility, although it was statistically significant.
 Causes mucoid intimal proliferation and fibrinoid necrosis in renal
vasculature which is irreversible.
 It was observed by many investigators that patients presenting with
acute-on-chronic renal failure had a poor outcome due to accelerated
hypertension.
 While others observed that with long term control of blood pressure,
renal function recovers sufficiently to allow for withdrawal of dialysis.
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26. c)Volume depletion
 was found to be a major factor in 10 patients with maximum degree of
reversibility,
 whereas patients who had hypotension along with volume depletion
had a lower degree of reversibility.
 Results of heart failure and bleeding were not statistically significant
because number of observation was less than 5.
 Mc Innes observed that patients with pre-renal failure had 60%
recovery, whereas patients with intrinsic renal failure had 48% mortality.
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27. d)Electrolyte disturbance
• Salt depletion - aggravating factor & found
hyponatraemia - most common electrolyte disturbance
• Burkhard - hyponatraemia was the most common electrolyte imbalance
It was not a strong predictor of renal function decline
Hypernatraemia was found to be a stronger predictor.
• Hyponatraemia - most common electrolyte disturbance in the present study
- found minimum degree of reversibility in patients with electrolyte
disturbance
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28. e)Obstructive uropathy
 Many investigators have observed
good reversibility of renal function on release of obstruction.
 However, Mc Innes
found poor outcome in these patients
which was probably due to malignant disease in the pelvis.
 In this study, 14 patients had obstructive uropathy as a major cause,
. and it was second most reversible factor.
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29. 7.CONCLUSION
On the basis of results of the present study it can be concluded
that:
- Patients presenting in a severe uraemic state may not be suffering
from ESRD and each patient should be investigated for the presence of
reversible risk factor(s).
so that * renal function can be restored and
* the need of renal replacement therapy can be
. delayed.
- Volume depletion and urinary tract infection were found to be the
most reversible aggravating factors observed by the study.
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30. 8.CRITICAL APPRAISAL
• Type of study not mentioned.
• Place where study done, not mentioned clearly.
• Basis of inclusion criteria not explained.
• Method of statistical analysis not mentioned.
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31. Refrences:
Medical Physiology by Indu Khurana
Pathophysiology (Concepts of altered health status) by Carol Mattson
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32. Thank You…………….
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