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27 beans   acute renal-failure

27 beans acute renal-failure






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    27 beans   acute renal-failure 27 beans acute renal-failure Presentation Transcript

    • Bad Beans Acute Renal Failure
    • 3 AM
      • “ Mr. Henle hasn’t peed all night long!”
      • How is UO measured? By shift or by hour? Foley or urinating on own? Has the patient been sleeping?
      • What is the trend over last 2-3 hours vs. last 24 hours?
        • Oliguria = <400ml/24 hrs or <20ml/hr
        • Anuria = <50ml/24 hrs
      • Recent surgery?
      • Other symptoms or changes in vital signs?
    • Nursing orders
      • While on way to see patient have nurse:
        • Flush catheter if patient has one
        • Obtain orthostatic blood pressures to help establish fluid status
    • Physical exam
      • Subjective: Dysuria, nausea, weakness, and fatigue
      • Tachycardia and/or a drop in HR >15 bpm or drop in SBP >15mmHg with orthostatics could indicate dehydration
      • Decreased mental status = decreased perfusion
      • Rales = fluid overload, CHF
      • Abdominal pain and distension = obstruction, UTI
      • Itching = azotemia
    • Labs
      • UA:
        • High specific gravity = dehydration
        • RBCs = UTI, urolithiasis
        • WBCs, bacteria = UTI
        • Casts: RBC (glomerulonephritis), WBC (pyelonephritis), and epithelial cells and granular casts (ischemic damage)
      • Electrolytes to assess for metabolic d/o
      • Urine Na, Creatinine
        • FENa = (UNa x Pcr)/(PNa x Ucr)
        • <1% = prerenal; >1% = renal
      • ECG to look for peaked T waves, indicates hyperkalemia
    • Etiology: Overview
      • Prerenal azotemia: most common cause of ARF (30-60% of all cases). Can lead to ATN
        • Rapidly reversible
        • Causes: hypoperfusion, NSAIDs, and ACE inhibitors.
      • Postrenal azotemia: (1-10% of hospital ARF), bladder outlet or ureteral obstruction
      • Intrinsic renal disease: most commonly presents as acute tubular necrosis (ATN) and acute interstitial nephritis (AIN).
        • ATN is caused by ischemia, toxins, and glomerulonephritis.
        • AIN is primarily caused by nephrotoxic drugs.
      • Elderly more susceptible to ARF (3.5 X more common); Creatinine clearance dependent on age
    • Prerenal
      • Potentially reversible
      • Volume depletion:
        • Surgical: Hemorrhage, shock
        • Gastrointestinal (GI) losses: Vomiting, diarrhea, fistulas
        • Renal: Over-diuresis, salt-wasting disorders
    • Prerenal
      • Decrease in cardiac output:
        • Acute disorders: Myocardial infarction, arrhythmias, malignant hypertension, tamponade, endocarditis
        • Chronic disorders: Valvular diseases, chronic cardiomyopathy (ischemic heart disease hypertensive heart disease)
      • Redistribution of extracellular fluid
        • Hypoalbuminemic states: Nephritic syndrome, advanced liver disease, malnutrition
        • Physical cause: Peritonitis, burns, crush
        • Peripheral vasodilation: Sepsis, antihypertensive agents
        • Renal artery stenosis (bilateral)
    • Postrenal
      • 1-10% of all cases
      • Ureteral obstruction: Bilateral or in a solitary kidney (calculi, neoplasm, clot, retroperitoneal fibrosis, iatrogenic)
      • Urethral obstruction: Prostatic hypertrophy, prostate cancer, prostatitis, clot, calculus, neoplasm, foreign object
      • Venous occlusion: Bilateral or a solitary kidney (renal vein thrombosis, neoplasm)
    • Renal/Intrinsic
      • Glomerular and small vessel disease:
        • Rapidly progressive glomerulonephritis (RPGN)
        • subacute bacterial endocarditis
        • proliferative glomerulonephritis
        • Vasculitides
        • progressive systemic sclerosis
        • malignant hypertension
        • HUS
        • Cryoglobulinaemia
        • Eclampsia
        • disseminated intravascular coagulation
      • Interstitial nephritis: Drug induced, infection, sarcoid, infiltrative
      • Tubular lesions: Post-ischemic, drugs pigment, light chain, hypercalcemia
    • Diagnosis: Procedures
      • Cystoscopy with retrograde pyelogram: evaluates for obstruction and upper tract tumors/malformations
      • Renal biopsy (for severe ARF of unknown cause):
        • Indicated with nephrotic syndrome, hematuria, or glomerular disease
      • Renal ultrasonography: kidney size
        • Small kidneys = reflect chronic renal disease.
        • Hydronephrosis = obstructive nephropathy.
    • Risk factors
      • Advanced age
      • Comorbid conditions (heart failure, liver or kidney failure, diabetes)
      • Contrast exposure (dehydrated, diabetic)
      • Nephrotoxic medications (aminoglycosides, NSAIDs, angiotensin converting enzyme inhibitors)
      • Volume depletion (especially in diabetes)
      • Rhabdomyolysis; surgery (cardiac surgery)
    • Management: General
      • Discontinue/re-dose nephrotoxic drugs
      • Foley catheterization for accurate output
      • Daily weight, monitor BP, labs
      • Diet
        • Eliminate potassium if serum level increased
        • Oral and IV amino acids
        • Provide nutrition with increased carbohydrates to decrease catabolism. T otal caloric intake of 35 to 50 kcal/kg/day should be maintained with most calories provided by carbohydrates (100 g/day).
      • Correct easy bleeding with DDAVP, estrogen, and cryoprecipitate
      • Prednisone in acute interstitial nephritis may help
      • Mannitol - alkaline diuresis in rhabdomyolysis
    • Management: Prerenal
      • Goal is to restore BP and intravascular volume
      • Fluid deficit:
        • Fluid bolus with 500ml, recheck fluid status, repeat.
        • Monitor vital signs and electrolytes
      • Normal or increased fluid status:
        • CHF: monitor O2 status. Lasix 20-80mg IV.
        • Monitor diuresis, potassium status, daily weight
    • Management: Postrenal
      • Place foley, note residual. If >400ml and discomfort is relieved, leave catheter in place.
      • If foley in place, flus with 20-30ml saline
      • Consider stones or mass obstruction
      • Daily weights, strict I/O
    • Management: Renal
      • Hyperkalemia:
        • Continuous cardiac monitoring
        • Kayexalate 15 to 30g in 50-100ml 20% sorbitol PO q 3-4 hours or in 200ml 20% sorbitol PR q 4 hours
        • Dialysis for failed kidneys: can remove 30-60 mEq/hr
      • Contrast dye:
        • Creatinine peaks within 72 hours with slow recovery over 7 to 14 days with appropriate therapy.
      • Aminoglycosides:
        • higher risk: elderly, volume depletion, >5 days, large doses, preexisting liver disease, and preexisting renal insufficiency.
        • Correct preexisting volume depletion and monitor drug levels
    • Management: Renal
      • Acidosis:
        • Treat as determined by cause of acidosis
        • Watch for co-existing hyperkalemia
        • Control is aided by restriction of dietary protein
      • Consider dialysis:
        • Fluid overload unresponsive to diuretics
        • Hyperkalemia with K+ >6 to 8
        • Metabolic acidosis pH <7.20
        • BUN >35mmol/L with mental status changes, pericarditis or seizure
    • Complications
      • Death (50%)
      • Sepsis infection (leading cause of mortality)
      • Once ARF stabilizes, fluid replacement should be equal to insensible losses (500 mL/day) plus urinary or other drainage losses to avoid hypervolemia
      • Hypertension exacerbated by fluid overload: Use antihypertensives that do not decrease renal blood flow (non-dihydropyridine calcium channel blockers, cardioselective beta-blockers, and central acting agents).
      • Anemia is common, caused by increased red blood cell (RBC) loss and decreased RBC production.
      • Platelet dysfunction may occur secondary to the uremia and present as gastrointestinal (GI) bleeding.
    • Special Cases
      • Elderly:
        • Elderly more susceptible to ARF (3.5 X more common)
        • Creatinine clearance dependent on age
        • Evolution to acute tubular necrosis more common
      • Pregnancy:
        • Infected uterus (e.g., Clostridium welchii clostridium perfringens)
        • Toxemia and related obstetric complications.
        • Pregnant patients only group with a sharp drop in ARF mortality (1.7%)
      • Pediatric: Congenital anomalies (e.g., nurethral valves, etc)