<ul><li>Acute Renal Failure </li></ul><ul><li>Dept of Family and Community Medicine </li></ul><ul><li>Perpetual Succour Ho...
<ul><li>General Objectives:  </li></ul><ul><li>To present a case of a 20 years old male who develop ARF secondary to rhabd...
<ul><li>A case of C.C., 20 years old </li></ul><ul><li>male, single, Filipino, Roman Catholic </li></ul><ul><li>Maya, Daan...
<ul><li>No Medical problem </li></ul><ul><li>Non-smoker,  occ’l alcoholic beverage drinker </li></ul><ul><li>No FDA </li><...
<ul><li>HPI: </li></ul><ul><li>NOI: MVA </li></ul><ul><li>POI: Maya, Daan Bantayan, Cebu </li></ul><ul><li>TOI: 11PM </li>...
<ul><li>Six hours PTA, patient was driving his motorcycle with his cousin </li></ul><ul><li>Accidentally loss control of t...
<ul><li>Brought to Daan Bantayan District Hospital, IVF was started </li></ul><ul><li>Suturing of lacerated wound chin </l...
<ul><li>Conscious, coherent, afebrile, not in respiratory distress </li></ul><ul><li>BP: 80/50  Hr:82   RR:23  Temp:37 </l...
<ul><li>Neck: supple, no LAD </li></ul><ul><li>C/L: ECE, Clear breath sounds, no rales </li></ul><ul><li>CVS: DHS, NRRR, n...
<ul><li>Ext:  multiple abrasions  noted at the  ant and medial part ,  hematoma  at the posterior part of the left thigh <...
<ul><li>Motor:  all ext 5/5 </li></ul><ul><li>Sensory: intact </li></ul><ul><li>Impression: 4 cm lacerated wound, mentum a...
On admission: <ul><li>IVF change to PNSS, run 300 mL, then regulated at 50 gtts/min </li></ul><ul><li>CXR Bucky and Skull ...
<ul><li>TT 0.5 mL IM R Deltoid </li></ul><ul><li>TIG 250 IU IM L Deltoid </li></ul><ul><li>Ranitidine 50 mg IV q 8hrs </li...
3 hrs after admission: <ul><li>Tramadol 50 mg IV q12 </li></ul><ul><li>UTZ of the liver and kidney: negative . </li></ul>
 
 
 
1 st  Hospital Day: <ul><li>Distended abdomen </li></ul><ul><li>RLQ pain  </li></ul><ul><li>LOM  left thigh  </li></ul><ul...
2 nd  Hospital Day: <ul><li>Abdominal distension and tenderness </li></ul><ul><li>NPO temporarily except meds </li></ul><u...
3 rd  Hospital Day: <ul><li>Persistence of abdominal pain and distension  </li></ul><ul><li>Referred to Surgery Service </...
<ul><li>Additional meds: </li></ul><ul><li>NaHCO3 ½ vial IV q 4hrs for 6 doses </li></ul><ul><li>Dopamine 200 mg/ 250 mL a...
Nephrologist Additional Meds: <ul><li>O2 inhalation at 2LPM </li></ul><ul><li>Mannitol 50 mg IV q 6 hrs </li></ul><ul><li>...
<ul><li>Urine Output: 1,800 mL/ 24hrs </li></ul><ul><li>Labs requested : </li></ul>
4 th  Hospital Day: <ul><li>Abd: Distended, hypoactive bowel sounds, no tenderness noted </li></ul><ul><li>Alluprinol 300 ...
5 th  Hospital Day: <ul><li>Repeat Creatinine: 14, BUN, K, BUA, Repeat CBC </li></ul><ul><li>Ciprofloxacin 250 mg 1 tablet...
6 th  Hospital Day: <ul><li>Lightheadedness </li></ul><ul><li>Ciprofloxacin was discontinued </li></ul><ul><li>Shifted to ...
7 th  Hospital Day : <ul><li>IJ Catheter was inserted </li></ul><ul><li>1st Hemodialysis for 3 cycles done </li></ul><ul><...
8 th  Hospital Day: <ul><li>For Repeat Creatinine, Potassium and Uric Acid </li></ul><ul><li>1 unit PRBC was transfused </...
9 th  Hospital Day: <ul><li>Dec breathsounds bibasal lungs </li></ul><ul><li>2 nd  Hemodialysis done </li></ul><ul><li>Rep...
10 th  Hospital Day: <ul><li>Still with distended abdomen, hypoactive bowel sounds </li></ul><ul><li>febrile episodes </li...
11 th  Hospital day: 3/19/09 <ul><li>Febrile episodes </li></ul><ul><li>Blood culture and sensitivity- Burkholderia cepaci...
12 th  Hospital Day: 3/20/09 <ul><li>Blood-streaked sputum </li></ul><ul><li>Abdominal distension </li></ul><ul><li>Hypera...
13 th  Hospital Day <ul><li>Patient improved, no dyspnea, afebrile </li></ul><ul><li>Bp 120/80 HR: 78 </li></ul><ul><li>EC...
14 th  Hospital Day <ul><li>Patient was able to sleep well </li></ul><ul><li>Comfortable, no dyspnea </li></ul><ul><li>BP:...
15 th  Hospital Day <ul><li>Still with febrile episodes </li></ul><ul><li>No dyspnea </li></ul><ul><li>ECE, minimal bibasa...
16 th  Hospital Day: 3/24/09 <ul><li>Still with minimal bibasal rales </li></ul><ul><li>Intake: 1600, Output: 1420 </li></...
17 th  hospital Day <ul><li>Still with febrile episodes </li></ul><ul><li>With minimal rales </li></ul><ul><li>Intake: 272...
18 th  Hospital Day <ul><li>Still with febrile episode </li></ul><ul><li>Intake: 2,700  Output: 5,650  +2950 </li></ul><ul...
20 th  Hospital Day <ul><li>Low Grade Fever was only noted </li></ul><ul><li>Still with rales both lungs </li></ul><ul><li...
21 st  Hospital Day <ul><li>Patient was afebrile </li></ul><ul><li>Repeat CBC: anemia  and Creatinine </li></ul><ul><li>IJ...
22 nd  Hospital Day <ul><li>MGH </li></ul><ul><li>To continue: </li></ul><ul><li>Iron supplements 1 cap OD </li></ul><ul><...
 
 
<ul><li>DISCUSSION </li></ul>
<ul><li>Discussion </li></ul>Urinary System
Functions of the Kidneys:   <ul><li>Excretion of metabolic waste products & foreign chemicals  </li></ul><ul><li>Regulatio...
<ul><li>Renal Blood Flow </li></ul><ul><li>In an average 70-kilogram man, the combined blood flow through both kidneys </l...
Acute Renal Failure <ul><li>rapid decline in (GFR) over hours to days  </li></ul><ul><li>Clinical features: </li></ul><ul>...
<ul><li>usually asymptomatic </li></ul><ul><li>DX: when a new increase in BUN and serum creatinine is noted </li></ul><ul>...
Prerenal ARF: <ul><li>Altered renal hemodynamics resulting in hypoperfusion  </li></ul><ul><li>A.  Low cardiac output stat...
<ul><li>Intrinsic causes of ARF: </li></ul><ul><li>(1) ischemic / nephrotoxic tubular injury </li></ul><ul><li>(2) tubuloi...
<ul><li>Prerenal ARF & ischemic ATN are part of a spectrum of manifestations of renal hypoperfusion </li></ul><ul><li>ATN ...
<ul><li>other risk factors for ARF: exposure to  nephrotoxins  / preexisting chronic kidney disease  </li></ul><ul><li>Rec...
<ul><li>Four phases of ischemic ATN: </li></ul><ul><li>A physiologic hallmark of ATN: failure to maximally dilute or conce...
<ul><li>3) maintenance phase  (1–2 weeks), GFR stabilizes at its nadir (5–10 mL/min), urine output is lowest, and uremic c...
<ul><li>Symptoms of  prerenal  ARF: thirst and orthostatic dizziness  </li></ul><ul><li>Physical signs of ARF: orthostatic...
Laboratory Studies <ul><li>BUN & creatinine: the ratio exceed 20:1  </li></ul><ul><li>CBC/peripheral smear :  presence of ...
<ul><li>Urine electrolytes serve as indicators of functioning renal tubules.  </li></ul><ul><li>FENa = (UNa/PNa) / (UCr/PC...
<ul><li>Renal UTZ  is useful for evaluating existing renal disease and obstruction of the urinary collecting system </li><...
<ul><li>Nuclear scan  used to assess renal blood flow and tubular functions.         </li></ul><ul><li>Aortorenal angiogra...
<ul><li>Renal biopsy:  useful in the diagnosis of intrarenal causes of AKI  </li></ul><ul><li>Also when renal function doe...
Treatment: <ul><li>Dietary modulation:  </li></ul><ul><li>become crucial in the management of oliguric renal failure, wher...
<ul><li>Furosemide (Lasix) </li></ul><ul><li>Increases excretion of water by interfering with chloride-binding cotransport...
<ul><li>Dopamine  </li></ul><ul><li>Stim adrenergic & dopaminergic receptors </li></ul><ul><li>Lower doses : stimulate dop...
<ul><li>calcium channel blockers : used to enhance the function of transplanted kidneys. </li></ul><ul><li>Nifedipine : re...
Outpatient Care   <ul><li>renal recovery is not complete and kidneys remain vulnerable to nephrotoxic effects of all thera...
<ul><li>Indications for dialysis in patients with AKI:  </li></ul><ul><ul><li>Volume expansion that cannot be managed with...
<ul><li>THANK YOU... </li></ul>
 
 
 
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Acute Renal Failure 2* to Rhabdomyolysis 2* to Motor Vehicular Accident

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Acute Renal Failure 2* to Rhabdomyolysis secondary to Motor Vehicular Accident

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Acute Renal Failure 2* to Rhabdomyolysis 2* to Motor Vehicular Accident

  1. 1. <ul><li>Acute Renal Failure </li></ul><ul><li>Dept of Family and Community Medicine </li></ul><ul><li>Perpetual Succour Hospital </li></ul><ul><li>April 28, 2009 </li></ul>
  2. 2. <ul><li>General Objectives: </li></ul><ul><li>To present a case of a 20 years old male who develop ARF secondary to rhabdomyolysis secondary to MVA </li></ul>
  3. 3. <ul><li>A case of C.C., 20 years old </li></ul><ul><li>male, single, Filipino, Roman Catholic </li></ul><ul><li>Maya, Daan Bantayan, Cebu </li></ul><ul><li>Multiple physical injuries secondary to MVA </li></ul>
  4. 4. <ul><li>No Medical problem </li></ul><ul><li>Non-smoker, occ’l alcoholic beverage drinker </li></ul><ul><li>No FDA </li></ul><ul><li>No hospitalization </li></ul>
  5. 5. <ul><li>HPI: </li></ul><ul><li>NOI: MVA </li></ul><ul><li>POI: Maya, Daan Bantayan, Cebu </li></ul><ul><li>TOI: 11PM </li></ul><ul><li>DOI: March 7, 2009 </li></ul>
  6. 6. <ul><li>Six hours PTA, patient was driving his motorcycle with his cousin </li></ul><ul><li>Accidentally loss control of the vehicle upon making a turn in a blind curve. </li></ul><ul><li>Patient was thrown, hitting his chin and left side of the body on the ground </li></ul><ul><li>Vomiting twice was noted </li></ul><ul><li>No loss of consciousness. </li></ul>
  7. 7. <ul><li>Brought to Daan Bantayan District Hospital, IVF was started </li></ul><ul><li>Suturing of lacerated wound chin </li></ul><ul><li>Referred to our institution for further management. </li></ul>
  8. 8. <ul><li>Conscious, coherent, afebrile, not in respiratory distress </li></ul><ul><li>BP: 80/50 Hr:82 RR:23 Temp:37 </li></ul><ul><li>Skin: warm, good turgor </li></ul><ul><li>HEENT: anicteric sclera, pink palpebral conjunctiva, 4 cm lacerated wound at the mentum </li></ul>
  9. 9. <ul><li>Neck: supple, no LAD </li></ul><ul><li>C/L: ECE, Clear breath sounds, no rales </li></ul><ul><li>CVS: DHS, NRRR, no murmur </li></ul><ul><li>Abd: flabby, Normoactive, soft, tenderness at the RLQ </li></ul><ul><li>GUT: normal KPS </li></ul>
  10. 10. <ul><li>Ext: multiple abrasions noted at the ant and medial part , hematoma at the posterior part of the left thigh </li></ul><ul><li>CNS: conscious, coherent, GCS 15 </li></ul>
  11. 11. <ul><li>Motor: all ext 5/5 </li></ul><ul><li>Sensory: intact </li></ul><ul><li>Impression: 4 cm lacerated wound, mentum and multiple abrasions left thigh sec to MVA </li></ul>
  12. 12. On admission: <ul><li>IVF change to PNSS, run 300 mL, then regulated at 50 gtts/min </li></ul><ul><li>CXR Bucky and Skull Series: negative </li></ul><ul><li>CBC . and BT: AB(-) . : leukocytosis, neutrophilic predominance </li></ul><ul><li>Urinalysis: hematuria </li></ul><ul><li>CT Scan – Brain Plain: negative </li></ul><ul><li>Repeat CBC 6 hrs after . </li></ul>
  13. 13. <ul><li>TT 0.5 mL IM R Deltoid </li></ul><ul><li>TIG 250 IU IM L Deltoid </li></ul><ul><li>Ranitidine 50 mg IV q 8hrs </li></ul><ul><li>Oxacillin 500 mg IV q 6hrs </li></ul><ul><li>Bactroban cream </li></ul>
  14. 14. 3 hrs after admission: <ul><li>Tramadol 50 mg IV q12 </li></ul><ul><li>UTZ of the liver and kidney: negative . </li></ul>
  15. 18. 1 st Hospital Day: <ul><li>Distended abdomen </li></ul><ul><li>RLQ pain </li></ul><ul><li>LOM left thigh </li></ul><ul><li>Meds: </li></ul><ul><li>Etoricoxib (Arcoxia) </li></ul><ul><li>Epirisone (Myonal) was added </li></ul>
  16. 19. 2 nd Hospital Day: <ul><li>Abdominal distension and tenderness </li></ul><ul><li>NPO temporarily except meds </li></ul><ul><li>Hyoscine Bromide 10 mg 1 amp IV q 8hrs PRN for severe pain </li></ul>
  17. 20. 3 rd Hospital Day: <ul><li>Persistence of abdominal pain and distension </li></ul><ul><li>Referred to Surgery Service </li></ul><ul><li>CBC , Potassium normal, Creatinine:10.50 </li></ul><ul><li>CT SCAN – Whole Abdomen </li></ul><ul><li>Referred to a Nephrologist </li></ul>
  18. 21. <ul><li>Additional meds: </li></ul><ul><li>NaHCO3 ½ vial IV q 4hrs for 6 doses </li></ul><ul><li>Dopamine 200 mg/ 250 mL at 10 cc/hr </li></ul><ul><li>Urinalysis was requested </li></ul><ul><li>Furosemide 40 mg IV q 8 hrs PRN for U/O <300/ shift </li></ul><ul><li>To secure 2 units WB </li></ul>
  19. 22. Nephrologist Additional Meds: <ul><li>O2 inhalation at 2LPM </li></ul><ul><li>Mannitol 50 mg IV q 6 hrs </li></ul><ul><li>Paracetamol 650 mg, 1 tab BID for 6 doses </li></ul><ul><li>NaHCO3 650 mg 2 tablets TID </li></ul><ul><li>Carnitine Oral Sol’n 1000 mg, 1 bottle TID </li></ul><ul><li>Allupurinol 300 mg tab OD </li></ul>
  20. 23. <ul><li>Urine Output: 1,800 mL/ 24hrs </li></ul><ul><li>Labs requested : </li></ul>
  21. 24. 4 th Hospital Day: <ul><li>Abd: Distended, hypoactive bowel sounds, no tenderness noted </li></ul><ul><li>Alluprinol 300 mg 1 tablet TID </li></ul><ul><li>Calci-Aid 1 cap BID pc </li></ul><ul><li>Furosemide 40 mg IV q 6 hrs </li></ul>
  22. 25. 5 th Hospital Day: <ul><li>Repeat Creatinine: 14, BUN, K, BUA, Repeat CBC </li></ul><ul><li>Ciprofloxacin 250 mg 1 tablet BID </li></ul><ul><li>Ketosteril 2 tabs TID </li></ul>
  23. 26. 6 th Hospital Day: <ul><li>Lightheadedness </li></ul><ul><li>Ciprofloxacin was discontinued </li></ul><ul><li>Shifted to Cefuroxime 750 mg IV q 12 hrs </li></ul><ul><li>Repeat Total CPK: 450 </li></ul><ul><li>FBC was inserted </li></ul>
  24. 27. 7 th Hospital Day : <ul><li>IJ Catheter was inserted </li></ul><ul><li>1st Hemodialysis for 3 cycles done </li></ul><ul><li>CBC- anemia </li></ul><ul><li>Cefuroxime 750 mg IV q12hrs </li></ul><ul><li>Oxacillin 500 mg IV q 6hrs </li></ul><ul><li>Allupurinol 300 mg tab BID dec to OD </li></ul><ul><li>Furosemide 40 mg IV q 8hrs </li></ul>
  25. 28. 8 th Hospital Day: <ul><li>For Repeat Creatinine, Potassium and Uric Acid </li></ul><ul><li>1 unit PRBC was transfused </li></ul>
  26. 29. 9 th Hospital Day: <ul><li>Dec breathsounds bibasal lungs </li></ul><ul><li>2 nd Hemodialysis done </li></ul><ul><li>Repeat Creatinine _ , K and Total CPK </li></ul><ul><li>Recormon 5000 units SQ was given </li></ul>
  27. 30. 10 th Hospital Day: <ul><li>Still with distended abdomen, hypoactive bowel sounds </li></ul><ul><li>febrile episodes </li></ul><ul><li>For repeat creatinine the next day </li></ul><ul><li>For Repeat Urinalysis . </li></ul>
  28. 31. 11 th Hospital day: 3/19/09 <ul><li>Febrile episodes </li></ul><ul><li>Blood culture and sensitivity- Burkholderia cepacia-S- Ceftazidime </li></ul><ul><li>Repeat Creatinine and CBC </li></ul><ul><li>Repeat CXR - PA </li></ul><ul><li>Cefuroxime was discontinued </li></ul><ul><li>Shifted to Ceftazidime 500 mg q 48hrs IV </li></ul>
  29. 32. 12 th Hospital Day: 3/20/09 <ul><li>Blood-streaked sputum </li></ul><ul><li>Abdominal distension </li></ul><ul><li>Hyperactive bowel sounds </li></ul><ul><li>3 rd Hemodialysis done </li></ul>
  30. 33. 13 th Hospital Day <ul><li>Patient improved, no dyspnea, afebrile </li></ul><ul><li>Bp 120/80 HR: 78 </li></ul><ul><li>ECE, Bibasal Rales </li></ul><ul><li>Ceftazidime </li></ul>
  31. 34. 14 th Hospital Day <ul><li>Patient was able to sleep well </li></ul><ul><li>Comfortable, no dyspnea </li></ul><ul><li>BP:120/70 HR:78 </li></ul><ul><li>Intake: 1270cc </li></ul><ul><li>Output: 550 </li></ul><ul><li>ECE, Bibasal rales, wheeze </li></ul><ul><li>CBC, Creatinine </li></ul>
  32. 35. 15 th Hospital Day <ul><li>Still with febrile episodes </li></ul><ul><li>No dyspnea </li></ul><ul><li>ECE, minimal bibasal rales, wheeze </li></ul><ul><li>O2 Inhalation dec to PRN </li></ul>
  33. 36. 16 th Hospital Day: 3/24/09 <ul><li>Still with minimal bibasal rales </li></ul><ul><li>Intake: 1600, Output: 1420 </li></ul><ul><li>Creatinine: 9.48 </li></ul><ul><li>Crea Clearance: 12.31 </li></ul><ul><li>Ceftazidime Increased to 1gm IVTT q12 </li></ul><ul><li>Repeat CXR </li></ul><ul><li>Comngt with Pulmonologist </li></ul>
  34. 37. 17 th hospital Day <ul><li>Still with febrile episodes </li></ul><ul><li>With minimal rales </li></ul><ul><li>Intake: 2720 Output: 2050 – 85cc/hr </li></ul>
  35. 38. 18 th Hospital Day <ul><li>Still with febrile episode </li></ul><ul><li>Intake: 2,700 Output: 5,650 +2950 </li></ul><ul><li>CBC, Na, Creatinine, Albumin </li></ul><ul><li>Erythropoeitin 5000 u sq once a week </li></ul>
  36. 39. 20 th Hospital Day <ul><li>Low Grade Fever was only noted </li></ul><ul><li>Still with rales both lungs </li></ul><ul><li>Repeat CXR: decrease infiltrates to both lung fields </li></ul><ul><li>Malarial Smear: negative </li></ul>
  37. 40. 21 st Hospital Day <ul><li>Patient was afebrile </li></ul><ul><li>Repeat CBC: anemia and Creatinine </li></ul><ul><li>IJ cath was removed </li></ul>
  38. 41. 22 nd Hospital Day <ul><li>MGH </li></ul><ul><li>To continue: </li></ul><ul><li>Iron supplements 1 cap OD </li></ul><ul><li>Follow up: April 4, 2009 with CBC, Creatinine and Calcium level </li></ul>
  39. 44. <ul><li>DISCUSSION </li></ul>
  40. 45. <ul><li>Discussion </li></ul>Urinary System
  41. 46. Functions of the Kidneys: <ul><li>Excretion of metabolic waste products & foreign chemicals </li></ul><ul><li>Regulation of water & electrolyte balances </li></ul><ul><li>Regulation of acid-base balance </li></ul><ul><li>Regulation of arterial pressure </li></ul><ul><li>Secretion, metabolism, & excretion of hormones </li></ul><ul><li>Gluconeogenesis </li></ul>
  42. 47. <ul><li>Renal Blood Flow </li></ul><ul><li>In an average 70-kilogram man, the combined blood flow through both kidneys </li></ul><ul><li>1,100 ml/min </li></ul><ul><li>22 per cent of the cardiac output. </li></ul>
  43. 48. Acute Renal Failure <ul><li>rapid decline in (GFR) over hours to days </li></ul><ul><li>Clinical features: </li></ul><ul><li>Retention of nitrogenous waste products </li></ul><ul><li>Oliguria (<400 mL/d ) </li></ul><ul><li>Electrolyte and acid-base abnormalities </li></ul>
  44. 49. <ul><li>usually asymptomatic </li></ul><ul><li>DX: when a new increase in BUN and serum creatinine is noted </li></ul><ul><li>causes of ARF : </li></ul><ul><li>1) prerenal ARF , or azotemia (~55%) </li></ul><ul><li>2) intrinsic ARF (~40%) </li></ul><ul><li>3) postrenal ARF (~5%). </li></ul>
  45. 50. Prerenal ARF: <ul><li>Altered renal hemodynamics resulting in hypoperfusion </li></ul><ul><li>A. Low cardiac output state : </li></ul><ul><li>B. Systemic vasodilation : </li></ul><ul><li>C. Renal vasoconstriction : </li></ul><ul><li>D. Impairment of renal autoregulatory responses : </li></ul><ul><li>E. Hepatorenal syndrome . </li></ul>
  46. 51. <ul><li>Intrinsic causes of ARF: </li></ul><ul><li>(1) ischemic / nephrotoxic tubular injury </li></ul><ul><li>(2) tubulointerstitial diseases </li></ul><ul><li>(3) diseases of the renal microcirculation and glomeruli </li></ul><ul><li>(4) diseases of larger renal vessels </li></ul>
  47. 52. <ul><li>Prerenal ARF & ischemic ATN are part of a spectrum of manifestations of renal hypoperfusion </li></ul><ul><li>ATN vs. prerenal ARF: renal tubular epithelial cells are injured in the prerenal ARF </li></ul><ul><li>ATN occur in: major cardiovascular surgery, severe trauma, hemorrhage , sepsis and volume depletion </li></ul>
  48. 53. <ul><li>other risk factors for ARF: exposure to nephrotoxins / preexisting chronic kidney disease </li></ul><ul><li>Recovery takes 1–2 weeks after normalization of renal perfusion </li></ul>
  49. 54. <ul><li>Four phases of ischemic ATN: </li></ul><ul><li>A physiologic hallmark of ATN: failure to maximally dilute or concentrate urine (isosthenuria). </li></ul><ul><li>initiation phase (lasting hours to days), GFR declines </li></ul><ul><li>extension phase is char by continued ischemic injury and inflammation. </li></ul>
  50. 55. <ul><li>3) maintenance phase (1–2 weeks), GFR stabilizes at its nadir (5–10 mL/min), urine output is lowest, and uremic complications may arise </li></ul><ul><li>4) recovery phase is char by tubular epithelial cell repair & regeneration </li></ul><ul><li>gradual return of GFR toward premorbid levels </li></ul>
  51. 56. <ul><li>Symptoms of prerenal ARF: thirst and orthostatic dizziness </li></ul><ul><li>Physical signs of ARF: orthostatic hypotension, tachycardia, reduced jugular venous pressure, decreased skin turgor and dry mucous membranes </li></ul>
  52. 57. Laboratory Studies <ul><li>BUN & creatinine: the ratio exceed 20:1 </li></ul><ul><li>CBC/peripheral smear : presence of myoglobin/free hemoglobin, increased uric acid level and schistocytes </li></ul><ul><li>Urinalysis : Reddish brown or cola-colored urine suggests the presence of myoglobin or hemoglobin </li></ul>
  53. 58. <ul><li>Urine electrolytes serve as indicators of functioning renal tubules. </li></ul><ul><li>FENa = (UNa/PNa) / (UCr/PCr) X 100 </li></ul><ul><li>Prerenal azotemia: FENa is usually <1%. </li></ul><ul><li>ATN: FENa is >1% </li></ul><ul><ul><li>Exceptions: ATN caused by severe burns, AGN and rhabdomyolysis. </li></ul></ul>
  54. 59. <ul><li>Renal UTZ is useful for evaluating existing renal disease and obstruction of the urinary collecting system </li></ul><ul><li>Doppler scans are useful for detecting the presence and nature of renal blood flow </li></ul><ul><li>RBF is reduced in prerenal/intrarenal AKI, test findings are of little use in the diagnosis of AKI. </li></ul>
  55. 60. <ul><li>Nuclear scan used to assess renal blood flow and tubular functions.        </li></ul><ul><li>Aortorenal angiography is used in the diagnosis of renal vascular diseases(renal artery stenosis, renal atheroembolic disease, atherosclerosis with aortorenal occlusion) </li></ul>
  56. 61. <ul><li>Renal biopsy: useful in the diagnosis of intrarenal causes of AKI </li></ul><ul><li>Also when renal function does not return for a prolonged period and prognosis is required to develop long-term management </li></ul>
  57. 62. Treatment: <ul><li>Dietary modulation: </li></ul><ul><li>become crucial in the management of oliguric renal failure, wherein the kidneys do not adequately excrete either toxins or fluids </li></ul><ul><li>Although diuretics seem to have no effect on the outcome, they appear useful in fluid homeostasis </li></ul>
  58. 63. <ul><li>Furosemide (Lasix) </li></ul><ul><li>Increases excretion of water by interfering with chloride-binding cotransport system </li></ul><ul><li>inhibits sodium and chloride reabsorption in the thick ascending loop of Henle and the distal renal tubule </li></ul><ul><li>peak of action: 60 min and lasting 6-8 h. </li></ul>
  59. 64. <ul><li>Dopamine </li></ul><ul><li>Stim adrenergic & dopaminergic receptors </li></ul><ul><li>Lower doses : stimulate dopaminergic receptors (renal and mesenteric vasodilation) </li></ul><ul><li>higher doses : cardiac stimulation & renal vasodilation </li></ul><ul><li>Adult </li></ul><ul><li>1-5 mcg/kg/min IV </li></ul>
  60. 65. <ul><li>calcium channel blockers : used to enhance the function of transplanted kidneys. </li></ul><ul><li>Nifedipine : relaxes smooth muscle and produces vasodilation </li></ul><ul><li>N-acetylcysteine: used for prevention of contrast toxicity & provide substrate for conjugation with toxic metabolites </li></ul><ul><li>600 mg PO bid on day preceding and day of procedure </li></ul>
  61. 66. Outpatient Care <ul><li>renal recovery is not complete and kidneys remain vulnerable to nephrotoxic effects of all therapeutic agents </li></ul><ul><li>agents with nephrotoxic potential are best avoided </li></ul>
  62. 67. <ul><li>Indications for dialysis in patients with AKI: </li></ul><ul><ul><li>Volume expansion that cannot be managed with diuretics </li></ul></ul><ul><ul><li>Hyperkalemia refractory to medical therapy </li></ul></ul><ul><ul><li>Correction of severe acid-base disturbances that are refractory to medical therapy </li></ul></ul><ul><ul><li>Severe azotemia (BUN >80-100) </li></ul></ul><ul><ul><li>Uremia </li></ul></ul>
  63. 68. <ul><li>THANK YOU... </li></ul>

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