Approach to Azotemia

2. Approach to Azotemia Dr. Shahrzad Shahidi Professor of Nephrology Isfahan University of Medical Sciences

3. Case 1 • مرد 55 ساله با ضعف و بی حالی از چند روز قبل مراجعه کرده است. • بیمار مورد شناخته شده کانسر می باشد که 10 روز قبل شیمی درمانی شده است بعد از آن دچار بی اشتهائی و سپس اسهال شده ، به تدریج از شدت علائم گوارشی کاسته شده ولی ضعف و بی حالی بیمار افزایش یافته است. • سابقه بیماری خاصی در گذشته نمی دهد. فقط از 3 سال قبل هیپرتانسیون خفیف دارد ولی داروئی نمی خورد. • کارمند شهرداری می باشد ازدواج کرده و 3 فرزند دارد. • نکات مثبت درمعاینه فیزیکی: خشکی مخاطها وBP : 100/60 در حالت خوابیده و BP : 80/60 در حالت نشسته

4. Case 1 • WBC 12000 • PMN 90% , Lym 10% • Hb 11 after 3 days of admission • BUN 145 • Cr 5.1 • Na 127 • K 3.1 • U/A: SG 1.018, Hyaline cast 2-3/lpf , Granular cast 1-2/lpf 10 85 3.4 132 3.3

5. Case 1 • تشخیص؟ • چه اقدامی برای بیمار انجام شده است؟

6. Case 1 • WBC 12000 • PMN 90% , Lym 10% • Hb 11 after 3 days of admission • BUN 145 • Cr 5.1 • Na 127 • K 3.1 • U/A: SG 1.008, Hyaline cast 3-4/lpf , Granular cast 4-5/lpf 10 150 9.2 130 5.1

7. Case 1 • چه اقدامی برای بیمار انجام شده است؟

8. Identification • Azotemia • Uremia or Uremic syndrome • AKI • CKD • ESRD

9. Acute Kidney Injury An abrupt (within 48 hs) reduction in kidney function currently defined as: • An absolute increase in Cr of either ≥ 0.3 mg/dl • A percentage increase of ≥50% • A reduction in urine output (documented oliguria of < 0.5 ml/kg/hr for >6 hs)

10. D.D of Azotemia • Acute Kidney Injury (AKI) • Chronic Kidney Disease (CKD) • Acute worsening of CRF or Acute on Chronic Renal Failure

11. D.D of Azotemia • Acute Kidney Injury (AKI) • Chronic Kidney Disease (CKD) • Acute worsening of CRF or Acute on Chronic Renal Failure

13. ARF • Prerenal Azotemia 55% • Renal 40% • ATN 90% • AIN • AGN or Vasculitis • Acute Renovascular Disease • Post renal 5% Admission in wards ~ 5% Admission in ICU ~ 30%

14. Syndromes of Renal Hypoperfusion ATN Pre renal A. Intermediate syndrome ACN

15. Syndromes of Renal Hypoperfusion

16. Urine Indices Used in the DD of Prerenal & Intrinsic Azotemia

17. Ranges of Biochemical Abnormalities in ARF

18. Acute Kidney Injury • Spectrum of disorders from reduced function to established failure • Multi-factorial causes

19. Staging of AKI

20. AKI Outcome & Prognosis • The development of AKI is associated with a significantly increased risk of in-hospital & long-term mortality, longer length of stay, & increased costs. • Survivors of an episode of AKI requiring temporary dialysis, are at extremely high risk for progressive CKD, & up to 10% may develop ESRD.

21. AKI Outcome & Prognosis • Postdischarge care under the supervision of a nephrologist for aggressive secondary prevention of kidney disease is prudent. • Patients with AKI are more likely to die prematurely after they leave the hospital even if their kidney function has recovered.

22. Treatment • Prevent it in the First Place!! • Treat / Remove the Cause • Restore adequate circulating Volume • Restore adequate BP • Restore adequate flow • Control fluid intake • Wait, Patience is a virtue! • Renal replacement therapy

23. D.D of Azotemia • Acute Renal Failure (ARF) • Chronic Kidney Disease (CKD) • Acute worsening of CRF or Acute on Chronic Renal Failure

24. CKD • Markers of kidney damage for > 3 ms, as defined by structural or functional abnormalities of the kidney with or without decreased GFR. OR • The presence of GFR <60 mL/min/1.73 m2for > 3 ms, with or without other signs of kidney damage as described above.

25. Stages of CKD

26. Leading Categories of Etiologies of CKD • Diabetic glomerular disease • Hypertensive nephropathy • Glomerulonephritis • Autosomal dominant polycystic kidney disease • Other cystic & tubulointerstitial nephropathy

27. Screening of CKD Individuals at high risk for kidney disease.

30. eGFR

31. Why Estimate GFR From SCr, Instead of Using SCr for Kidney Function? *B = black; †W = all ethnic groups other than black. GFR calculator available at: www.kidney.org/index.cfm?index=professionals. Accessed 3/28/05.

32. eGFRcreat Report eGFRcreat in adults using the 2009 CKD-Epidemiology Collaboration (CKD-EPI) cr equation

33. eGFRcreat Cockroft-Gault formula: Clcr = (140- age ) Lean BW Cr x 72 in female x 85%

34. eGFRcreat Equation from the Modification of Diet in Renal Disease study (MDRD) eGFR (ml/min/1.73 m2) = 1.86 x (PCr)–1.154 x (age)–0. 203     Multiply by 0.742 for women Multiply by 1.21 for Blacks

35. D.D of Azotemia • Acute Renal Failure (ARF) • Chronic Renal Failure (CRF) • Acute worsening of CRF or Acute on Chronic Renal Failure

36. Causes of Acute on CRF • Hypovolemia • Infection • CHF • Nephrotoxic drugs • Urinary tract obstruction • Severe HTN • Pregnancy • Exacerbation of primary renal disease • …

37. Useful Features That Suggest CRF or ARF • Chronic Hx of: • Nocturia, polyuria, edema or hematuria • Pruritus, neuropathy, impotence, other uremic symptoms • Underlying predisposing illness (DM, HTN)

38. Useful Features That Suggest CRF or ARF (cont.) • Objective Findings: • Bilateral Small Kidneys • Renal Osteo Dystrophy • Band keratopathy

39. Useful Features That Suggest CRF or ARF (cont.) • Less reliable: • Anemia • Hypocalcemia • Hyperphosphatemia

40. - +

45. RBC Cast

46. WBC (Pyuria)

48. Preventing the Progression of CKD • Avoidance of nephrotoxins • Dose adjustment of drugs • Early referral to nephrologist • Prompt treatment of UTI • Prompt relief of urinary tract obstruction • Control BP • Induce diuresis before, during & after radiocontrast administration

49. Preventing the Progression of CKD (cont) 8.Dietary advice: • Avoidance of excessive dietary Pr & salt intake • Maintain weight • Treat obesity 9. Treat hyperglycemia uncontrolled by dietary measures 10. Treat hyperlipidemia uncontrolled by dietary measures 11. Screen for renovascular disease

50. Drug Doses in Renal Failure