0
Acute Renal Failure Or The Kidney Is Your Friend Katie Murphy MD September 2007
Katie’s Approach to Medical Topics <ul><li>For any topic, I ask the following questions: </li></ul><ul><ul><ul><li>What Is...
What Is Acute Renal Failure ? <ul><li>There is no universally accepted definition of acute renal failure (ARF). </li></ul>
What Is Acute Renal Failure ? <ul><li>There is no universally accepted definition of acute renal failure (ARF). </li></ul>...
What Is Acute Renal Failure? <ul><li>Oliguric Renal Failure </li></ul>
What Is Acute Renal Failure? <ul><li>Oliguric Renal Failure </li></ul><ul><li>Less than 500 ml urine output/day in adults ...
What Is Acute Renal Failure? <ul><li>Oliguric Renal Failure </li></ul><ul><li>Less than 500 ml urine output/day in adults ...
What Is Acute Renal Failure? <ul><li>Oliguric Renal Failure </li></ul><ul><li>Less than 500 ml urine output/day in adults ...
What Is Acute Renal Failure? <ul><li>Oliguric Renal Failure </li></ul><ul><li>Less than 500 ml urine output/day in adults ...
What Is Acute Renal Failure? <ul><li>Oliguric Renal Failure </li></ul><ul><li>Less than 500 ml urine output/day in adults ...
Chronic Kidney Disease <ul><li>The new nomenclature for renal disease: </li></ul><ul><ul><li>Stage 1 CKD: kidney damage bu...
Why Do We Care ? <ul><li>ARF occurs in 5% of hospitalized patients. </li></ul><ul><li>ARF has been found to be related to ...
Etiologies of Acute Renal Failure <ul><li>Pre-Renal  </li></ul><ul><li>Post-Renal  </li></ul><ul><li>Intrinsic or Intra-Re...
Pre-Renal Acute Renal Failure <ul><li>Accounts for 60-70% of ARF. </li></ul><ul><li>Etiologies: </li></ul><ul><ul><li>True...
Post-Renal Acute Renal Failure <ul><li>Accounts for 5-10% of ARF. </li></ul><ul><li>Remember anatomy and have a systematic...
Intrinsic Renal ARF <ul><li>Accounts for 25-40% of  </li></ul><ul><li>ARF. </li></ul><ul><li>Again, remember the </li></ul...
Intrinsic Renal ARF <ul><li>Accounts for 25-40% of ARF. </li></ul><ul><li>Again, remember the component anatomy of the kid...
What Do We Need to Do ? <ul><li>First, you need to suspect acute renal failure. </li></ul><ul><li>Presentation of ARF: </l...
What Do We Need to Do Part 2 <ul><li>Now, we need to look for risk factors, symptoms and signs </li></ul><ul><li>History: ...
History Continued <ul><li>Causes of Volume Depletion </li></ul><ul><li>Autoimmune Disease </li></ul><ul><li>Previous Histo...
Physical Exam <ul><li>Volume Status:  </li></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Mucous membranes </li><...
Physical Exam Continued <ul><li>Dermatologic: Rashes, petechia, purpura </li></ul><ul><li>Abdomen: CVAT, enlarged bladder....
What Do We Need to Do ? Part 3 <ul><li>We need to act quickly to initiate workup </li></ul><ul><li>Labs and Studies: </li>...
UA Interpretation <ul><li>Hyaline Casts : Not indicative of renal disease  </li></ul><ul><ul><li>Concentrated urine, febri...
Labs and Studies Continued <ul><li>In oliguric ARF, calculate FeNa:  </li></ul><ul><li><1% (pre-renal, acute GN, contrast,...
Studies and Labs Continued <ul><li>Renal Ultrasound </li></ul><ul><ul><li>r/o hydronephrosis </li></ul></ul><ul><ul><li>Bi...
Treatment <ul><li>Place Foley or flush Foley if already present. </li></ul><ul><li>As a large percentage of ARF is pre-ren...
Treatment <ul><li>Place Foley or flush Foley if already present. </li></ul><ul><li>As a large percentage of ARF is pre-ren...
Treatment Continued <ul><li>D/C all meds with kidney damaging potential and adjust dosing of renally cleared meds. </li></...
An Ounce of Prevention... <ul><li>Check troughs after third dose of aminoglycosides. </li></ul><ul><li>Use oral N-acetylcy...
Where Can I Learn More About Acute Renal Failure? <ul><li>Acute Renal Failure Core Curriculum Handout </li></ul><ul><li>Th...
Upcoming SlideShare
Loading in...5
×

Acute Renal Failure

647

Published on

1 Comment
1 Like
Statistics
Notes
No Downloads
Views
Total Views
647
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
26
Comments
1
Likes
1
Embeds 0
No embeds

No notes for slide

Transcript of "Acute Renal Failure"

  1. 1. Acute Renal Failure Or The Kidney Is Your Friend Katie Murphy MD September 2007
  2. 2. Katie’s Approach to Medical Topics <ul><li>For any topic, I ask the following questions: </li></ul><ul><ul><ul><li>What Is It? (Definitions, Classifications) </li></ul></ul></ul><ul><ul><ul><li>Why Do I Care? (Prevalence, Morbidity, Mortality) </li></ul></ul></ul><ul><ul><ul><li>What Do I Need to Do? (Workup) </li></ul></ul></ul>
  3. 3. What Is Acute Renal Failure ? <ul><li>There is no universally accepted definition of acute renal failure (ARF). </li></ul>
  4. 4. What Is Acute Renal Failure ? <ul><li>There is no universally accepted definition of acute renal failure (ARF). </li></ul><ul><li>Commonly used definition is > or = to 0.5mg/dl increase in serum creatinine in 2 weeks or less if the baseline creatinine is less than 2.5mg/dl. </li></ul><ul><li>If baseline creatinine is greater than 2.5mg/dl, ARF is defined as a greater than 20% increase. </li></ul>
  5. 5. What Is Acute Renal Failure? <ul><li>Oliguric Renal Failure </li></ul>
  6. 6. What Is Acute Renal Failure? <ul><li>Oliguric Renal Failure </li></ul><ul><li>Less than 500 ml urine output/day in adults </li></ul>
  7. 7. What Is Acute Renal Failure? <ul><li>Oliguric Renal Failure </li></ul><ul><li>Less than 500 ml urine output/day in adults </li></ul><ul><li>Derived from the fact that a healthy kidney, if maximally concentrating the urine, will have to excrete 500 ml urine per day to get rid of the daily osmotic load from dietary intake and metabolic byproducts . </li></ul>
  8. 8. What Is Acute Renal Failure? <ul><li>Oliguric Renal Failure </li></ul><ul><li>Less than 500 ml urine output/day in adults </li></ul><ul><li>Derived from the fact that a healthy kidney, if maximally concentrating the urine, will have to excrete 500 ml urine per day to get rid of the daily osmotic load from dietary intake and metabolic byproducts . </li></ul><ul><li>Anuric Renal Failure </li></ul>
  9. 9. What Is Acute Renal Failure? <ul><li>Oliguric Renal Failure </li></ul><ul><li>Less than 500 ml urine output/day in adults </li></ul><ul><li>Derived from the fact that a healthy kidney, if maximally concentrating the urine, will have to excrete 500 ml urine per day to get rid of the daily osmotic load from dietary intake and metabolic byproducts . </li></ul><ul><li>Anuric Renal Failure </li></ul><ul><li>Less than 100 ml/day urine output </li></ul>
  10. 10. What Is Acute Renal Failure? <ul><li>Oliguric Renal Failure </li></ul><ul><li>Less than 500 ml urine output/day in adults </li></ul><ul><li>Derived from the fact that a healthy kidney, if maximally </li></ul><ul><li>concentrating the urine, will have to excrete 500 ml urine </li></ul><ul><li>per day to get rid of the daily osmotic load from dietary </li></ul><ul><li>intake and metabolic byproducts . </li></ul><ul><li>Anuric Renal Failure </li></ul><ul><li>Less than 100 ml/day urine output </li></ul><ul><li>Non-Oliguric Renal Failure </li></ul>
  11. 11. Chronic Kidney Disease <ul><li>The new nomenclature for renal disease: </li></ul><ul><ul><li>Stage 1 CKD: kidney damage but normal GFR (>90ml/min) </li></ul></ul><ul><ul><li>Stage 2 CKD: mild kidney damage (GFR 60-89ml/min) </li></ul></ul><ul><ul><li>Stage 3 CKD: moderate kidney damage (GFR 30-59ml/min) </li></ul></ul><ul><ul><li>Stage 4 CKD: severe kidney damage (GFR 15-29ml/min) </li></ul></ul><ul><ul><li>Stage 5 CKD: kidney failure (GFR < 15ml/min or ESRD on renal replacement therapy) </li></ul></ul>
  12. 12. Why Do We Care ? <ul><li>ARF occurs in 5% of hospitalized patients. </li></ul><ul><li>ARF has been found to be related to a 20% mortality rate (often infectious or cardiorespiratory) </li></ul><ul><li>When serum creatinine increases by >3.0mg/dl, mortality approaches 40-50% and thus prompt diagnosis and institution of appropriate treatment is crucial. </li></ul>
  13. 13. Etiologies of Acute Renal Failure <ul><li>Pre-Renal </li></ul><ul><li>Post-Renal </li></ul><ul><li>Intrinsic or Intra-Renal </li></ul>
  14. 14. Pre-Renal Acute Renal Failure <ul><li>Accounts for 60-70% of ARF. </li></ul><ul><li>Etiologies: </li></ul><ul><ul><li>True Volume Depletion (blood loss, dehydration) </li></ul></ul><ul><ul><li>Effective Circulating Volume Depletion (CHF, sepsis) </li></ul></ul><ul><ul><li>Hypotension (sepsis, meds, cardiogenic shock) </li></ul></ul><ul><ul><li>ACE-Inhibitors </li></ul></ul><ul><ul><li>NSAIDS </li></ul></ul><ul><ul><li>Hepatorenal Syndrome </li></ul></ul>
  15. 15. Post-Renal Acute Renal Failure <ul><li>Accounts for 5-10% of ARF. </li></ul><ul><li>Remember anatomy and have a systematic approach. </li></ul><ul><li>Etiologies include: </li></ul><ul><ul><li>Ureteral: Tumors, stones, clot and lymphadenopathy </li></ul></ul><ul><ul><li>Bladder: Tumors, stones, neurogenic, drugs </li></ul></ul><ul><ul><li>Prostate: Hypertrophy, tumors </li></ul></ul><ul><ul><li>Urethral: Strictures, tumors </li></ul></ul>
  16. 16. Intrinsic Renal ARF <ul><li>Accounts for 25-40% of </li></ul><ul><li>ARF. </li></ul><ul><li>Again, remember the </li></ul><ul><li>component anatomy </li></ul><ul><li>of the kidney . </li></ul>
  17. 17. Intrinsic Renal ARF <ul><li>Accounts for 25-40% of ARF. </li></ul><ul><li>Again, remember the component anatomy of the kidney . </li></ul><ul><li>Vessels : Vasculitis, Emboli </li></ul><ul><li>Glomerulus : Nephrotic syndromes, Nephritic Syndromes </li></ul><ul><li>Tubules : Acute Tubular Necrosis, Rhabdomyolysis, Contrast Nephropathy </li></ul><ul><li>Interstitium(peri-tubular and peri-arteriolar tissue) : Acute Interstitial Nephritis, Severe Pyelonephritis . </li></ul>
  18. 18. What Do We Need to Do ? <ul><li>First, you need to suspect acute renal failure. </li></ul><ul><li>Presentation of ARF: </li></ul><ul><ul><ul><li>Most patients are asymptomatic, but symptoms include </li></ul></ul></ul><ul><ul><ul><li>Malaise Hypertension </li></ul></ul></ul><ul><ul><ul><li>Hematuria Encephalopathy </li></ul></ul></ul><ul><ul><ul><li>Flank Pain Pruritis </li></ul></ul></ul><ul><ul><ul><li>Dyspnea Bleeding from platelet </li></ul></ul></ul><ul><ul><ul><li>dysfunction </li></ul></ul></ul><ul><ul><ul><li>Edema Oliguria/Anuria </li></ul></ul></ul>
  19. 19. What Do We Need to Do Part 2 <ul><li>Now, we need to look for risk factors, symptoms and signs </li></ul><ul><li>History: </li></ul><ul><ul><li>Drugs: Anticholinergics, IV Contrast, Aminoglycosides, Amphotericin. </li></ul></ul><ul><ul><ul><li>Classic AIN Medications: </li></ul></ul></ul><ul><ul><ul><ul><li>Penicillins </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cephalosporins </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Sulfa drugs </li></ul></ul></ul></ul><ul><ul><ul><ul><li>NSAIDS </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Rifampin </li></ul></ul></ul></ul>
  20. 20. History Continued <ul><li>Causes of Volume Depletion </li></ul><ul><li>Autoimmune Disease </li></ul><ul><li>Previous History of ARF </li></ul>
  21. 21. Physical Exam <ul><li>Volume Status: </li></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Mucous membranes </li></ul></ul><ul><ul><li>Orthostatics </li></ul></ul><ul><ul><li>Vital signs </li></ul></ul>
  22. 22. Physical Exam Continued <ul><li>Dermatologic: Rashes, petechia, purpura </li></ul><ul><li>Abdomen: CVAT, enlarged bladder. </li></ul><ul><li>Mental Status: Altered Mental Status </li></ul><ul><li>CV: Pericardial friction rub </li></ul>
  23. 23. What Do We Need to Do ? Part 3 <ul><li>We need to act quickly to initiate workup </li></ul><ul><li>Labs and Studies: </li></ul><ul><li>Stat: </li></ul><ul><li>BMP UA with micro </li></ul><ul><li>Una Ucr </li></ul><ul><li>Uosm: </li></ul><ul><ul><ul><li>>400 in pre-renal </li></ul></ul></ul><ul><ul><ul><li><350 in post-renal </li></ul></ul></ul><ul><ul><ul><li><350 in intrinsic renal </li></ul></ul></ul>
  24. 24. UA Interpretation <ul><li>Hyaline Casts : Not indicative of renal disease </li></ul><ul><ul><li>Concentrated urine, febrile disease, post-strenuous exercise, diuretic therapy </li></ul></ul><ul><ul><li>Granular Casts : Degenerating cellular casts, non-specific </li></ul></ul><ul><ul><li>RBC Casts : Glomerulonephritis, vasculitis </li></ul></ul><ul><ul><li>WBC Casts : Pyelonephritis, Interstitial nephritis </li></ul></ul><ul><ul><li>Renal Tubular Cell Casts : Nonspecific, degenerating cellular casts </li></ul></ul><ul><ul><li>Waxy casts : Chronic renal failure </li></ul></ul>
  25. 25. Labs and Studies Continued <ul><li>In oliguric ARF, calculate FeNa: </li></ul><ul><li><1% (pre-renal, acute GN, contrast, hepatorenal), </li></ul><ul><li>>1% Intrinsic renal failure (Damaged kidney can not concentrate urine, loses Na) </li></ul><ul><ul><ul><li>Una/Pna x 100 </li></ul></ul></ul><ul><ul><ul><li>Ucr/PCr </li></ul></ul></ul><ul><ul><ul><li>FeNa has a 96% sensitivity and a 95% specificity for distinguishing pre-renal from ATN. </li></ul></ul></ul><ul><ul><ul><li>Not accurate with diuretics. </li></ul></ul></ul>
  26. 26. Studies and Labs Continued <ul><li>Renal Ultrasound </li></ul><ul><ul><li>r/o hydronephrosis </li></ul></ul><ul><ul><li>Bilateral Small Kidneys: Chronic Renal Disease </li></ul></ul><ul><ul><li>Unilateral Small Kidney: Renal Artery Stenosis </li></ul></ul><ul><ul><li>Enlarged Kidneys: HIV, amyloid, PCKD, early DM </li></ul></ul>
  27. 27. Treatment <ul><li>Place Foley or flush Foley if already present. </li></ul><ul><li>As a large percentage of ARF is pre-renal, IVF challenge appropriate in many cases. </li></ul><ul><li>Evaluate for life-threatening complications: </li></ul><ul><ul><li>A: </li></ul></ul><ul><ul><li>E: </li></ul></ul><ul><ul><li>(I): </li></ul></ul><ul><ul><li>O: </li></ul></ul><ul><ul><li>U: </li></ul></ul>
  28. 28. Treatment <ul><li>Place Foley or flush Foley if already present. </li></ul><ul><li>As a large percentage of ARF is pre-renal, IVF challenge appropriate in most cases. </li></ul><ul><li>Evaluate for life-threatening complications: </li></ul><ul><ul><li>A: Acidemia </li></ul></ul><ul><ul><li>E: Electrolyte Abnormalities (Hyperkalemia) </li></ul></ul><ul><ul><li>(I: Ingestion) </li></ul></ul><ul><ul><li>O: Overload (CHF) </li></ul></ul><ul><ul><li>U: Uremic Encephalopathy or pericarditis </li></ul></ul><ul><ul><li>ALL OF THE ABOVE ARE INDICATIONS FOR EMERGENT HEMODIALYSIS </li></ul></ul>
  29. 29. Treatment Continued <ul><li>D/C all meds with kidney damaging potential and adjust dosing of renally cleared meds. </li></ul><ul><li>Monitor strict Is/Os, follow CBC to evaluate for anemia and bleeding disorders. </li></ul><ul><li>Control hyperkalemia </li></ul><ul><li>No longer recommended to give furosemide to convert anuric to oliguric renal failure. </li></ul><ul><li>Consult renal for intra-renal or rapidly progressive renal failure. </li></ul>
  30. 30. An Ounce of Prevention... <ul><li>Check troughs after third dose of aminoglycosides. </li></ul><ul><li>Use oral N-acetylcysteine or bicarbonate for contrast loads in patients with risk factors for ARF. </li></ul><ul><li>Avoid diagnostic studies involving contrast unless absolutely necessary. </li></ul><ul><li>Monitor Is/Os in patients with ESLD, febrile states, prolonged NPO. </li></ul>
  31. 31. Where Can I Learn More About Acute Renal Failure? <ul><li>Acute Renal Failure Core Curriculum Handout </li></ul><ul><li>Thadhani, et. Al., “Acute Renal Failure,”NEJM, May 30, 1996 Review Article </li></ul><ul><li>Agrawal,N., et. Al., “Acute Renal Failure,” APF 2000;61:2077-2088. </li></ul><ul><li>Your local public library </li></ul>
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×