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Acute Renal Failure Anil Menon 11/27/06
A simple algorithm <ul><li>Malingering </li></ul><ul><li>Rapid fall in GFR leading to increased waste products </li></ul>
Relevance <ul><li>Complicates up to 7% of admissions </li></ul><ul><li>Mortality when dialysis is required ranges 50%-75% ...
DDX
Diagnostic Approach <ul><li>Cr/BUN, UOP, serum cystatin K, IL18 </li></ul><ul><li>H&P  </li></ul><ul><li>Meds </li></ul><u...
 
Acute or Chronic? <ul><li>History </li></ul><ul><li>Previous creatinine </li></ul><ul><li>Small kidneys on u/s </li></ul>
Obstruction excluded? <ul><li>History </li></ul><ul><li>Complete anuria </li></ul><ul><li>Palpable bladder </li></ul><ul><...
Euvolemic? <ul><li>Pulse, JVP/CVP, orthostatic, wgt, I/O </li></ul><ul><li>Disproportionate inc in urea:Cr ratio </li></ul...
Evidence of parenchymal dz? Other than ATN <ul><li>H+P (systemic factors) </li></ul><ul><li>Urine dipstick and micro  </li...
Major vascular occlusion? <ul><li>Athreosclerosis </li></ul><ul><li>Renal Assymetry </li></ul><ul><li>Groin pain </li></ul...
Treatment <ul><li>Prevention </li></ul><ul><ul><li>Risk factors (age,DM,HTN,Vasc,renal) </li></ul></ul><ul><ul><li>Maintai...
General <ul><li>Correct prerenal/postrenal factors </li></ul><ul><li>Optimise CO, RBF </li></ul><ul><li>Review meds </li><...
No strong evidence <ul><li>Loop diuretic </li></ul><ul><li>Dopamine </li></ul><ul><li>Natriuretic peptide </li></ul><ul><l...
ATN <ul><li>Sepsis in ICU 35-50% </li></ul><ul><li>Prerenal azotemia spectrum with ischemic ATN </li></ul><ul><li>Initiati...
Post Op <ul><li>18-40% hospital aquired. 1.2% surgery. </li></ul><ul><li>Pre-op BP control  (Carmaichael J Surgery 2003) <...
Contrast <ul><li>Isotonic crystalloid 1-1.5ml/kg for 3-12 hours pre proc and 6-24 hours post </li></ul><ul><li>Mucomyst no...
 
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ARF.ppt

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  • Nitrogenous and non-nitrogenous waste products. Cr/BUN. Remember Cr not good indicator of GFR in non-steady state (production/volume distribution). Many definitions.
  • 75% in context of sepsis and critical care.
  • 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%.
  • Duration of sxm, nocturia, absence of acute illness, anemia, hyper pho, hypo cal
  • Previous stones. Sxm. Bladder flow. Complete anuria rare in arf without obsruction. See dilation of pelvis and calyx if not malignancy
  • High antiADH leads to urea resorp by tubules. Fena okay without diuretics. Care for pulm edema in oliguric patients
  • Rash, arthralgia, myalgia, abx, nsaids AIN. Red casts nepritis or eos AIN think nephrologist
  • 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 out
  • Ototoxic in high does, tach/periph gangrene, hypotension, blank, blank, inc mort in critical pt
  • Snake bite, crush injury, nephrotoxin, sepsis.
  • Prognosis jumps from 4.3 to 67% when adjusted for cormorbitites in cardiac group
  • 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.
  • Transcript of "ARF.ppt"

    1. 1. Acute Renal Failure Anil Menon 11/27/06
    2. 2. A simple algorithm <ul><li>Malingering </li></ul><ul><li>Rapid fall in GFR leading to increased waste products </li></ul>
    3. 3. Relevance <ul><li>Complicates up to 7% of admissions </li></ul><ul><li>Mortality when dialysis is required ranges 50%-75% </li></ul>
    4. 4. DDX
    5. 5. Diagnostic Approach <ul><li>Cr/BUN, UOP, serum cystatin K, IL18 </li></ul><ul><li>H&P </li></ul><ul><li>Meds </li></ul><ul><li>Labs </li></ul><ul><li>Imaging </li></ul>
    6. 7. Acute or Chronic? <ul><li>History </li></ul><ul><li>Previous creatinine </li></ul><ul><li>Small kidneys on u/s </li></ul>
    7. 8. Obstruction excluded? <ul><li>History </li></ul><ul><li>Complete anuria </li></ul><ul><li>Palpable bladder </li></ul><ul><li>Renal u/s </li></ul>
    8. 9. Euvolemic? <ul><li>Pulse, JVP/CVP, orthostatic, wgt, I/O </li></ul><ul><li>Disproportionate inc in urea:Cr ratio </li></ul><ul><li>FENA </li></ul><ul><li>Fluid challenge </li></ul>
    9. 10. Evidence of parenchymal dz? Other than ATN <ul><li>H+P (systemic factors) </li></ul><ul><li>Urine dipstick and micro </li></ul><ul><li>(red cells, red cell casts, eosinophils, prot) </li></ul>
    10. 11. Major vascular occlusion? <ul><li>Athreosclerosis </li></ul><ul><li>Renal Assymetry </li></ul><ul><li>Groin pain </li></ul><ul><li>Complete Anuria </li></ul><ul><li>Macro Hematuria </li></ul>
    11. 12. Treatment <ul><li>Prevention </li></ul><ul><ul><li>Risk factors (age,DM,HTN,Vasc,renal) </li></ul></ul><ul><ul><li>Maintain BP and Volume, avoid neprhotox </li></ul></ul><ul><ul><li>Measure plasma aminoglycoside </li></ul></ul><ul><ul><li>Allopurinol/urine alk in cancer </li></ul></ul>
    12. 13. General <ul><li>Correct prerenal/postrenal factors </li></ul><ul><li>Optimise CO, RBF </li></ul><ul><li>Review meds </li></ul><ul><li>Monitor I/O </li></ul><ul><li>Nutritional support </li></ul><ul><li>Treat infection, bleeding </li></ul><ul><li>Start dialysis before uremic </li></ul>
    13. 14. No strong evidence <ul><li>Loop diuretic </li></ul><ul><li>Dopamine </li></ul><ul><li>Natriuretic peptide </li></ul><ul><li>Intermittent HD vs Continuous </li></ul><ul><li>ILF </li></ul><ul><li>Thyroxine </li></ul>
    14. 15. ATN <ul><li>Sepsis in ICU 35-50% </li></ul><ul><li>Prerenal azotemia spectrum with ischemic ATN </li></ul><ul><li>Initiation, maintenance, recovery </li></ul><ul><li>BUN/Cr normal 10:1 </li></ul><ul><li>Rapid rise plasma Cr </li></ul><ul><li>Muddy brown epi casts </li></ul><ul><li>FENa > 2% </li></ul><ul><li>Ucr / PCr </li></ul>
    15. 16. Post Op <ul><li>18-40% hospital aquired. 1.2% surgery. </li></ul><ul><li>Pre-op BP control (Carmaichael J Surgery 2003) </li></ul><ul><li>Hydration and prevention </li></ul><ul><li>Poor prognosis of ARF when adjusted (Svensson J Vasc Surg 1989) </li></ul><ul><li>Nephrology </li></ul>
    16. 17. Contrast <ul><li>Isotonic crystalloid 1-1.5ml/kg for 3-12 hours pre proc and 6-24 hours post </li></ul><ul><li>Mucomyst not consistently useful </li></ul><ul><li>Current eval of theophyline, statins, vit c, pg E </li></ul><ul><li>CCB, L-arg, fenoldopam, dopamine, ANP not useful </li></ul><ul><li>Prophylactic HD no gain </li></ul><ul><li>(Stacul 2006 CIN consensus working panel) </li></ul>
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