Tirkmlis mwvave dazianeba

aris Tirkmlis filtraciuli unaris uecari an swrafi daqveiTeba

Tirkmlis mwvave dazianebis definicia sisxlSi kreatininis donis momateba sawyisidan >50% an Sardis gamoyofa <0.5 ml/kg/sT 6 saaTis ganmavlobaSi

romelia Tirkmlis mwvave dazianebis scenari?

1. 85 mamakaci, S/diabetiT, kreat 120, Cveulebriv 80

2. 82 qali, diabetiT, Sardovana 15.2, kreat 150 3. 60 mamakaci, diabetiT, kreat 250, Cveulebriv 200 4. 74 mamakaci, legionela pneumonia, Na 118, kreat 130,

sawyisi 70 5. 63 qali, diabetiT, myokardiumis infarqtiT, GFR 25,

sawyisi GFR 35

sisxlSi kreatinini > 50% sawyis maCvenebelze

• sawyisi kreatinini 80 mmol/L • dinamikaSi mateba 120 mmol/L • gamoxatutuli Tirkmlis dazianeba • moqmedebis droa – Zalian gviania roca kreatininis done miaRwevs 400

Lameire N et al. (2006) The changing epidemiology of acute renal failure Nat Clin Pract Neprol 2: 364–377 doi:10.1038/ncpneph0218

Lameire N et al. (2006) The changing epidemiology of acute renal failure Nat Clin Pract Neprol 2: 364–377 doi:10.1038/ncpneph0218

Percentage distribution of causes of acute renal failure in (A) non-ICU and (B) ICU settings

Lameire N et al. (2006) The changing epidemiology of acute renal failure Nat Clin Pract Neprol 2: 364–377 doi:10.1038/ncpneph0218

Suspect AKI in a sick patient with a modest rise in their creatinine

GFR falls rapidly to near zero - only shown by oliguria

Large acute drop in GFR with oligoanuria

Slow rise in Cr until eventually a new steady state is reached

Only a small early rise in Cr: not easy to recognise as AKI

Tirkmlis mwvave ukmarisobis diagnostika ar xdeba

• Sardovana – araspecifiuria

• GFR – gamoiyeneba Tirkmlis qronikuli ukmarisobis Sesafaseblad

• eletrolituri disbalansi

• viTardeba Tirkmlis mwvave ukmarisobis dros,magram araspecifiuria

Sardis analizi

- Eefeqturia renuli daavadebebis diagnostikisTvis glomerulonefriti - hematuria da proteinuria analiziT = nefrologis konsultacia

saSarde sistemis eqoskopia

- obstruqcia - palpaciiT moculobiTi warmonaqmni - intra-abdominuri simsivneebi- saSarde sistemis kompresia

- roca mizezi ar aris cnobili

klasifikacia

Tirkmlis mwvave dazinebis tipi

renuli

Mmwvave glomerulonepriti

Mwvave intersticiuli

nefriti

prerenuli

hipotenzia

hipovolemia

CO

Mmilakovani nekrozi

Ppostrenuli- Sard sasqeso sistemis

obstruqcia

RIFLE criteria for classification of acute renal failure

Modified from Crit Care Clin, 21, Bellomo R, Defining, quantifying, and classifying acute renal failure, 223–237, Copyright (2005), with permission from Elsevier. Lameire N et al. (2006) The changing epidemiology of acute renal failure

Nat Clin Pract Neprol 2: 364–377 doi:10.1038/ncpneph0218

AKIN    

I stadia sisxlSi kreatininis momateba ≥0.3 mg/dl ansawyisidan mateba ≥150–200%

<0.5 ml/kg/sT 6 sT

II stadia sisxlSi kreatininis momateba >200–300% sawyisi maCveneblidan

<0.5 ml/kg/sT > 12 sT

III stadia

sisxlSi kreatininis momateba >300% sawyisi maCveneblidan

<0.3 ml/kg/sT 24 sT an anuria for 12 sT

ganmavlobaSi

Tirkmlis mwvave ukmarisoba: mizezebi

• mniSvnelovania 3 ZiriTadi mizezi: • sefsisi/hipovolemia 70%

• medikament-asocirebuli, mwvave gn 20% • obstruqcia 10%

pre-renuli

renuli

post-renuli

• 74 w qali

• operacia- menj-barZayis saxsris endoprotezireba

• kreat -150,sawyisi -100

• Sardis gamoyofa 20ml/bolo 2 saaTi

• T/A 110/50, HR 95

Tirkmlis mwvave ukmarisobis menejmenti

Aaqvs pacients Tirkmlis mwvave ukarisoba?

Mmoculobis Sefaseba + siTxis infuzia

sisxlis airebi da eleqtrolitebi

Sardis analizi

eqoskopia

Nnefrologis konsultacia

• pacientebis umravlesoba postoperaciulad hipovolemiuria (70%)

• moculobis Sefaseba - 500ml + pacientis Sefaseba

• “normaluri” T/A 75 wlis asakSi – 150/70 - post operaciulad T/A 110 dabalia

CamoTvlilidan romelia hipovolemiis indikatori?

1. kapilaruli avsebis dro > 5 wm

2. sauRle venuri pulsi ar aris gamoxatuli 30º

3. sistoluri wneva < 95 mm Hg

4. sistoluri venuri wnevis mateba 250 ml NaCl bolus > 20 mm

Mmoculobis Sefasebis kriteriumebi

• MEWS score • kapilaruli avseba • T/A, HR, • JVP • filtvebis auskultacia • periferiuli SeSupeba • Sardis gamoyofa

• 67 wlis,75 kg mamakaci

• maRali temperaturiT T- 38.5 ,qoSiniT hipotenziiT T/A 85/60

• Tavs avad grZnobs 1kviraa

• anamneziT aqvs hipertenzia,Rebulobs enalaprils

• dietiT menejirebuli S/diabeti.

• gulmkerdis r-grafiiT- marjvenamxrivi pnevmonia

• dawyebul iqna 100% oqsigenoTerapia

• daedga 0,9% NaCl infuzia swrafi wveTiT

• dawyebul iqna antimikrobuli Terapia

• gamovlinda metaboluri acidozi,K-4,5, kreat. 140

• diurezi 0.3 ml/kg/sT

Tirkmlis mwvave ukmarisobis risk-faqtorebi

• pacientebis umravlesobas aqvs >1 risk-faqtori

• asaki • medikamentebi (agf inhibotorebi,Sardmdenebi,asasm)

• hipovolemia/sefsisi • diabeti

Stage-based management of AKI. Shading of boxes indicates priority of action—solid shading indicates actions that are equally appropriate at all stages whereas graded shading indicates increasing priority as intensity increases. AKI, acute kidney injury; ICU, intensive-care unit.

Stage-based management of AKI. Shading of boxes indicates priority of action—solid shading indicates actions that are equally appropriate at all stages whereas graded shading indicates increasing priority as intensity increases. AKI, acute kidney injury; ICU, intensive-care unit.

• ar aris rekomendebuliSardmdenebis gamoyeneba Tirkmlis mwvave ukmarisobis prevenciisTvis

• ar aris rekomendebuli dopaminis gamoyeneba Tirkmlis mwvave ukmarisobis prevenciasa da mkurnalobaSi

• ar aris rekomendebuli fenoldopamis gamoyeneba Tirkmlis mwvave ukmarisobis prevenciasa da mkurnalobaSi

• ar aris rekomendebuli ANP gamoyeneba Tirkmlis mwvave ukmarisobis prevenciasa da mkurnalobaSi

• ar aris rekomendebuli Igf 1 gamoyeneba Tirkmlis mwvave ukmarisobis prevenciasa da mkurnalobaSi

• rekomendebulia insulinoTerapia, samizne glukozis done 110-149 mg/dl (6.1-8.3 mmol/l)

• Tmu nebismier stadiaze rekomendebulia 20-30kkal/kg/dReSi

• ar aris rekomendebuli cilis SezRudva

• rekomendebulia 0.8-1.0 g/kg/dReSi cila Tmu arasadializo pacientebSi, 1.0-1.5 g/kg/dReSi sadializo pacientebSi,maqs. 1.7 g/kg/d cila mudmiv dializze pacientebSi

• Tmu pacientebi umjobesia ikvebon enteruli gziT

…7 saaTis Semdeg

• Ppacienti intubirebulia

• Ddiurezi 100ml/10sT

• Mkreat. 400,Sardovana 29, K-6.2 • metaboluri acidozi rCeba

• Ffiltvebis auskultaciiT sveli xixini

Hhiperkaliemiis mkurnaloba

• kalciumis glukonati 10% 10 ml i.v

• 10 U aqtrapidi + 40% 50ml glukoza i.v

• salbutamoli 2.5 mg nebulaizeriT

• hemodializi

• natriumis bikarbonati ???

HCO3- deficit = deficit/L (desired serum HCO3

- - measured HCO3

-) x 0.5 x body weight (volume of distribution for HCO3

-)

TirkmelCanacvlebiTi Terapia

Cveneba

• anuria an oliguria

• hiperkaliemia

• acidozi

• Sardovana > 30 mmol/l

• kreatinini > 300 mkmol/l

• hipervolemia

• uremiuli garTulebebi

• temperatura

• sefsisi

ganmarteba

• Sardis gamoyofa < 200ml/12sT

• sislSi K > 6.5 mmol/l

• pH < 7.2 • sidideebi absoluturi ar

aris

• filtvebis Segubeba

• encefalopaTia,neiropaTia,mioaTia

• hiper an hipoTermia

farmakokinetika

Ggamoidevneba hemodializiT

• salicilatebi

• meTanoli

• barbituratebi

• liTiumi

• aminoglikozidebi

• cefalosporinebi

ar gamoidevneba hemodializiT

• digoqsini

• tricikluri antidepresantebi

• benzodiazepinebi

• bB-blokerebi

• peroraluri hipoglikemiuri medikamentebi

Furosemide in ARF – meta-analysis - Ho et al 2006, BMJ Aar aumjobesebs avadobas Aar amcirebs dializis saWiroebas