Renalfail Final 6 Th June11

8/3/2019 Renalfail Final 6 Th June11

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ACUTE RENAL FAILURE


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Background Reversible illness

Commonin Hospitalizedpatients Associated withhigh Morbidityand

Mortality

Often Multifactorial

Identifiable riskfactors.


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Acute Renal Failure Suddendecrease kidneyfunction(hours-

days)

Oftenmultifactorial

Pre-renalandintrinsicrenalcauses : 70%

oliguric UOP < 400-500 ml (35%)

Non-oliguric (upto 65%) Associated withhighmortalityand

morbidity,ifnotttedproperly


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Acute Renal Failure

Diagnosis Laboratory Evaluation:

Scr, More reliable markerofGFR

smallchange reflectslarge change in GFR

BUN/urea,generallyfollowsScrincrease

Elevation may be independent of GFR ( normal

kidney function but high urea/bun)

Steroids, GIB, Catabolic state, hypovolemia

BUN/Cr ratiohelpfulinclassifyingcause of

ARF

ratio> 20:1 suggestsprerenal cause

ratio 10-15:1 suggestsintrinsic renal cause


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Acute Renal Failure

Diagnosis (contd) Urinalysis

MAY BE NORMAL in,pre and post renal

causes

Renal

Differentiates ATN vs. AIN. vs. AGN

Muddybrowncastsin ATN WBC castsin AIN


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Prerenal ARF Nearlyascommonas ATN (thinkofas

earlypartofthe disease spectrum)

Diagnose byhistoryandphysical exam N/V, Diarrhea, Diureticuse,...

highBUN/creatratio,

normalurinarysediment Treat: correctionofpredisposingfactors


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Acute Renal Failure

Etiologies Acute TubularNecrosis

Mostcommonintrinsic ARF

Oftenmultifactorial

LOW URINE OUTPUT,carriesbetterprognosis

(1) Ischemic ATN:

Hypotension,sepsis,prolongedpre-renalstate

(2) Nephrotoxic ATN:

Contrast/ DYE, Antibiotics, Heme proteins

COMBINATION OF BOTH, MANY TIMES


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Acute TubularNecrosis (ATN) -- 2

Diagnosebyhistory,

Urine sediment withcoarse granularcasts,

Treatment;

(A) supportive care.

(1)Maintenance ofeuvolemia /normalbody volume

(with judicioususe ofdiuretics, IVF,asnecessary)

(2) T reat,hypotension

(3) Avoid,nephrotoxicdrugs (including NSAIDsand

ACE-I) whenpossible

(B) Dialysis,if norecovery

OUTCOME: 80% willrecover,ifinitialinsult

treateda ressivel


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Contrastnephropathy 12-24 hourspost exposure,peaksin 3-5

days

Non-oliguric

treatment/Prevention: 1/2 NS 1 cc/kg/hr12

hourspre/post

Mucomyst 600 BID pre/post (4 doses)

RiskFactors: CRF, Hypovolemia./DM


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Rhabdomyolytic ARF

CAUSE : aftertrauma (crushinjuries),

seizures,burns

Diagnose:

o serum CPK(usu.> 10,000),

urine dipstick(+) forblood, without RBCs

onmicroscopy,

pigmentedgranularcasts

Treatment; HYDRATION &

Alkalinizationofurine .


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Acute Interstitial Nephritis Usuallydruginduced

methicillin, rifampin, NSAIDS

Develops3-7 days afterexposure

Fever, Rash,and eosinophiliacommon

Urine: revealsWBC,WBC casts, +

HanselstainTreatment: Oftenresolves

spontaneously

Steroids maybe beneficial ( ifScr>2.5


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Acute Renal Failure

Etiologies Post-Renal

Bladderoutletobstruction

BPH,intrapelvicpathology Crystalluria (DRUGS)

Acyclovir, Indanivir, Uric Acid


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PreventionWhat works?

Maintenance ofeuvolemia

Avoidance ofnephrotoxins whenpossible

NSAIDs,aminoglycoside, Amphotericin, IV

contrast

BPcontrol--avoidance ofexcessive hypo-

orhypertension


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PreventionWhatdoesnt work?

Empiricuse of:

Diuretics (i.e.,? Furosemide, Mannitol)

Dopamine (orDopamine agonistssuchas

Fenoldopam)

Calcium-channelblockers


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Acute Renal Failure

Treatment Waterandsodiumrestriction

Proteinrestriction

Potassiumandphosphate restriction

Adjustmedicationdosages

Avoidance offurtherinsults

BPsupport Nephrotoxins


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Hyperkalemia Dangeroustoheart

Highly Arrhythmogenic

ECG changes Peaked T waves --->Widened QRS-->Sinus wave

K> 5.5 meq/L needs evaluation/intervention


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Dialysis Indications Refractoryhyperkalemia

Metabolicacidosis

Volume overload

Mentalstatuschanges


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Renalfail Final 6 Th June11

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