Renal failure
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RENAL FAILURE. DR..M.H.MUMTAZ. TYPES. 1, REVERSIBLE DYSFUNTION (acute R.failure) 2, IRREVERSIBLE DYSFUNTION (Chronic R failure). ACUTE RENAL FAILURE. 1, PRE RENAL 2, RENAL

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RENAL FAILURE

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Renal failure

RENAL FAILURE

DR..M.H.MUMTAZ


Types

TYPES

1, REVERSIBLE DYSFUNTION

(acute R.failure)

2, IRREVERSIBLE DYSFUNTION

(Chronic R failure)


Acute renal failure

ACUTE RENAL FAILURE

  • 1, PRE RENAL

  • 2, RENAL

  • 3, POST RENAL


Pre renal failure

PRE RENAL FAILURE

  • CAUSES

    a,total body water depletion

    b,water redistribution

    ivs--------iss

    vasodilation,sepsis,anaphy.

    c,low CO--------low BP (S,M.D)


Renal

RENAL

a, Interstitial nephritis

b, A.T.N.

hypoperfusion

chemical

trauma , toxins

sepsis


Pathology

PATHOLOGY

T.obstruction

T.damage

T.backleakage


Diagnosis

DIAGNOSIS

a,History

oligurea,concentrated U

b,Tests

lab. Serum,urine

radiodiagnostics

C.T. MRI. Ultrasount


Alternative class

ALTERNATIVE CLASS.

Filteration failure

Tubular dysfuntion

Oliguric/non oliguric


Risk factors

Acute diseases

sepsis

SIRS

jaundice

I.A.P.

renal trauma

transfusion DIC

Anaphylaxis

muscle injury

thermal burn

electrocution

RISK FACTORS


Risk factors1

RISK FACTORS

CHRONIC DISEASES

advancing age

diabetes mellitis

renal disease

vascular disease

hyperuricaemia


Risk factors2

Physiological changes

1. ^ age

2. ^ HR hypotension

^ CVP, lowRVPP

high or low co,svr

abnormal OER

olig/polyurea

3. Fluid balance

Oedaema

high/low protein

intake

RISK FACTORS


Risk factors3

RISK FACTORS

Chronic drug therapy

NSAIDS

Diuretics

Cyclosporins


Risk factors4

Acute drug therapy

A. ATN

aminoglycosides

cephalosporins

diuretics contra.

rifampicin

lithium

cisplatin

B. Interstitial nephritis

cephalosporins

diuretics

aspirin,NSAIDS

cemetidine

captopril

RISK FACTORS


Risk factors5

RISK FACTORS

Proceedures

a. Aortic/renal cross clamping

b.Transfusion

c. Major surgery


Risk factors6

RISK FACTORS

IMPAIRED RBF

hypotension/m.hypertension

renal art. Occlosion

hepatorenal failure

endotoxaemia

renal vein thrombosis

renal venous hypertansion


Risk factors7

Metaboic causes

1. Electrilytes

hyper-cal

hypo-k

hyper-phosphate

2. High oncotic P.

3. Metabolites

Pigments

bilirubin

myoglobin

haemoglobin

RISK FACTORS


Risk factors8

Post-renal

urethral/blader obs.

bil.ureter obs.

stones/clot/tumur

papillary necrosis

Retroperitoneal fibrosis

Surgical ligation

Blader rupture

Renal pelvic trauma

Urethral trauma

RISK FACTORS


Acute tubular necrosis

ACUTE TUBULAR NECROSIS

PHASES

a,Initiation phase

b,Maintenance phase


Initiation phase

ISCHAEMIA

^ symp.stimulation

^ renin activity

PGE2

ANH inhibition

^ ADH

^ adenosine

^ endothelin

NEPHROTOXINS

Ischaemia increases the

susceptibility to

nephrotoxic agents

INITIATION PHASE


Mantenance phase

MANTENANCE PHASE

  • Factors acting to maintain filteration failure

    1,tubular obstruction

    2,tubular backleak

    3,vasodilatation of efferent art.

    4,decreased GMP


Mechanism of oligurea

Mechanism of oligurea

a,glomerulo-tubular balance

b,decreased GMP

c,itratubular obstruction

d,interstitial oedema

e,cortical ischaemia


Complications of arf atn

A,oligurea

absolute

relative

B, azotaemia

normal solute load

maximum

in catabolic states

in ARF

^ urea/d

^ cr/d

Complications of ARF/ATN


Complications

C,Biochamical

^NaCl/water

^ K

^ HPO4

hypocalcaemia

^ Mg

^ uric acid

M.acidosis

D,Haematological

Anaemia

Thrombocytopaenia

Leukocyte dysf.

Complications


Complications1

E,Immunosupression

Lumphopaenia

Reduced IgG

Reduced comple.

Impaired PMN

R.I.response

Drug effects

Infections

F,C.V.S.

CCF

Hypertention

Arrhythmias

Pericarditis

Effusion

Complications


Complications2

G, G.I.T.

Anorexia,Nausea,

Ileus,Hmge.

H,Neurological

Lethargy,somnolance

Confusion,

Convulsions

^ sensitivity to

anaesthetics

Complications


Complications3

Complications

I,causes of pulmonary infilterates in ARF

1,LVF/CCF

2,bacterial pmeumonia

3,Atypical pneumonia

4,Septicaemia

5,ARDS

6,Autoammune diseases


Causes of acidosis in arf

A,Tubular dysfuntion

B,Glomerular dysfuntion

C,Other causes

low C.O.

Resp.F

Starvation

Rhabdomyolysis

Hyperkalaemia

Organic acids

Causes of Acidosis in ARF


Investigations in arf

Biochemistry

INVESTIGATIONS IN ARF


Investigations

INVESTIGATIONS


Investigations 1 biochemistry

Investigations-1, Biochemistry


Definitions

Definitions

  • RFI=RENA FAILURE INDEX

  • =urine(Na)/(U/P creatinine)

  • FEna=%fractional excretio Na

  • =(U/P Na).100/(U/P creatinine)


Abnormal urea creatinine ratio

Abnormal urea/creatinine ratio

  • Normal U:C ratio 100:1( R;70-150)

  • Pre-renal disease >200:1


Abnormal urea creatinine ratio1

Abnormal urea/creatinine ratio

  • High Ratio

  • ^ urea .dehydration/hypovol.

  • .GIT.bleeding

  • .Catabolic state

  • .Hyperalimentation

  • .Drugs

  • low creatinie .elderly,low m. mass


Abnormal urea creatinine ratio2

Abnormal urea/creatinine ratio

  • Low Ratio

  • low urea. Liver failure

  • hepato-renal synd

  • Malnutrition

  • High creatinie rhabdomyolysis

  • acute m.disease

  • ketones,drugs


Creatinine clearance

CREATININE CLEARANCE

  • 1,

    clearance(ml/min=(N-age[years])*BW(kg)/serum creat.

    N = 150 foe female

    N = 160 for male > 70

    N = 170 for male < 70

    2,

    clearance(ml/min)=UV*1000 /p*420

    U=urine creatinine level

    V=urine volume (midnight &7 am)

    P= plasma creatinine level


2 urinary sediment

2. Urinary sediment

  • .Cast types

  • i,hyaline casts, fever,diuretics,RD

  • ii,red cell casts glomerulonephritis

  • iii,w.cell casts pyelonephritis

  • iv,waxy casts chronic renal disease


3 imaging

3,Imaging

  • 1, Ultrasound

  • 2, CT scan

  • 3, IV pylogram

  • 4, radio-isotope perfusion scan

  • 5, renal angiogram


4 renal biopsy

4,Renal biopsy

  • 1, glomerulonephritis

  • 2, vasculitis

  • 3, SLE

  • 4, Goodpasture syndrome

  • 5, TTP

  • 6, Interstitial nephritis

  • 7, oligurea lasting > 8 weeks


Renal failure prophylaxis protection

Renal failureprophylaxis&protection

  • Methods

  • 1, physiological

  • 2,physical

  • 3,pharmacological

  • 4,replacement therapies


Physiological methods

Physiological methods

  • a, normalise blood volume

  • iv fluids,(Na containg)

  • b,optimise cardiac output

  • iv fluids.inotropes,vasopressors

  • c, optimise O2 delivery

  • Hb,Spo2,avoid acidosis

  • d, high sodium excretion


Physical methods

Physical methods

  • Detection/management of IOH

  • Detection/management-post renal obs.

  • Limitation of aortic clamp times

  • Avoidance of embolisation

  • Minimise direct trauma


Pharmacological methods

Pharmacological methods

  • Avoid nephrotoxins

  • Avoid inhibitors of autoregulation

  • Diuretics

  • Renodilators

  • Other agents

  • free radical scavengers

  • Ca channel blockers


Renal replacement methods

Renal replacement methods

  • Haemo- filtration

  • Haemo-diafiltration

  • Haemodialysis

  • R. Transplant.


Renal failure frusemide

Renal failure---Frusemide

  • Beneficial effects

  • Increased tubular&urine flow

  • Increase Na &osmolar clearance

  • Decreased tubular O2 demand

  • Stimulate vasodilator prostaglandins

  • Deleterious effects

  • Hypovolaemia

  • Hypokalamia,Hyponatraemia

  • Ototoxicity


Uses in non renal failure

Uses in non renal failure

  • Fluid overload

  • Cerebral oedema

  • Hyperkalaemia

  • Renal protection

  • ( decreased O2 demand)


Renal failure mannitol

Renal failure---Mannitol

  • 1,Osmotic diuresis

  • 2,Anti sludging ,tubular protect.

  • 3,renal vasodilatory PG synthesis

  • 4,Free radical scavenger

  • 5,Decreased T. swelling


Renal failure dopamine

Renal failure---Dopamine

  • Increases Fe Na excretion

  • Increases urine out put

  • Does not increase creatinine clearance

  • Inotropic effect

  • Doesnot prevent ac.renal failure

  • Side effects,

  • gastric stasis,inhibition of

  • ant pit.hormones,hypoxic

  • drive depression.


Renal failure nor adrenaline

Renal failure---Nor-adrenaline

  • Increases perfusion pressure by increase

  • of efferent arteriolar resistance

  • more than afferent art.resistance


Other therapies

Other therapies

  • 1,Calcium channel blockers

  • 2,Adenicine recepter antagonists

  • 3,Oxypentifylline

  • 4,Chlorpromazine

  • 5,Clonidine

  • 6,ATP-MgCl2

  • 7,ANF


Conclusion renal rescue therapy

Conclusion,Renal rescue therapy

  • Normalise;-

  • Blood flow

  • blood volume

  • blood pressure

  • O2 delivery

  • CO—CI

  • Blood Pressure, s,m,d.


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