A Brief Look at Renal Anatomy & Physiology Structures of the Renal System:

The renal system is comprised of the Kidneys and those structures including the ureters, bladder and urethra that form the urinary system. The primary role of the kidneys is to remove metabolic wastes and maintain fluid and electrolyte balance. The kidneys also have a role in: Blood Pressure Control Red Blood Cell Synthesis Bone Metabolism Acid- Base Balance Renal dysfunction can negatively impact on all of these roles.
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Cross Section of the Kidney:

The kidneys are situated in the retroperitoneum located between T12 and L3 on each side of the vertebral column. Two layers form them internally. The outer layer is the Cortex that contains: Glomeruli Proximal Tubules Cortical Portions of Loops of Henle Distal Tubules Cortical Collecting Ducts
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The inner layer or Medulla is comprised of Renal Pyramids. The pyramids contain: Medullary portions of Loops of Henle Medullary Portions of Collecting Ducts
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Multiple pyramids taper and join forming a minor calyx. Several combined make a major calyx. The major calyces join and enter a funnel shaped renal pelvis that directs urine into the ureter.
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Components of the Nephron:

Approximately one million nephrons comprise each kidney. The nephron consists of:

 Glomerulus Bowman Capsule Proximal Convoluted Tubule Loop of Henle Distal Convoluted Tubule Collecting Duct
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There are two types of nephron: Cortical Nephrons Juxtamedullary Nephrons Cortical Nephrons: Approximately 85 % Perform excretory and regulatory functions Juxtamedullary Nephrons: Approximately 15 % Responsible for concentration and dilution of urine
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Urine Formation: Three processes required for urine formation include: Glomerular Filtration Tubular Reabsorption Tubular Secretion
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Glomerulus Filters fluid and solutes from blood Proximal Convoluted Tubule Reabsorbs Na , K , Cl , HCO3 , urea, glucose & amino acids Filtrate Continues Loop of Henle
+ + -

 Reabsorbs Na , K & Cl

Blocks reabsorption of H2O Dilutes/Concentrates Urine Filtrate Continues Distal Tubule Na , K , Ca , PO4 selectively reabsorbed H2O reabsorbed in presence of Antidiuretic Hormone (ADH) Filtrate Continues Collecting Duct Reabsorption similar to distal tubule HCO3 & H reabsorbed/secreted to acidify urine Filtrate leaves hyperosmotic/hypoosmotic depending on the bodys requirements
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Composition of Urine: H 2O Electrolytes- Na , K , Cl , HCO3

+ + -

End products of protein metabolism- urea, creatinine, PO4, SO4 End products of nucleic acid metabolism- uric acid Breakdown products of phosphoric and sulphuric acid
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H ions excreted bound to buffers such as PO4 and NH3 Renal Anatomy & Physiology in Summary: Kidneys filter blood of waste products

Functional units of the kidneys are called nephrons Nephrons consist of a glomerulus, tubule and collecting duct Urine is formed through glomerular filtration, tubular reabsorption and tubular secretion Urine moves from the collecting duct via the renal pelvis and ureters into the bladder, where it is excreted from the body through the urethra Some substances are reabsorbed into the blood and others excreted into the filtrate

Summary of Acute Renal Failure Definition: Acute renal failure (ARF) is a clinical syndrome, characterised by an abrupt decline in glomerular filtration rate (GFR). There is a subsequent retention of metabolic waste products and an inability to maintain electrolyte and acid-base 1,7,8,16,18,23 homeostasis. Regulation of fluid volume is also affected. ARF occurs rapidly resulting in fifty percent or more nephrons to lose function, and as this occurs quickly the body is unable to compensate. There are three 23 classifications of ARF based on the location of the cause. Prerenal Renal dysfunction is largely related to systemic factors that limit blood flow and reduce glomerular filtration rate. Examples include:
Hypotension Hypovolaemic shock- dehydration, blood loss Cardiogenic shock post MI Septic Shock Bilateral renal vascular obstruction- thrombosis
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Intrarenal Renal impairment occurs secondary to damage that is sustained at the site of the nephrons. This may be the result of a number of conditions or nephrotoxins: Acute Tubular Necrosis (ATN) Acute Glomerulonephritis Acute Pyelonephritis Acute Cortical Necrosis Malignant Hypertension Acute Vasculitis Rhabdomyolysis - drugs, trauma Nephrotoxins - IV contrast, aminoglycosides
1,8,9,16,18,23

Postrenal Renal failure secondary to obstruction that prevents excretion of urine Prostatic Hypertrophy Renal Calculi Tumour Blocked Urinary Catheter
1,8,9,16,18,23

Signs & Symptoms Fluid and electrolyte abnormalities Metabolic acidosis Anaemia Pruritis secondary to uremic frost Nausea & vomiting Confusion LOC Congestive heart failure resulting in acute pulmonary oedema
1,8,16,18,23

Renal Replacement Therapy Renal replacement therapy (RRT) is an extracorporeal technique of blood purification. Blood passes over a semipermeable membrane (filter) allowing solutes and water to cross over to a collection side. There are various modalities included under the 19 umbrella of RRT. Continuous Modalities (CRRT)
Haemofiltration Haemodialysis Haemodiafiltration Ultrafiltration Advantages: Better for haemodynamic instability Readily accessible Effective fluid removal and clearance of solutes Can be performed by ICU staff rather than specialised renal nurses Disadvantages: Patient mobilisation is limited Access complications Anticoagulation Reduced blood flow rates secondary to small filters when compared to IHD
2,4,5,9,17,20 2,4,5,9,17,20

Intermittent Haemodialysis (IHD) Advantages: Quick and effective Large amounts of fluid and solutes can be removed over a short period Disadvantages: Access Complications- formal access such as A.V. Fistula is eventually required Requires specialised staff and is therefore not readily accessible May not be well tolerated by haemodynamically unstable patients Intermittent fluid removal with IHD can be associated with fluid overload and increased electrolytes between treatments
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Peritoneal Dialysis This form of dialysis utilises the peritoneum as the semipermeable membrane. Advantages: Comparatively Cheaper

 No anticoagulation required

 No haemodynamic instability Disadvantages: High incidence of peritonitis Slow clearance

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Access Formal access required (Tenkhoff catheter) Limitations on patient as it is required frequently
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Continuous Renal Replacement Therapy (CRRT) Indications

Fluid Overload, pulmonary oedema Worsening Metabolic Acidosis Hyperkalaemia Worsening Azotaemia Drug overdoses Removal of toxins
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Basic Principles The basic principles incorporated in the function of CRRT involve: Convection Diffusion Ultrafiltration Hydrostatic Pressure
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Terminology Diffusion The movement of small and middle molecule solutes from an area of high concentration to low concentration across a semipermeable-membrane.
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Osmosis The movement of water from an area of high water concentration to an area of lower water concentration across a semi-permeable membrane.
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Ultrafiltration The movement of water and solutes across a semipermeable membrane by solvent drag created by convection and hydrostatic pressure.
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Convection Water flow across a semi-permeable membrane by hydrostatic pressure that drags solutes with it (the way a waterfall moves pebbles and sand) Hydrostatic Pressure The force that pushes fluid and solutes across the membrane. The mechanical blood pump on the dialysis machine creates this. Oncotic Pressure Plasma proteins including albumin, globulin and fibrinogen create the pulling pressure that favours fluid retention and opposes hydrostatic pressure. Counter Current The flow of two fluids in opposing directions. The direction of dialysis flows opposite to that of blood flow maximising the concentration difference between blood and dialysate. Dialysate
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A synthetic solute free solution used to achieve diffusive solute clearance Effluent

Erroneous term used to indicate the solute and solvent discarded form the patient. Replacement Pre or post dilution fluid Pre-dilution Administration of the replacement fluid into the circuit prior to the filter Post-dilution Administration of replacement fluid into the circuit after the filter
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Modalities Slow Continuous Ultrafiltration (SCUF) Continuous Arterio/Venovenous Haemofiltration (CAVH/CVVH) Continuous Arterio/Venovenous Haemodialysis (CAVHD/CVVHD) Continuous Arterio/Venovenous Haemodiafiltration (CAVHDF/CVVHDF) SCUF Slow Continuous Ultrafiltration is the method used when fluid removal is the only objective. Dialysate and replacement fluids are not utilised. Maximum fluid removal is 2000ml/hr.
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= pump SCUF System Setup

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CAVH/CVVH Continuous Venovenous Haemofiltration uses convective clearance to remove water and solutes. Replacement is used to replace ultrafiltrate. Maximum fluid removal is 1000ml/hr.
2,17,20

= pump CVVH System Setup

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CAVHD/CVVHD Continuous Venovenous Haemodialysis uses diffusion to remove fluid and solutes. Dialysate is pumped in a counter current to blood flow. Maximum fluid removal is 1000ml/hr.
2,17,20

= pump CVVHD System Setup

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CAVHDF/CVVHDF Continuous Venovenous Haemodiafiltration utilises both convection and diffusion to remove fluid and solutes. Dialysate and replacement is used. Maximum fluid removal is 1000ml/hr.
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= pump CVVHDF System Setup

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CRRT Modality Summary Mode

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Filtering Process
ConvectionUltrafiltration ConvectionUltrafiltration

Removes
Fluid, Minimal solutes Fluid removal. Moderate solute removal. Urea clearance approximately 1517ml/min Fluid removal. More aggressive solute removal. Urea clearance approximately 1721ml/min.

Indication
Fluid Overload Heart failure Moderate electrolyte imbalances Oliguria with parenteral nutrition or blood requirements Septic Shock Fluid overload with haemodynamic instability Azotaemia Electrolyte disturbance and acidosis Parenteral nutrition accompanying fluid overload Fluid Overload, pulmonary oedema Worsening Metabolic Acidosis Hyperkalaemia Worsening Azotaemia Drug overdoses Removal of toxins

Slow Continuous Ultra Filtration (SCUF) Continuous Arterio/Venovenous Haemofiltration (CAVH/CVVH)

Continuous Arterio/Venovenous Haemodialysis (CAVHD, CVVHD)

Diffusion

Continuous Arterio/Venovenous Haemodiafiltration (CAVHDF/CVVHDF

Convection & Diffusion

Maximum fluid and solute removal. Urea clearance approximately 2526ml/min.