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14 Ri   Acute Nonoliguric Renal Failure
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14 Ri Acute Nonoliguric Renal Failure

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  • The mortality rate was 46.5% and the most important causes of death were: sepsis (38%), respiratory failure (19%), and multiple organ failure (11%).

14 Ri   Acute Nonoliguric Renal Failure 14 Ri Acute Nonoliguric Renal Failure Presentation Transcript

  • Acute nonoliguric renal failure Ri 黃正憲 2003/10/27
  • Acute Renal Failure
    • Definitions:
      • An increase in the serum creatinine of  0.5 mg/dl over baseline value
      • An increase in the serum creatinine of more than 50% over base line value
      • A reduction in the calculated creatinine clearance of 50%
      • A decrease in the renal function that results in the need for dialysis
  • Category
    • 1. urine output
      • Anuric: <100 mL/d
      • Oliguric: 100-500 mL/d
      • Nonoliguric: >500 mL/d
    • 2. the more common
      • Pre-renal
      • Intrinsic
      • Post-renal
  • Acute Renal Failure
    • Pre Renal Causes
    • - Intravascular volume depletion from vomiting diarrhea,
    • poor fluid intake, fever, use of diuretics
    • - Decreased glomerular perfusion in the setting of
    • renal artery atherosclerotic disease with decreased
    • systolic head of BP, use of ACE inhibitors or NSAIDS
    • - Decreased effective arterial blood volume in CHF, liver dysfunction, septic shock, anesthesia
  • Acute Renal Failure
    • Pre Renal Causes
    Post Renal Causes - External compression to the outflow tract from tumors, increased intra abdominal pressure, retroperitoneal fibrosis - Intrinsic blockage from tumor, calculi, blood clots, papillary necrosis - Intratubular obstruction from crystals and myeloma chains - Blocked Foley catheter
  • Acute Renal Failure
    • Pre Renal Causes
    Post Renal Causes Intrinsic causes Tubulo- Glomerular Vascular Interstitial
  • Acute Renal Failure
    • Pre Renal Causes
    Post Renal Causes Intrinsic causes Tubular Interstitial Acute necrosis nephritis glomerulonephritis (10% of cases) (5% of cases) Ischemia Toxins (50% of cases) (35% of cases)
  • Ischemic Acute Renal Failure
    • Intravascular volume depletion and hypotension
    • Gastrointestinal, renal, dermal losses, hemorrhage, shock
    Generalized or localized reduction in renal blood flow Ischemic Acute Renal Failure Decreased effective intravascular volume : CHF, cirrhosis, nephrosis, peritonitis Medications : ACE inhibitors, NSAIDS, radiocontrast agents, Ampho B, Cyclosporin Hepatorenal syndrome Large vessel renal vascular disease : Renal artery thrombosis or embolism, operative arterial cross clamping, renal artery stenosis Small vessel renal vascular disease : Atheroembolism, vasculitis, malignant hypertension, hypercalcemia, transplant rejection Sepsis
  • Toxin induced Acute Renal Failure
    • Reduction in renal perfusion through alteration of intra renal hemodynamics
    • Direct tubular injury
    • Heme pigment induced ARF
    • Intratubular obstruction
    • Allergic Interstitial Nephritis
    • Hemolytic Uremic Syndrome
    • NSAIDs, ACE inhibitors, Cyclosporin, Tacrolimus, IV contrast, Ampho B
    • Aminoglycosides, IV contrast, Cyclosporin, Cisplatin, Ampho B, Heavy metals, IV immunoglobulins
    • Rhabdomyolysis, Hemolysis, Cocaine, Ethanol, Statins
    • Acyclovir, Sulfonamides, Ethylene glycol, myoglobin
    • Penicillins, Cephalosporins, Sulfonamides, Rifampin, Cipro, NSAIDs, Thiazides, Cimetidine, Allopurinol
    • Cyclosporin, Cocaine, Mitomycin, Quinine
    • Categories of anuria, oliguria, and nonoliguria may be useful in differential diagnosis of ARF.
    • Anuria - Urinary tract obstruction, renal artery obstruction, RPGN, bilateral diffuse renal cortical necrosis
    • Oliguria - Prerenal failure, hepatorenal syndrome
    • Nonoliguria – AIN, AGN, partial obstructive nephropathy, nephrotoxic and ischemic ATN, radiocontrast-induced ARF, and rhabdomyolysis
  • Nonoliguric ARF
    • Oliguria is a frequent but not invariable clinical feature (~50%).
    • Harrison’s 15ed
  • Nonoliguric ARF
    • ATN: aminoglycoside, streptomycin, polymyxin B, lithium, or cisplatin nephrotoxicity.
    • Case report:
        • Celecoxib-induced nonoliguric acute renal failure
        • Annals of Pharmacotherapy. 36(1):52-4, 2002 Jan.
        • Lupus nephritis
          • American Journal of the Medical Sciences. 321(6):381-7, 2001 Jun.
          • Isoniazid-induced crescentic glomerulonephritis
          • Omeprazole-induced acute interstitial nephritis .
        • …… .
  • Nonoliguric ARF
      • Glomerular alterations in experimental oliguric and nonoliguric acute renal failure.
      • tubular damage was more pronounced in oliguric kidneys…. There was no significant difference in these glomerular changes between oliguric and nonoliguric kidneys.
      • The findings suggest that less reduction in the whole-kidney GFR in nonoliguric ARF kidneys is ascribed largely to less pronounced tubular damage rather than to less severe glomerular morphologic alterations.
            • Renal Failure. 15(2):215-24, 1993.
  • Nonoliguric ARF
      • Acute renal failure: clinical outcome and causes of death.
      • Higher mortality was observed in oliguric patients (62.9%) than nonoliguric (34.5%) (p < 0.05) and in ischemic renal failure (56.7%) when compared to nephrotoxic renal failure (14.7%) (p < 0.05).
      • Renal Failure. 19(2):253-7, 1997 Mar
  • Nonoliguric ARF
      • Acute renal failure in a teaching hospital.
      • … Compared with nonoliguric patients, oliguric patients had higher mortality (56.3% vs 18.9%, p < 0.01), and needed dialysis more frequently (43.8% vs 12.9%, p < 0.01)
      • Singapore Medical Journal. 36(3):278-81, 1995 Jun.
  • Conclusion
    • Nonoliguric acute renal failure
    • Although the causes of nonoliguric renal failure varied, nephrotoxic failure occurred more frequently in nonoliguric than in oliguric subjects (P <0.01).
    • As compared to oliguric patients, those without oliguria had significantly lower urinary sodium concentrations (P<0.05) and FENa (P < 0.02), had shorter hospital stay (P < 0.01), had fewer septic episodes, neurologic abnormalities, gastrointestinal bleeding and acidemia, required dialysis less frequently (P < 0.001) and had lower mortality rate (P < 0.05).
    • NEJM. 296(20):1134-38,1977 May
  • Management of acute renal failure
    • Management of volume homeostasis
    • Management of electrolyte homeostasis
    • Management of acid- base homeostasis
    • Management of uremia
    • Nutritional management in acute renal failure
    • Dialysis in acute renal failure
  • Management of volume homeostasis
    • Record I/O
    • Physical examination
    • Fluid = urine output + 300-500
    • Sodium intake<2 g/day
    • Diuretics
    • Low dose dopamin ( 0.3 ug/kg/min)
    • CVP or pulmonary capillary wedge pressure
  • Management of electrolyte homeostais
    • Hypernatremia and hyponatremia
    • Hyperkalemia
    • Hypocalcemia
    • Hypomagnesemia
    • Hyperphosphatemia
  • Management of acid- base homeostasis
    • Dietary protein restriction 0.8-1.0g/kg of body weight 30 kcal /kg/day ( except hypercatabolism )
    • Look for cause of acidosis
    • Sodium bicarbonate
    • Dialysis
  • Management of uremia
    • Fatigue, lethargy, mental dullness, norexia and nausea
    • More serious– myoclonus, confusion, delirium or coma, seizure and pericarditis
    • Diet protein control
    • Check GI bleeding
    • Hemodialysis
  • Nutritional management in acute renal failure
    • Minimal recommand protein intake0.6-0.8g/kg/day
    • Carbohydrate and lipid should maximal with a target of providing 30-65kcal /kg/day
    • Limit fluid volume potassium , magnesium, and phosphorus should avoid.
  • Indications for dialysis
    • Absolute indications
    • uremic symptoms
    • uremic pericarditis
    • Relative indications
    • volume overlosd
    • hyperkalemia
    • metabolic acidosis
    • Other electrolyte abnormalities
  • Drug management in acute renal failure
    • Stop nephrotoxic drugs
    • Adjust medication dose
    • Check drug level
  • Thanks for your attention