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I Wanna Pee…But I Can’t!!! Renal Failure & Dialysis In the ED

I Wanna Pee…But I Can’t!!! Renal Failure & Dialysis In the ED. A.F. Chad, MD, CCFP Resident Rounds: July 25, 2002. Definitions: ARF . Deteriorating GFR over hours to days 50% decrease in GFR 50% decrease in CrCl 50% increase in Scr Need dialysis Non-oliguric vs oliguric vs anuric.

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I Wanna Pee…But I Can’t!!! Renal Failure & Dialysis In the ED

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  1. I Wanna Pee…But I Can’t!!!Renal Failure & Dialysis In the ED A.F. Chad, MD, CCFP Resident Rounds: July 25, 2002

  2. Definitions: ARF • Deteriorating GFR over hours to days • 50% decrease in GFR • 50% decrease in CrCl • 50% increase in Scr • Need dialysis • Non-oliguric vs oliguric vs anuric

  3. Plumbing • GFR • Gradient: Glomerulus & Bowman’s Capsule • Glomerulus pressure depends on RBF • RBF: afferent & efferent arterioles

  4. When Kidney Pie Goes Wrong • Acute • Chronic • Acute on Chronic • Transplant

  5. When Kidney Pie Goes Wrong • Pre-renal • Intrinsic • Post-renal • Evil Kidney Gnomes

  6. Before Kidney Pie Goes Wrong • Most common cause • 40-80% • Decreased renal perfusion

  7. Before Kidney Pie Goes Wrong • Hypovolemia • Sequestration • Cardiac • Renal artery • Small Vessel

  8. Inside Kidney Pie Goes Wrong • 11-45% • 45% of kids • ATN 2nd to ischemia • 25% nephrotoxins

  9. Inside Kidney Pie Goes Wrong • Tubular • Interstitial • Glomerulonephritis • Vasculitides

  10. After Kidney Pie Goes Wrong • 2-5% • 20-35% of Old Men • Young Men - stones • Young Women - CA • Kids • M: postrior urethral valve • F: VCUR

  11. After Kidney Pie Goes Wrong • Urethra and Bladder Outlet • Ureter • Intra Renal Failure

  12. When It All Goes Down the Loo • GFR -> gradient b/t glomerulus & Bowman • Pressure determined by aff & eff a.a. • Prerenal: decreased RBF • Intrinsic: release of vasoconstrictors • Postrenal: increased tubular pressure

  13. When It All Goes Down the Loo • Low RBF -> cell death -> slough ->block • Nephrons: ++ Filtration & hypertrophy • Too many damaged -> ++ hypertrophy -> sclerosis -> Decreased GFR -> CRF

  14. This is NOT good for you!!! • Mortality 40-90% • No change since Dialysis (other causes now) • OR for dying: 4.9 for ARF • Worse for anuric / oliguric • 20-60% will need dialysis • 25% of these long term

  15. What 2 Ask? • FIFE • Sx of Hypovolemia (N&V&D, CVD, Hemorrhage, insensible) • Infxn, HypoTN, Meds, Xray, MSK, Allergy • Prostatism, OR, Gyne, Stones • Usuals (PMHx, All, ROS, FHx, SHx)

  16. What 2 look for? • ABC’s, VS (esp HR& BP - orthostatic) • Fluid status • Derm (skin, eyes) • CV & Resp • Abdo (MAGIC FINGER!!!) • MSK

  17. What 2 Order? (Pizza? Chinese?) • R&M • BUN, Creatinine, • Lytes • CBC • Urine Lytes • ABG • other

  18. What 2 Calculate • Cockroft-Gault Equation (He taught me & does ice sculptures @ Xmas) • CrCl=[(140-age)xWt] / Scr • (x 0.85 for F) • N~120mL/min • Fractional Excretion of Na • FeNa = (UNa/PNa) X (UCr/PCr) X 100 • <1% - Prerenal, >1% ATN

  19. What 2 See? • U/S • IVP • CT • Nuc Med • KUB • Renal Biopsy

  20. Who Cares About This Crap! What Do I Do?!?! • ABCD • Stop Toxins • Rx post renal - Catheter • Volume status • Correct Lytes, Acid-Base • Drugs? • Dialyse

  21. Diuretics? CRAP! 92 pts with ARF given diuretic or placebo NO change in recovery, need for HD, death Shilliday IR, Quinn KJ, Allison ME. Loop diuretics in the management of acute renal failure: a prospective, double-blind, placebo-controlled, randomized study. Nephrol Dial Transplant 1997 Dec;12(12):2592-6

  22. Dopamine? Not helpful in RCT of CVD OR pts Lassnigg A, Donner E, Grubhofer G, Presterl E, Druml W, Hiesmayr M.Lack of renoprotective effects of dopamine and furosemide during cardiac surgery. J Am Soc Nephrol 2000 Jan;11(1):97-104 • Not Helpful in Anaesthesia either • Hladunewich M. Pathophysiology and management of renal insufficiency in the perioperative and critically ill patient. Anesthesiol Clin North America - 01-Dec-2000; 18(4): 773-89

  23. CCB? • Not helpful 4 prevention radiocontrast tox Carraro M, Mancini W, Artero M, Stacul F, Grotto M, Cova M, Faccini LDose effect of nitrendipine on urinary enzymes and microproteins following non-ionic radiocontrast administration. Nephrol Dial Transplant 1996 Mar;11(3):444-8

  24. Mannitol & HCO3? • Good for Rhabdo within 6hrs • Better OS, Rubenstein I: Management of shock and acute renal failure in casualties suffering from the crush syndrome. Ren Fail 19:647 1997.

  25. Pee for Them: Hemodialysis • Acidosis • Lytes (esp K+) • Fluid (too much) • Uremia (pericarditis, encephalopathy) • Drugs • Evil Humours

  26. Disposition: Bring ‘em in!!!

  27. Definitions: CRF • Progressive decline in GFR over months to years • Irreversible • Chronic insufficiency: GFR=30-70mL/min • CRF: GFR<30mL/min • ESRD: GFR<10mL/min

  28. CRF: problems • Lytes • Pericardium • IHD • HypoTN • Dysequilibrium • Infection • Vascular

  29. ESRD • Kidneys don’t work -> Uremia • 96 - USA- 300,000 Rx (75,000 new) • DM (33%), HTN (25%), Glomerular (18%), Evil Kidney Gnomes (0.371%) • Either get New Kidney(s) or Dialysis • 30% 5 year survival rate (with Rx!) • CVD (50%), Infxn (25%), Withdrawal

  30. ESRD: Beware the Gnomes!

  31. UREMIA: This is Mucho Bad!!! • CLINICAL Dx!!!

  32. UREMIA: Neuro • Uremic Encephalopathy • Dialysis Dementia • SDH • Peripheral

  33. UREMIA: CV • HTN • CHF • Pericarditis

  34. UREMIA: Heme • Anemia • Bleeding • Immunocompromise

  35. UREMIA: GI • GIB • Ascites • N&V • Diverticular Dx

  36. UREMIA: Bone • Metastatic Calcification • #’s • Cysts • CTS

  37. I Will Be Your Kidney: Dialysis

  38. How Does HD Work? • Pt’s blood into HD machine • Filter instead of glomerulus • Gradient determines fluid & solute removal • Lytes (Na, K, Cl, HCO3, Ca, Mg), Glucose • Not proteins

  39. How Does PD Work? • Uses peritoneum as filter • Diasylate: varied osmotic pressures • Fluid left in for a while, then drained

  40. I Will Be Your Kidney: Dialysis • Chart review 50 CRF pts in Camden, NJ: 68% went home post HD in ED ERSacchetti A .ED hemodialysis for treatment of renal failure emergencie.sAm J Emerg Med - 01- May-1999; 17(3): 305-7 • Chart review 288 HD pts presenting to ER in Albany, NY: 68% admittedMcErlean Met al.The Emergency Department Care of Hemodialysis Patients. Acad Emerg Med - 1999; 6(5):538.

  41. Complications During HD • Vascular • Hypotension • Dysequilibrium • Air Embolism • Lytes

  42. What 2 Ask HD? • Cause ESRD? • Dialysis schedgy (missed appt?) • Baseline Weight, Labs • Weight gain b/t HD • Sx Uremia

  43. What 2 Look 4 HD? • VS • Vascular Access • CV • Neuro

  44. What 2 Ask PD? • Cause ESRD? • Recent PD complications • Baseline weight, labs • Sx Uremia

  45. What 2 Look 4 PD? • VS • Abdomen • Peritoneal catheter

  46. I can PEE …Again!!!! Transplant Specific Issues • Rejection • Infection • ARF • CVD • Liver Dx • The BIG C

  47. Pee 4 You: What 2 Ask? • FIFE • Temp? • Date of Transplant • Graft Source? • Rejection Hx • Chronic Infxn • Baseline (creatinine, wt, VS) • PMHx, Meds, All, SHx

  48. Special 4 Borrowed Kidneys: ARF • AFR in Transplanted: 20% change in Scr • Causes: • Surgical complications • Rejection • Immunosuppressive Nephrotoxicity

  49. Special 4 Borrowed Kidneys: Infections ONE mos post Surg • UTI (E.Coli) • IV’s (S.aureus, S. viridans) • Pneumonias (streptococcus)

  50. Special 4 Borrowed Kidneys: Infections SIX mos post Surg • Viremia (CMV, EBV) • Meningitis (Listeria) • Sepsis (Aspegillosis)

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