acute renal failure

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acute renal failure

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1. Acute Renal Failure Anil Menon 11/27/06

2. Nitrogenous and non-nitrogenous waste products. Cr/BUN. Remember Cr not good indicator of GFR in non-steady state (production/volume distribution). Many definitions.Nitrogenous and non-nitrogenous waste products. Cr/BUN. Remember Cr not good indicator of GFR in non-steady state (production/volume distribution). Many definitions.

3. Relevance Complicates up to 7% of admissions Mortality when dialysis is required ranges 50%-75% 75% in context of sepsis and critical care. 75% in context of sepsis and critical care.

4. DDX MAP of 70 is when GFR begins to become impaired (autoregulation). Autoregulation is prerenal dilation regulated by prosglandins and NO and post glom constriction by ATII. NSAIS interfere with these. At risk group elderly, CRI, athero. ATN most common, then post op pre renal 25%, then radiocontrast. Post renal 10%.MAP of 70 is when GFR begins to become impaired (autoregulation). Autoregulation is prerenal dilation regulated by prosglandins and NO and post glom constriction by ATII. NSAIS interfere with these. At risk group elderly, CRI, athero. ATN most common, then post op pre renal 25%, then radiocontrast. Post renal 10%.

5. Diagnostic Approach Cr/BUN, UOP, serum cystatin K, IL18 H&P Meds Labs Imaging

6.

7. Acute or Chronic? History Previous creatinine Small kidneys on u/s Duration of sxm, nocturia, absence of acute illness, anemia, hyper pho, hypo calDuration of sxm, nocturia, absence of acute illness, anemia, hyper pho, hypo cal

8. Obstruction excluded? History Complete anuria Palpable bladder Renal u/s Previous stones. Sxm. Bladder flow. Complete anuria rare in arf without obsruction. See dilation of pelvis and calyx if not malignancyPrevious stones. Sxm. Bladder flow. Complete anuria rare in arf without obsruction. See dilation of pelvis and calyx if not malignancy

9. Euvolemic? Pulse, JVP/CVP, orthostatic, wgt, I/O Disproportionate inc in urea:Cr ratio FENA Fluid challenge High antiADH leads to urea resorp by tubules. Fena okay without diuretics. Care for pulm edema in oliguric patientsHigh antiADH leads to urea resorp by tubules. Fena okay without diuretics. Care for pulm edema in oliguric patients

10. Evidence of parenchymal dz? Other than ATN H+P (systemic factors) Urine dipstick and micro (red cells, red cell casts, eosinophils, prot) Rash, arthralgia, myalgia, abx, nsaids AIN. Red casts nepritis or eos AIN think nephrologistRash, arthralgia, myalgia, abx, nsaids AIN. Red casts nepritis or eos AIN think nephrologist

11. Major vascular occlusion? Athreosclerosis Renal Assymetry Groin pain Complete Anuria Macro Hematuria Elderly athreo, renovascular in 34% elderly with CHF. Occlusion of normal renal artery groin pain and hematuria. If one goes down because athero then embolism to the remaining is bad. ACE/Diuretics in stenosis or instrumentation. Cholesterol embolism post angiographhy or surgery livedo reticularis, arf, esoin one to four weeks outElderly athreo, renovascular in 34% elderly with CHF. Occlusion of normal renal artery groin pain and hematuria. If one goes down because athero then embolism to the remaining is bad. ACE/Diuretics in stenosis or instrumentation. Cholesterol embolism post angiographhy or surgery livedo reticularis, arf, esoin one to four weeks out

12. Treatment Prevention Risk factors (age,DM,HTN,Vasc,renal) Maintain BP and Volume, avoid neprhotox Measure plasma aminoglycoside Allopurinol/urine alk in cancer

13. General Correct prerenal/postrenal factors Optimise CO, RBF Review meds Monitor I/O Nutritional support Treat infection, bleeding Start dialysis before uremic

14. No strong evidence Loop diuretic Dopamine Natriuretic peptide Intermittent HD vs Continuous ILF Thyroxine Ototoxic in high does, tach/periph gangrene, hypotension, blank, blank, inc mort in critical ptOtotoxic in high does, tach/periph gangrene, hypotension, blank, blank, inc mort in critical pt

15. ATN Sepsis in ICU 35-50% Prerenal azotemia spectrum with ischemic ATN Initiation, maintenance, recovery BUN/Cr normal 10:1 Rapid rise plasma Cr Muddy brown epi casts FENa > 2% Ucr / PCr Snake bite, crush injury, nephrotoxin, sepsis. Snake bite, crush injury, nephrotoxin, sepsis.

16. Post Op 18-40% hospital aquired. 1.2% surgery. Pre-op BP control (Carmaichael J Surgery 2003) Hydration and prevention Poor prognosis of ARF when adjusted (Svensson J Vasc Surg 1989) Nephrology Prognosis jumps from 4.3 to 67% when adjusted for cormorbitites in cardiac groupPrognosis jumps from 4.3 to 67% when adjusted for cormorbitites in cardiac group

17. Contrast Isotonic crystalloid 1-1.5ml/kg for 3-12 hours pre proc and 6-24 hours post Mucomyst not consistently useful Current eval of theophyline, statins, vit c, pg E CCB, L-arg, fenoldopam, dopamine, ANP not useful Prophylactic HD no gain (Stacul 2006 CIN consensus working panel) NS better than 1/2 because the inc sodium reduces renin pathway response. Duration not clear, oral fluids maybe for outpatient. Emergency? Prep for HD with severe renal failure.NS better than 1/2 because the inc sodium reduces renin pathway response. Duration not clear, oral fluids maybe for outpatient. Emergency? Prep for HD with severe renal failure.

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