RENAL FAILURE 1. 2 ACUTE RENAL FAILURE Acute renal failure (ARF) Community-acquired Acute renal...

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Transcript of RENAL FAILURE 1. 2 ACUTE RENAL FAILURE Acute renal failure (ARF) Community-acquired Acute renal...

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  • RENAL FAILURE 1
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  • 2 ACUTE RENAL FAILURE Acute renal failure (ARF) Community-acquired Acute renal failure Hospital-acquired Acute renal failure ICU-acquired Acute renal failure to kidney Multifocal insult to kidney 2007 American college of clinical pharmacy (ACCP)
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  • 3 ACUTE RENAL FAILURE Acute renal failure (ARF) 2007 American college of clinical pharmacy (ACCP) Polycystic kidney disease
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  • Acute renal failure (ARF) ARF or AKI is an acute decrease in kidney function (GFR) over hours associated with an accumulation of nitrogen waste products and (usually) volume. ACUTE RENAL FAILURE 4 2007 American college of clinical pharmacy (ACCP)
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  • Dec. of 25% in GFR Inc. in SCr 0.5 mg/dl (in patient with normal renal function ) Inc. in SCr 1 mg/dl (in patient with chronic kidney disease) Urine output less than 0.5 mL/kg/hour for more than 6 hours. *Fluid overload * Acid-base abnormalities Inc. in BUN out of proportion to increases in the SCr.
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  • Urine output Classification: ACUTE RENAL FAILURE 6
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  • 7 Community-acquired Acute renal failure Hospital-acquired Acute renal failure 2007 American college of clinical pharmacy (ACCP)
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  • 2- Community-acquired Acute renal failure Low incidence (
  • ACUTE RENAL FAILURE 27 Prerenal and functionIntrensicPostrenal HistoryVolume depletion Renal artery stenosis CHF HTN NSAID /ACEI Cyclosporine Ischemic injury Nephrotoxins (e.g., contrast) Vasculitis Glomerulonephritis Kidney Benign prostatic hypertrophy Cancers Physical examinationHypertension Dehydration Petechia if thrombotic Ascites Acute interstitial nephritis Rash, fever Distended bladder Enlarged prostate BUN/SCr Ratio> 20:115:1 Urine Sodium (Una)< 20 meq/L> 40 meq /L Fraction excreation of Na % FE Na < 1> 2Variable Urinary creatinine Serum creatinine (Ucr :SCr) > 40:1< 20:1 Urine sedimentHyaline casts, may be normalMuddy brown granular casts Tubular epithelial casts Variable may be normal Urinary WBC Urinary RBC Proteinuria -ve 2 - 4+ Positive Variable 1 + Negative CLASSIFCATION OF ARF
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  • Avoid nephrotoxic drugs when possible. Ensure adequate hydration. Patient education
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  • Correct primary hemodynamics Normal saline if volume depleted Pressure management if needed Blood products if needed
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  • Relieve obstruction. Early diagnosis is important. Consult urology and/or radiology
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  • No specific therapy universally effective Eliminate the causative hemodynamic abnormality or toxin. Avoid additional insults. Fluid and electrolyte management. Prevent volume depletion or overload and electrolyte imbalance
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  • Fenoldopam and Atrial natriuretic peptide : May reduce need for renal replacement therapy (RRT) and in-hospital mortality Loop diuretics: Consider loop diuretics for patients who are Oliguric, euvolemic or hypervolemic. Diuretic does not reduce mortality or improve renal recovery but may assist in fluid/ electrolyte management. Given intravenously at relatively high doses Low-dose dopamine. Ineffective. Avoid
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  • Renal replacement therapyIndications BUN greater than 100 Volume overload unresponsive to diuretics Uremia or encephalopathy Life-threatening electrolyte imbalance e. Refractory acidosis
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  • Avoid nephrotoxic drugs. Hydration : 0.9% NACL. Pt. education *Tight glycemic control 80-110 mg/dl using insulin (reduce ARF by 41%) Also reduce infection, days on mechanical ventilation and ICU length of stay. ACUTE RENAL FAILURE 34 2007 American college of clinical pharmacy (ACCP)
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  • A-Fluid management - Maintain renal perfusion & production of urine - Diuretic therapy: (consider of Pt. who are oliguric and euvolemic, or hypervolemic) B. Loop diuretic: bumetanide-furosemide-torsemide ethacrynic acid Parenteral therapy Furosemide intermittent therapy:40-80 mg IV q 6-8 hrs Furosemide continous inf.: 40-80 mg IV bolus, then 10- 20 mg /hr Other diuretics: Thiazide - Metolazone - Mannitol 35 ACUTE RENAL FAILURE 2007 American college of clinical pharmacy (ACCP)
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  • 36 Acidosis 1)Restrict dietary protein (< 0.5 g/kg/day of high quality protein 2)Sodium bicarbonate to maintain bicarbonate (HCO3 ) > 15 meq /L and arterial P 7.2 3)Dialysis Electrolyte and nutrition abnormalities ACUTE RENAL FAILURE 2007 American college of clinical pharmacy (ACCP)
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  • 37 ACUTE RENAL FAILURE 2007 American college of clinical pharmacy (ACCP)
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  • Drugs are responsible for kidney damage through many mechanisms Evaluate potential drug-induced nephropathy based on the period of ingestion, patient risk factors, and the propensity of the suspected agent to cause kidney damage
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  • Idiosyncratic reaction: not predictable Predictable reactions : High dose Risk factors Epidemiology Kidney at risk Pseudo drug induced nephropathy 39 ACUTE RENAL FAILURE 2007 American college of clinical pharmacy (ACCP)
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  • Predictable reactions based PK and Pt. risk factors -Hypoperfusion/ischemia -Inflammation -Direct cellular damage Risk factors -Prior history of CKD -Increased age 40 ACUTE RENAL FAILURE Contd 2007 American college of clinical pharmacy (ACCP)
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  • 7% of all drug toxicities 18%27% of AKI in hospitals 1%5% of NSAID users in community Most implicated medications: Aminoglycosides NSAIDs, ACEIs Contrast dye Amphotericin
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  • High exposure to toxin: Kidney receives 20% 25% cardiac output High intrarenal drug metabolism Tubular transport processes Concentration of solutes (i.e., toxins) in tubules High-energy requirements of tubule epithelial cells Urine acidification
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  • Drugs that inhibit Cr tubular secretion: Triamterene; cimetidine Drugs that increase BUN: Corticosteroids; tetracycline Drugs that interfere with Cr assay: Cefoxitin and other cephalosporins
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  • Most common drug-induced kidney disease in the inpatient setting
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  • 1-Aminoglycoside nephrotoxicity (1.7 % - 58 % ) 45 ACUTE RENAL FAILURE Pathogenesis -Proximal tubule damage (obstruction of the lumen) -Cationic charge of drug bind to tubular epithelial cells and uptake into those cells -Accumulation of phospholipids & toxicity Presentation - CRs & GFR after 6-10 days of therapy - Non-oliguric RF - Wasting of K + and Mg 2+ 2007 American college of clinical pharmacy (ACCP)
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  • 1-Aminoglycoside nephrotoxicity 46 ACUTE RENAL FAILURE Risk factors Relating to dosing (accumulation, prolonged therapy, high conc.>2mg/L Concurrent use of other nephrotoxins Pt. pre-existing renal insufficiency (age-poor nutrition- shock- gram negative bact ) Liver disease-Albumin, obstructive jaundice, dehydration K + - Mg 2+ Prevention - Avoid in high risk Pt. -Adequate hydration - the total cumulative aminoglycoside dose -Avoid other nephrotoxins -Use of extended interval (once daily) dosing. 2007 American college of clinical pharmacy (ACCP)
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  • 47 ACUTE RENAL FAILURE 2. Radiographic contrast media nephrotoxicity (IV contrast) 3 rd leading cause of inpatient ARF 2 % - 50 % (incidence) * Hospital mortality rate 34 % Radiographic contrast media nephrotoxicity Consists of Iso-osmolar (300 mOsm/kg) low-osmolar (780800 mOsm/kg) high-osmolar (more than 1000 mOsm/kg) agents Also categorized as ionic versus nonionic 2007 American college of clinical pharmacy (ACCP)
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  • 48 ACUTE RENAL FAILURE Pathogenesis Direct tubule toxicity due to reactive oxygen species Renal ischemia Hyperosmolar contrast >900 mOsmo/Kg osmotic diuresis dehydration ) Hypotension Renal vasoconstriction Presentation - Transient osmotic diuresis followed by tubular proteinuria -SCr & peak after 2-5 days -50 % of Pt. Oliguria & some will require dialysis 2. Radiographic contrast media nephrotoxicity (IV contrast) 2007 American college of clinical pharmacy (ACCP)
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  • 49 ACUTE RENAL FAILURE Risk factors Diabetes mellitus, Pre existing kidney disease Volume depletion Age older than 75 years Anemia Conditions with decreased blood flow to the kidney (e.g., CHF) Hypotension Other nephrotoxins Large doses of contrast (more than 140 mL) 2007 American college of clinical pharmacy (ACCP)
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  • 50 ACUTE RENAL FAILURE Prevention Hydration: IV NS Begin 612 hours before procedure. Maintain urine output greater than 150 mL/hour Discontinue nephrotoxic agents. Avoid diuretics. Use low-osmolar or iso-osmolar contrast agents in patients at risk 2007 American college of clinical pharmacy (ACCP)
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  • 51 ACUTE RENAL FAILURE Prevention contrast-induced nephropathy Non Emergency (elective) ( A) NS or ( NaHCo3 in 5% Dex. ) *Before Procedure 1-3 mL/kg/hr for 6-12 hrs *After Procedure 1 mL/kg/hr (B) Acetylcysteine *Before Procedure 600 mg orally 2 time/day for 2dosese *After Procedure 600 mg orally 2 time/day for 2dosese 2-Radiographic contrast media nephrotoxicity (IV contrast)
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