10 Palevsky Acute Renal Failure

  • 5,063 views
Uploaded on

 

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
No Downloads

Views

Total Views
5,063
On Slideshare
0
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
349
Comments
0
Likes
9

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. Acute Renal Failure Paul M. Palevsky, M.D. Professor of Medicine Chief, Renal Section VA Pittsburgh Healthcare System
  • 2. Acute Renal Failure
    • Definition
      • The loss of renal function (measured as GFR) over hours to days
      • Expressed clinically as the retention of nitrogenous waste products in the blood
  • 3. Relationship Between GFR and Serum Creatinine in ARF 120 40 80 0 GFR (mL/min) 0 7 14 21 28 4 Days 2 0 6 Serum Creatinine (mg/dL)
  • 4. Acute Renal Failure
    • Definitions
      • Azotemia - the accumulation of nitrogenous wastes
      • Uremia - symptomatic renal failure
      • Oliguria - urine output < 400-500 mL/24 hours
      • Anuria - urine output < 100 mL/24 hours
  • 5. Manifestations of ARF
    • Azotemia progressing to uremia
    • Hyperkalemia
    • Metabolic acidosis
    • Volume overload
    • Hyperphosphatemia
    • Accumulation and toxicity of medications excreted by the kidney
  • 6. Differential Diagnosis of Azotemia
    • Etiologies of acute elevations of BUN
      • Acute renal failure
      • Protein loading
      • GI bleeding
      • Catabolic steroids
      • Tetracycline antibiotics
  • 7. Differential Diagnosis of Azotemia
    • Etiologies of acute elevations of creatinine
      • Acute renal failure
      • Medications that block creatinine secretion
        • cimetidine
        • trimethoprim
      • Substances that interfere with creatinine assay
        • cefoxitin
        • flucytosine
        • acetoacetate
  • 8. Classification of the Etiologies of Acute Renal Failure Acute Renal Failure Acute Tubular Necrosis Acute Interstitial Nephritis Acute GN Acute Vascular Syndromes Intratubular Obstruction Prerenal ARF Postrenal ARF Intrinsic ARF
  • 9. Physiologic Response to Volume Depletion Na Reabsorption AII AII PG RPF GFR P GC FF Urea Reabsorption
  • 10. Prerenal Acute Renal Failure Na Reabsorption AII AII PG RPF GFR P GC FF Urea Reabsorption
  • 11. Pathogenesis of Prerenal Azotemia Renal Vasoconstriction Decreased GFR Angiotensin II Adrenergic nerves Vasopressin + + + Nitric oxide Prostaglandins - - Volume Depletion Congestive Heart Failure Liver Failure Sepsis
  • 12. Prerenal Acute Renal Failure
    • Volume Depletion
    • Decreased effective blood volume
      • congestive heart failure
      • cirrhosis
      • nephrotic syndrome
      • sepsis
    • Renal vasoconstriction
      • hepatorenal syndrome
      • hypercalcemia
      • nonsteroidal anti-inflammatory drugs
  • 13. Prerenal Acute Renal Failure: Clinical Presentation
    • History
      • volume loss (e.g., diarrhea, acute blood loss)
      • heart disease
      • liver disease
      • evidence of infection
      • diuretic use
      • thirst
      • orthostatic symptoms
  • 14. Prerenal Acute Renal Failure: Clinical Presentation
    • Physical Examination
      • Blood pressure and pulse
      • Orthostatic changes in blood pressure
      • Skin turgor
      • Dryness of mucous membranes and axillae
      • Neck veins
      • Cardiopulmonary exam
      • Peripheral edema
  • 15. Prerenal Acute Renal Failure: Clinical Presentation
    • BUN:Creatinine ratio
      • > 20:1
    • Urine indices
      • Oliguria
        • usually < 500 mL/24 hours; but may be non-oliguric
      • Elevated urine concentration
        • U Osm > 700 mmol/L
        • specific gravity > 1.020
      • Evidence of high renal sodium avidity
        • U Na < 20 mmol/L
        • FE Na < 0.01
      • Inactive urine sediment
  • 16. Fractional Excretion of Sodium FE Na = Filtered Sodium Excreted Sodium FE Na = P Na x GFR U Na x V FE Na = U Cr / P Cr U Na / P Na
  • 17. Fractional Excretion of Sodium
    • Etiologies of a fractional excretion of sodium < 0.01
      • normal renal function
      • prerenal azotemia
      • hepatorenal syndrome
      • early obstructive uropathy
      • contrast nephropathy
      • rhabdomyolysis
      • acute glomerulonephritis
  • 18. Treatment of Prerenal Acute Renal Failure
    • Correction of volume deficits
    • Discontinuation of antagonizing medications
      • NSAIDs/COX-2 inhibitors
      • Diuretics
    • Optimization of cardiac function
  • 19. Postrenal Acute Renal Failure
    • Urinary tract obstruction
      • level of obstruction
        • upper tract (ureters)
        • lower tract (bladder outlet or urethra)
      • degree of obstruction
        • partial
        • complete
  • 20. Postrenal Acute Renal Failure
  • 21. Postrenal Acute Renal Failure
  • 22. Postrenal Acute Renal Failure
  • 23. Pathophysiology of Renal Failure in Obstructive Uropathy
    • Early
      • Increased intratubular pressure
      • Initial increase followed by decrease in renal plasma flow
    • Late
      • Normal intratubular pressure
      • Marked decrease in renal plasma flow
  • 24. Etiologies of Postrenal Acute Renal Failure
    • Upper tract obstruction
      • Intrinsic
        • nephrolithiasis
        • papillary necrosis
        • blood clot
        • transitional cell cancer
      • Extrinsic
        • retroperitoneal or pelvic malignancy
        • retroperitoneal fibrosis
        • endometriosis
        • abdominal aortic aneurysm
    • Lower tract obstruction
        • benign prostatic hypertrophy
        • prostate cancer
        • transitional cell cancer
        • urethral stricture
        • bladder stones
        • blood clot
        • neurogenic bladder
  • 25. Postrenal Acute Renal Failure: Clinical Presentation
    • History
      • Symptoms of bladder outlet obstruction
        • urinary frequency
        • urgency
        • intermittency
        • hesitancy
        • nocturia
        • incomplete voiding
  • 26. Postrenal Acute Renal Failure: Clinical Presentation
    • History
      • Changes in urine volume
        • anuria
        • polyuria
        • fluctuating urine volume
      • Flank pain
      • Hematuria
      • History of pelvic malignancy
  • 27. Postrenal Acute Renal Failure: Clinical Presentation
    • Physical Examination
      • Suprapubic mass
      • Prostatic enlargement
      • Pelvic masses
      • Adenopathy
  • 28. Postrenal Acute Renal Failure: Clinical Evaluation
    • Diagnostic studies
      • BUN: Creatinine ratio > 20:1
      • Unremarkable urine sediment
      • Variable urine chemistries
  • 29. Postrenal Acute Renal Failure: Clinical Evaluation
    • Diagnostic studies
      • Post-void residual bladder volume
        • > 100 mL consistent with voiding dysfunction
      • Radiologic studies
        • Ultrasound
        • CT scan
        • Nuclear medicine
        • Retrograde pyelography
        • Antegrade nephrostograms
  • 30. Renal Ultrasound - Hydronephrosis
  • 31. Treatment of Postrenal Acute Renal Failure
    • Relief of obstruction
      • Lower tract obstruction
        • bladder catheter
      • Upper tract obstruction
        • ureteral stents
        • percutaneous nephrostomies
    • Recovery of renal function dependent upon duration of obstruction
    • Risk of post-obstructive diuresis
  • 32. Intrinsic Acute Renal Failure
    • Acute tubular necrosis (ATN)
    • Acute interstitial nephritis (AIN)
    • Acute glomerulonephritis (AGN)
    • Acute vascular syndromes
    • Intratubular obstruction
  • 33. Acute Tubular Necrosis
  • 34. Acute Tubular Necrosis
    • Ischemic
        • prolonged prerenal azotemia
        • hypotension
        • hypovolemic shock
        • cardiopulmonary arrest
        • cardiopulmonary bypass
    • Sepsis
    • Nephrotoxic
      • drug-induced
        • radiocontrast agents
        • aminoglycosides
        • amphotericin B
        • cisplatinum
        • acetaminophen
      • pigment nephropathy
        • hemoglobin
        • myoglobin
  • 35. Pathophysiology of ATN: Tubular Epithelial Cell Injury and Repair Loss of polarity Normal Epithelium Migration , Dedifferentiation of Viable Cells Differentiation & Reestablishment of polarity Sloughing of viable and dead cells with luminal obstruction Ischemia/ Reperfusion Apoptosis Necrosis Cell death Adhesion molecules Na + /K + -ATPase Proliferation
  • 36. Pathophysiology of Acute Tubular Necrosis
    • Mechanisms of decreased renal function
      • Vasoconstriction
      • Tubular obstruction by sloughed debris
      • Backleak of glomerular filtrate across denuded tubular basement membrane
  • 37. Phases of Ischemic ATN Prerenal Initiation Extension Maintenance Recovery GFR Time
  • 38. Pathophysiology of ATN Ischemia Endothelial Injury Capillary Obstruction & Continued Ischemia Inflammation Tubular Injury Disruption of Cytoskeleton Loss of Cell Polarity Desquamation of Cells Tubular Obstruction & Backleak Apoptosis & Necrosis Activation of Vasoconstrictors Impaired Vasodilation Increased Leukocyte Adhesion
  • 39. Acute Tubular Necrosis: Clinical Presentation
    • History
      • Acute illness
      • Exposure to nephrotoxins
      • Episodes of hypotension
    • Physical examination
      • Hemodynamic status
      • Volume status
      • Features of associated illness
    • Laboratory data
      • BUN:Creatinine ratio < 10:1
      • Evidence of toxin exposure
  • 40. Acute Tubular Necrosis: Clinical Presentation
    • Urine indices
      • Urine volume
        • may be oliguric or non-oliguric
      • Isosthenuric urine concentration
        • U Osm  300 mmol/L
        • specific gravity  1.010
      • Evidence of renal sodium wasting
        • U Na > 40 mmol/L
        • FE Na > 0.02
      • Urine sediment
        • tubular epithelial cells
        • granular casts
  • 41. Acute Tubular Necrosis: Clinical Presentation
  • 42. Acute Tubular Necrosis: Treatment
    • Supportive therapy
    • No specific pharmacologic treatments
    • Acute dialysis for:
      • volume overload
      • metabolic acidosis
      • hyperkalemia
      • uremic syndrome
        • pericarditis
        • encephalopathy
      • azotemia
  • 43. Prognosis of Acute Tubular Necrosis
    • Mortality dependent upon comorbid conditions
      • overall mortality ~ 50%
    • Recovery of renal function seen in ~ 90% of patients who survive - although not necessarily back to prior baseline renal function
  • 44. Mortality in Acute Tubular Necrosis Chertow et al: Arch Int Med 1995; 155:1505-1511 Number of Failed Non-Respiratory Organ Systems
  • 45. Effect of Contrast Nephropathy on Mortality Levy et al: JAMA 1996; 275:1489-1494
  • 46. Acute Interstitial Nephritis
    • Acute renal failure due to lymphocytic infiltration of the interstitium
    • Classic triad of
      • fever
      • rash
      • eosinophilia
  • 47. Acute Interstitial Nephritis
  • 48. Acute Interstitial Nephritis
    • Drug-induced
      • penicillins
      • cephalosporins
      • sulfonamides
      • rifampin
      • phenytoin
      • furosemide
      • NSAIDs
    • Malignancy
    • Idiopathic
    • Infection-related
      • bacterial
      • viral
      • rickettsial
      • tuberculosis
    • Systemic diseases
      • SLE
      • sarcoidosis
      • Sjögren’s syndrome
      • tubulointerstitial nephritis and uveitis
  • 49. Acute Interstitial Nephritis: Clinical Presentation
    • History
      • preceding illness or drug exposure
    • Physical examination
      • fever
      • rash
    • Laboratory Findings
      • eosinophilia
  • 50. Acute Interstitial Nephritis: Clinical Presentation
    • Urine findings
      • non-nephrotic protinuria
      • hematuria
      • pyuria
      • WBC casts
      • eosinophiluria
  • 51. Acute Interstitial Nephritis: Clinical Presentation
  • 52. Acute Interstitial Nephritis: Clinical Presentation
  • 53. Acute Interstitial Nephritis: Treatment
    • Discontinue offending drug
    • Treat underlying infection
    • Treat systemic illness
    • Glucocorticoid therapy may be used in patients who fail to respond to more conservative therapy
  • 54. Acute Glomerulonephritis
    • Nephritic presentation
      • proteinuria
        • may be in nephrotic range (> 3 g/day)
      • hematuria
      • RBC casts
    • Diagnosis usually requires renal biopsy
  • 55. Acute Glomerulonephritis
  • 56. Acute Glomerulonephritis
    • Etiologies
      • poststreptococcal glomerulonephritis
      • postinfectious glomerulonephritis
      • endocarditis-associated glomerulonephritis
      • systemic vasculitis
      • thrombotic microangiopathy
        • hemolytic-uremic syndrome
        • thrombotic thrombocytopenic purpura
      • rapidly progressive glomerulonephritis
  • 57. Acute Vascular Syndromes
    • Renal artery thromboembolism
    • Renal artery dissection
    • Renal vein thrombosis
    • Atheroembolic disease
  • 58. Atheroembolic Disease
  • 59. Intratubular Obstruction
    • Intratubular crystal deposition
      • tumor lysis syndrome
        • acute urate nephropathy
      • ethylene glycol toxicity
        • calcium oxylate deposition
    • Intratubular protein deposition
      • multiple myeloma
        • -Bence-Jones protein deposition
  • 60. Differential Diagnosis of Acute Renal Failure
    • Prerenal ARF
    • Postrenal ARF
    • Intrinsic ARF
      • acute tubular necrosis
      • acute interstitial nephritis
      • acute glomerulonephritis
      • acute vascular syndromes
      • intratubular obstruction
  • 61. Acute Renal Failure: Diagnostic Evaluation
    • Evaluate for prerenal causes
      • clinical exam
        • blood pressure
        • orthostasis
      • central venous pressures and cardiac output
      • intake/output record
      • urine sediment
      • urine sodium
        • U Na < 20 mmol/L
      • therapeutic trial of volume replacement
      • skin turgor
      • mucosal membrane hydration
      • FE Na < 0.01
  • 62. Acute Renal Failure: Diagnostic Evaluation
    • Evaluate for postrenal causes
      • bladder catheterization
      • renal ultrasound
  • 63. Acute Renal Failure: Diagnostic Evaluation
    • Evaluation for intrinsic ARF
      • clinical history
        • medications
        • hypotension
      • physical exam
      • urinalysis
        • crystals
        • paraproteins
      • radiocontrast agents
      • sepsis
      • cells
      • casts
  • 64. Diagnostic Evaluation of ARF Muddy brown casts; tubular epithelial cells > 2% >40 <10:1 ATN Normal or RBC’s variable >20 variable Vascular RBC’s, RBC casts <1% <40 variable AGN WBC’s WBC casts, RBC’s, eosinophils >1% >20 <20:1 AIN Intrinsic Normal or RBC’s variable >20 >20:1 Postrenal Normal < 1% <20 >20:1 Prerenal Urine Sediment FE Na U Na (mEq/L) BUN:Cr Form of ARF
  • 65. Acute Renal Failure: Management
    • Prerenal ARF
      • volume repletion
      • inotropic support
      • discontinue diuretics
    • Postrenal ARF
      • bladder catheterization
      • percutaneous nephrostomy or ureteral stents
      • fluid management during post-obstructive diuresis
  • 66. Acute Renal Failure: Management
    • Intrinsic ARF
      • General supportive care
        • fluid management
        • diuretics
        • bicarbonate supplementation
        • potassium
        • phosphate
        • drug dosing
        • nutrition
  • 67. Acute Renal Failure: Management
    • Indications for dialysis
      • volume overload
      • metabolic acidosis
      • hyperkalemia
      • uremic syndrome
        • pericarditis
        • encephalopathy
      • azotemia