Acute renal failure

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  • Note how to differentiate between ATN and pre renal renal failure – loss of concentrating mechanism. In ATN urine sodium is high and osmolartiy is low, in pre renal ARF urine Na is low and osmolarity high to preserve water.
  • urine dip positive for leucocytes +/- nitrites would be expected.
  • urine dip positive for leucocytes +/- nitrites would be expected.
  • http://depts.washington.edu/physdx/audio/rub.mp3,
  • Acute renal failure

    1. 1. Acute Kidney Injury Jingzhou He
    2. 2. Acute Kidney Injury  Goals of talk  Renal/prerenal/post renal  Definition of acute renal failure  Case based  Emergency management  Investigations  Drugs
    3. 3. Definition  Rise in  Rapid creatinine of of renal function deterioration 26 mmol/l in 48h  >50% rise in creatinine over 7 days and acid Inability to maintain fluid, electrolyte base balance  <0.5ml/kg/hour for more than 6 hours
    4. 4. Important?  13-18%  £500 of all hospital admissions million/year  2009 national inquiry – 50% who died of AKI had “good care”  Inpatient mortality 25-30%  Prognosis proportional to severity of AKI
    5. 5. Risk Factors  CKD  IV  Heart  Liver failure failure contrast  Urological obstruction  Diabetes  Age  History  Oligo-uria of AKI  Hypovolaemia  Sepsis  Nephrotoxics
    6. 6. Causes
    7. 7. Prerenal  Volume depletion  Oedematous state  Hypotension  Cardiovascular  Renal hypoperfusion
    8. 8. „Renal Causes‟ of Renal failure  Large Vascular  Small vascular and Glomerular  Interstitial nephritis  Acute tubular necrosis  Myeloma  Cast nephropathy  Light chain deposition  Amyloid  Hypercalcaemia, hyperuricaemia, fluid depletion
    9. 9. „Renal Causes‟ of Renal failure  Large Vascular   Renal artery thrombosis/dissection  Cholersterol emboli (recent Cardiac cath/aortic surgery)  Renal vein Thrombosis (hypercoagulable, ? Nephrotic)   Renovasc disease + ACEI History and risk factors are key Acute Glomerulonephritis (GN)/Small vascular IgA nephropathy, lupus nephritis, FSGS  Vasculitis  HUS/TTP  Malignant hypertension  Urine dip and inflammatory markers key  Needs full renal screen (OHCM) and diagnose with biopsy 
    10. 10. „Renal Causes‟ of Renal failure  Acute Tubulo-Interstitial Nephritis (AIN)  Drug related (NSAID, antibiotics, diuretics, allopurinol)  Infections/TB/Autoimmune disease  Fever, arthralgia, rash  Normal interval 3-21 days  Bland urine dip or with mild blood/prot  Possibly eosinophils in urine  Diagnose with biopsy
    11. 11. „Renal Causes‟ of Renal failure  Acute Tubular Necrosis (ATN)  Ischaemic – Hypotension, shock, devascularization (AAA)  Nephrotoxic  endogenous   Myoglobinuria  Myeloma casts   Haemaglobinuria Crystals (Tumour lysis syndrome etc...) exogenous  Nephrotoxic drugs  Radio contrast
    12. 12. Postrenal  Calculus  Blood clot  Urethral stricture  BPH/malignancy  Bladder  Pelvic tumour malignancy
    13. 13. Case 1  70 female  GP referral to EMU  PMHx  HTN  CCF  Febrile  RIF pain  Treated in community for UTI
    14. 14. Case 1  DHx Drug Dose Frequency Ibuprofen 400mg TDS Ramipril 10mg ON Paracetamol 1g QDS Bisoprolol 2.5mg OD Spironolactone 25mg OD Trimethoprim 200mg BD
    15. 15. Bloods Na 140 K 5.0 Cr 195 Ur 8.8 Bic 24 Hb 13.1 WCC 16.6 Plt 345 CRP 96 Amylase 30
    16. 16. Case 1 questions  What is your diagnosis/differential?  What investigations?  Does this lady have AKI?  What are the causes for the raised creatinine  What medications would you stop/start?
    17. 17. Case 1 questions  What is your diagnosis/differential?   What investigations   Depends on previous renal function. What are possible causes for the raised creatinine   Urine dip/MC+S, Abdo/Renal tract USS, ?CT Does this lady have AKI?   Appendicitis/pyelonephritis Sepsis, pre-renal, medication What medications would you stop/start?  Pyelonephritis, temporarily stop ramipril, avoid NSAIDs for pain, stop spironolactone
    18. 18. Case 1  Always do a urine dip, and MC+S  Use computer/GP records to review old MC+S and creatinine  Stop potentially nephrotoxic medications  Especially avoid NSAIDs
    19. 19. Case 2  78 male  PMH    1 day post Right Hemiarthroplasty Poor U/O 10 mls/h for 4 hours  T2DM   OA CCF DHx  Lisinopril 10mg OD  Metformin 500mg TDS  Diclofenac 50mg OD  Paracetamol 1g QDS  Bisoprolol 5mg OD
    20. 20. Review  What are you looking out for when reviewing him?  What investigations do you want to do?
    21. 21. Review  What are you looking out for when reviewing him?   Fluid status – dry? Fluid input/output chart. Obs. Review medications. Review hip wound, check for palpable bladder, catheter working? What investigations do you want to do?  Bloods, urine dip +/- MSU  Renal tract USS
    22. 22. Review  O/E  BP 96/60, HR 110  Chest clear  Apyrexial  Abdomen SNT  Dry mucous membranes  JVP down  U/O in last 6 hours – 100mls  Fluid in – nil
    23. 23. Investigations  Urine dip Blood 1+ Protein Nitrites Neg pH Bloods Neg Leuc  1+ 6 Na 140 K 5.8 Cr 230 (baseline 140) Ur 14 (baseline 8) Wcc 9 CRP 160 Hb 85 (pre-op 100)
    24. 24. Management  What do you do now?
    25. 25. Case 2  Post-operative risk  Pre-renal common  Review medications  IV fluids
    26. 26. Case 3        85 male 1/12 gradually worsening back pain 1/7 confusion No urine for last day Now unable to get out of bed and fluctuating conscious level Nocturia x 3 Negative urine dip by GP   PMH DH   Amlodipine  Omeprazole   NKA Paracetamol SH  Lives with wife  No carers
    27. 27. Case 3 – On Examination  Bp 160/100, PR 100, sats 92% on air, T 36  Dry skin  JVP difficult  Ankle oedema  GCS 12/15  Not able to answer questions  CVS  Systolic murmur  Resp   Bibasal creps Abdo    Soft non tender suprapubic mass PR smooth large prostate Neuro  Nil focal but weak with muscle pain and power 3/5 globally
    28. 28. Initial questions  What are the first steps in this patients management?  Are there any particularly concerning features which point to severe acute renal failure?  What is the most likely diagnosis?
    29. 29. Initial questions  What are the first steps in this patients management?   Are there any particularly concerning features which point to acute renal failure?   ABC, ECG/monitor, bloods/ABG for K Decreased conscious level, weakness and muscle pain, heart murmur, clinical fluid overload What is the most likely diagnosis?  Obstructive renal failure
    30. 30. Bloods Na 140 K 7.3 Cr 745 Ur 50.5 Bic 8 Hb 10.3 WCC 14.2 Plt 345 CRP 43 Glu 7
    31. 31. ECG
    32. 32. CXR
    33. 33. Question 1  Outline your management at this point
    34. 34. Question 1  Outline your management at this point  Cardiac  monitor, IV Calcium, insulin/dextrose CAUTION INSULIN DOSE (10u/DEXTROSE DOSE/POST TX HYPO)  Salbutamol neb  Oxygen, sit up  Catheterise (note residual at 15 mins, hourly UO)  Tell senior (HDU/ITU)  Stop all unnecessary meds  Dip and send urine  Full acute screen (OHCM)
    35. 35. Question 2  What are the indications for emergency dialysis?
    36. 36. Question 2  What are the indications for emergency dialysis?  Hyperkalaemia  Pulmonary oedema  Severe acidosis  Uraemia – (pericardial rub, encephalopathy)
    37. 37. Question 3  How would you investigate the underlying diagnosis?
    38. 38. Question 3  How would you investigate the underlying diagnosis?  Bloods  LFTS (Ca/ALP/Alb), PSA (when well), myeloma screen  PR – when catheterised  Abdo USS  Bone scan  Urology opinion with CT/MRI pelvis
    39. 39. Question 4  What does the enlarged non-tender bladder imply about the aetiology?  Can people present with obstructive renal failure when no bladder is palpable, or when they are still passing urine?
    40. 40. Question 4  What does the enlarged non-tender bladder imply about the aetiology?   Chronic Can people present with obstructive renal failure when no bladder is palpable or when they are still passing urine?  Yes (tumour/stone/extrinsic compression affecting ureters)  Only one kidney being obstructed can still cause RF
    41. 41. Case 3  Acute management of hyperkalaemia  Emergency dialysis  Obstructive renal failure  chronic v acute  USS crucial, as can still be passing urine and bladder may not be enlarged  Other treatments to decompress (nephrostomy/stents)
    42. 42. Urine Dip Colour  Turbidity  pH   4.5-8 but most often acidic  Important in RTA  Haematuria/haemoglobinuria/myoglobinuria  Proteinuria  Renovascular, glomerular, tubule-interstitial disease  Overflow of abnormal proteins (MM)  Glucose  Nitrites    50% sensitive, 90% specific Positive suggests presence in sig numbers (>10000/ml) Leucocytes  65% sensitive, 20-90% specific  Much higher accuracy in urology patients
    43. 43. ARF Screen  ARF Screen  BASICS  FBC/U+E/LFT/Ca/Phos/Mg/Gluc/Lipid/Bic/CRP  Lactate/COAG /G+S/SEP/Blood cultures  If needs HD - Hep B+C+HIV serology  Venous/Arterial Gas  Urine DIPSTICK/ PCR + BJP/ MC and S.  CXR, urgent USS  ECG +/- monitor if K high  GN SCREEN (think about specific diagnoses)  ANCA/ANA/antiGBM/ASOT/Igs/C3/C4/LDH/blood film  +/- Cryoglobulins (take to lab warm)/RhF  Chronic – PTH/haematinics once during admission
    44. 44. Conclusion  Acute renal failure  Always think pre/intrinsic/post  First ensure safe potassium and volume status  Drugs are often implicated  Urine dip is vital and often not done  If patient unwell with renal failure involve a senior early

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