Renal failure
Sponsored Links
This presentation is the property of its rightful owner.
1 / 51

Renal Failure PowerPoint PPT Presentation


  • 373 Views
  • Uploaded on
  • Presentation posted in: General

Renal Failure. Rebecca Burton-MacLeod R5, Emerg Med Nov 8 th , 2007. Overview of RF. Renal Failure. Chronic renal failure. Acute renal failure. Acute on chronic renal failure. Acute renal failure . 2 main renal physiological functions that are easily measured in ED: Urine output

Download Presentation

Renal Failure

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Renal Failure

Rebecca Burton-MacLeod

R5, Emerg Med

Nov 8th, 2007


Overview of RF

Renal Failure

Chronic renal failure

Acute renal failure

Acute on chronic renal failure


Acute renal failure

  • 2 main renal physiological functions that are easily measured in ED:

    • Urine output

    • Excretion of water soluble waste products of metabolism

  • Therefore, definition of ARF:

    • Decline in Cr clearance of 50%

    • Increase in serum Cr of 50%

    • Renal insult causing pt to require dialysis


ARF

  • May have anuric (<100cc/24h), oliguric (<0.5cc/kg/h), or non-oliguric renal failure

  • Mortality lower with non-oliguric renal failure; however, may still have renal failure with NORMAL urine output!!


Pre-renal (most common; 55% hosp pts)

Intravascular depletion (hemorrhage, dehydration, diuresis, GI losses, skin losses)

Vasodilation or dec cardiac output (sepsis, anaphylaxis, nitrates, antihypertensives, liver failure)

Post-renal (obstruction anywhere along UT)

Renal calculi

Urethral valves

VUR

Cervical Ca or pelvic inflammation

Prostatic disease

Etiology


Etiology: renal causes

  • ATN (ischemia, rhabdo, toxins—contrast, aminoglycosides, NSAIDs, ACEi, ARBs, tacrolimus, cyclosporine, cisplatinum, heavy metals, ethylene glycol, cocaine)

  • Interstitial insult (adverse drug rxn, often assoc with fever, rash, jt pain)

  • Glomerular insult (glomerulonephritis)

  • Vascular insult (renal art thrombosis or stenosis, renal vein thrombosis, scleroderma)


History:

Hx thirst

GI losses

Hemorrhage, burns, trauma

Pancreas/liver disease

Meds

Recent illness

Urgency/frequency/ hesitancy in males

Physical:

Vitals

Volume status

CV—dysrhythmia, s/s endocarditis

Abdo—aneurysm, flank tender, bladder size

Neuro—asterixis, LOC

Derm—rashes, edema

Differentiating causes


Diagnosing

  • Lytes, BUN, Cr

  • EKG

  • U/A, Urine lytes

  • U/S +/- CT KUB


U/A

  • Casts:

    • Hyaline—generally assoc with pre-renal or post-renal obstructive causes

    • RBC—always significant; assoc with glomerulonephritis

    • WBC—renal parenchymal inflammation

    • Granular—cellular remnants and debris

    • Fatty—nephrotic s/o or other nonglomerular renal disease


Urine Na

Fractional excretion Na

(Urine Na x plasma Cr) / (plasma Na x urine Cr)

Affected if mannitol or loop diuretics administered

Urine Na <20 and FENa <1%

Pre-renal failure, acute obstruction, contrast-induced ATN, rhabdo-induced ATN, nonoliguric ATN

Urine Na >40 and FENa >1%

ATN, chronic obstruction, underlying CRF

Urine lytes


Prevention

  • Adequate volume replacement

  • Foley/percutaneous nephrostomy

  • Avoid nephrotoxic agents if possible, or else use OD dosing

  • Renal-dosing dopamine in conjunction with lasix may aid in converting oliguric to non-oliguric RF

  • Consider low-dose vasopressin in sepsis


Management of specific problems

  • HyperPh: give oral Ca antacids which bind to Ph

  • Symptomatic hypoCa: 10cc of 10% Cagluconate IV

  • HyperK: if >6.5 and EKG changes…be aggressive!

  • Volume overload: diuretics, nitrates, dialysis


Indications for dialysis with ARF

  • Fluid overload in oliguric/anuric RF

  • HyperK

  • Severe acidemia

  • Uremic encephalopathy

  • Toxins: ethylene glycol, methanol, ASA, Li, theophylline


Prognosis in ARF

  • If receive dialysis for ARF then 16% remain dialysis-dependent

  • Also, 40% of pts develop CRF


Chronic renal failure

  • Definition:

    • CRF—GFR <60cc/min, but decreased by <75%

    • ESRD—GFR <10cc/min, serious life-threatening complications without dialysis or transplant


Etiology

  • DM (45%)

  • Hypertension (30%, up to 40% in black popn)

  • Glomerulonephritis

  • Collagen vascular disease (SLE, scleroderma, Wagners)

  • Hereditary (PCKD, Alports s/o)

  • Obstructive uropathy (BPH, retroperitoneal tumor, nephrolithiasis)

  • HIV

  • Nephrotoxins (contrast, heroin, ampho B, aminoglycosides)

  • Peds—reflux nephropathy


Complications

  • Uremia

  • Renal osteodystrophy

  • Normocytic normochromic anemia

  • Infections (impaired WBC function)

  • GIB (stress ulcers and impaired hemostasis)

  • Pericarditis (up to 20% of dialysed pts)


What ? Do you need to ask…

  • Dry weight?

  • Dialysis schedule?

  • Form of dialysis (hemo, peritoneal)?

  • Missed dialysis?


Mgmt of specific disorders

  • Cases…


Case 1

  • 68yo F with sharp lower abdo pain x2d, worsening. Small amount of blood in stool this a.m.

  • You’re convinced you need a CT abdo. Speak to Radiol. They ask what her Cr is…

  • ….long pause…..142….

  • Do you still want CT? What are your options?


Contrast nephropathy

  • Risk factors—DM, underlyling renal d/o, amyloidosis, MM, hypo-proteinuric states, larger doses of contrast, repeat exposures to contrast <72hr, type of contrast

  • NAC?

  • Bicarb?


Papers…

  • Several studies done looking at benefit of NAC vs. bicarb vs. saline for prevention of contrast nephropathy


  • N=264; received either bicarb infusion, or N/S infusion, or NAC and N/S infusion

  • 6 hrs pre and post angio

  • Baseline Cr 139

  • Change in Cr clearance significantly better with bicarb than with other regimens


Cont’d


  • DBRCT n=326 pts undergoing angio

  • All had chronic renal disease

  • Protocols: 1) N/S x12 hrs pre and post and NAC 2) bicarb x1h pre and 6h post and NAC 3) N/S and ascorbic acid and NAC

  • All pts had NAC day prior to procedure and days after


Cont’d

  • Outcome:

    • In N/S and NAC: 9.9% developed CN

    • In bicarb and NAC: 1.9% developed CN

    • In N/S and ascorbic acid and NAC: 10.3% CN

    • Bicarb and NAC significantly better in medium to high risk pts for CN


  • N=118 with Cr >110

  • Bicarb 3ml/kg/h x1h prior then 1ml/kg/h x6h post vs. N/S infusion as above

  • Significantly greater nephroprotective effects from bicarb

  • Postulated due to inc flow, local tubular alkalinization, partial correction of ischemic acidosis


Case 2

  • 72yo M presents c/o chest pain, weakness. At triage, HR noted to be 32.

  • Brought back to monitored bed.

  • Hx of DM, hypertension, recent w/u for back pain

  • Meds: metformin, lasix, propanolol, penicillin, one other med he can’t remember the name of…


Case cont’d

  • O/e: HR 34, SBP 86, RR 16, sats 93%

  • Pt pale, slightly diaphoretic; nil else remarkable on exam

  • BG—6.8

  • Plan?


EKG

Any thoughts ?

Plan ?


Case cont’d

  • ABG– K 9.8

  • Cr 589


HyperK in RF

  • CaCl 5cc IV bolus, rpt q5min prn

    • ?is he on digoxin?

  • Bicarb 50meq IV, rpt x1 prn

    • Watch for volume overload!!

  • Ventolin nebs, rpt or continuous

  • Insulin—give 10-20U Hum R mixed with glucose

    • Use D20 or D50 to decrease volume

  • Kayexalate, mixed with sorbitol

    • Watch for Na overload as exchanges K for Na

  • IV diuretics

    • Only works if residual renal function!

  • Dialysis!!!


How quickly will K drop?

  • Insulin drops K by 1meq/L after 1h

  • IV Ventolin drops K by 1.1meq/L after 15min

  • Dialysis:

    • Hemodialysis—removes up to 50meq/h

    • Peritoneal dialysis—removes 15meq/h


Case 3

  • 47yo F hemodialysis patient presents to ED c/o SOB

  • Last dialysis 5d ago (missed one because travelling back from US); states weight up 6lbs

  • O/e: HR 110, BP 145/87, sats 88% r/a

  • Tachypneic, ++crackles to bilat lungs, elevated JVP

  • You call her Nephrologist…waiting for them to get back to you…

  • Plan?


Pulmonary edema

  • Hemodialysis…

  • Oxygen, sitting position

  • Consider CPAP

  • Nitrates: SL, IV or nitroprusside

  • Lasix 60-100mg IV (for pulm vasodilation)

  • +/- IV morphine

  • Sorbitol 70% 50-100cc dose q20-60min (causes osmotic shift into gut)

  • Hemodialysis…


Case 4

  • 59yo M presents to ED c/o cough, SOB, fever x3d

  • Mild chest pain, no abdo pain, no n/v

  • PMHx: hemodialysis pt, DM, pacemaker

  • O/e: HR 115, SBP 95, RR 30, sats 95% r/a

  • Slight JVD, normal HS, lungs clear, abdo soft

  • Investigations?


CXR

Old XR (1y ago)

Today


EKG


Uremic pericarditis

  • Aggressive volume support

  • Indomethacin

  • Hemodialysis ++++++

  • +/- pericardiocentesis (if unstable)

  • +/- steroid instillation


Case 5

  • You get a call from dialysis unit. They’re mid-way thru a run of HD with a pt who has now developed hypotension. They can’t get a hold of Nephro and are not sure what to do with the pt.

  • You asked if they’ve slowed the rate and amount of ultrafiltration (duh!)…

  • They want to send him down to ED…


Cont’d

  • Before the pt even arrives, you’re thinking Ddx:

    • Hypovolemia (dialysis related, GIB, hemorrhage)

    • CV causes (MI, dysrhythmias, tamponade)

    • Lyte d/o (Ca, Mg, K)

    • Air embolism

    • Hypoxemia

    • Drugs (narcotics, antihypertensives, anxiolytics)

    • Hypersensitivity rxn (to ethylene oxide which sterilizes dialyzer, polyacrylonitrile in the membranes)

    • Autonomic neuropathy

    • Acetate-based dialysate


Mgmt of hypotension

  • Obviously, decrease flow rate and amount of ultrafiltration

  • N/S IV bolus: 250-500cc in small boluses of 100-200cc and frequently reassess!

  • Try to figure out why…


Case 6

  • 86yo F presents to ED c/o high BP. Says she takes her BP at home regularly and today it was 195/115. She’s been told this is “too high”. You go in to take a quick hx…nothing exciting. Nurse has not checked pt in yet.

  • O/e: NAD. Lungs nil acute. CV nil acute. Abdo nil acute. Skin—note made of Cimino-Brescia fistula in L arm with thrill present

  • You ask for a set of vitals and disappear to see your next pt…


Cont’d

  • You come back a while later and find the BP cuff cycling q1min measuring her BP…last one 158/90.

  • It’s cycling on her L arm…any problem?

  • You check her fistula site and notice there is no longer a thrill, but still feel a strong palpable pulse. Concerned?


Thrombosis of access

  • Avoid manipulating access site, as may cause venous embolization

  • Call Vascular

  • Occasionally they may use thrombolytic agents to open thrombosed access but usually surgical revision required

  • Bottom line: don’t put tourniquet, check BP, or circumferential bandages on arm with fistula!!


Case 7

  • 43yo M presents to ED c/o generalized abdo pain, malaise. He has a peritoneal dialysis line in place. Last seen by Nephro about 3wks ago, everything going well. Very conscientious about his peritoneal catheter and keeping it sterile!

  • ROS: small amount of foul urine produced, diarrhea x1 yest, sore throat ~1wk ago


Cont’d

  • O/e: T 38.2, HR 92, BP 142/78, sats 98%

  • Lungs clear, HS normal, H+N small cervical lymphadenopathy, abdo sl distended, catheter site appears clean, mild abdo tenderness, no guarding, no rebound

  • Investigations?


Cont’d

  • CBC, lytes, Cr, lipase

  • Dialysate analysis

  • U/A


Results

  • WBC 12

  • Lytes N, Cr 327, lipase N

  • U/A--+RBC, +leuks, +WBC and granular casts

  • Dialysate—cloudy, 105 WBC, 60% neuts, Gm stain pending


Peritonitis

  • 70% of cases caused by staph aureus or staph epidermidis

  • If polymicrobial infection, then suggests direct contamination from GI tract and should search for perf or fistula!

  • Usually can be easily treated as oupt and does not require removal or replacement of catheter


Mgmt

  • Intraperitoneal abx x10-14d:

    • Vanco 30mg/kg IP q5-7d

    • Ceftazidine 1gm IP q1d

    • Gentamicin 2mg/kg IP then 20mg/L q1d

  • Don’t forget to think about other intra-abdo causes of peritonitis!!


  • Login