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    Renal Function Iin ICU Renal Function Iin ICU Presentation Transcript

    • RENAL FUNCTION IN THE ICU S. ESFANDIARI MD, SURGICAL INTENSIVE CARE UNIT
    • RENAL FUNCTION IN ICU
      • Renal Clearance/GFR/ FENa
      • Hepato -Renal Syndrome SIADH
      • Rhabdomyiolosis, contrast induced ARF
    • Case Study 86 year Male 40 Kg had been admitted to ICU for G.I. Bleeding last 12 hr. BUN = 65 Creat 1.6 Urine Output = 30 cc/h BP = 140/90 C.I. 3.4L/min PCWP = 28 Medication Lasix 40 mg. Q/ d + Renal dose Dopa Urine Creat ( 2H)= 105 mg/L Urine Na = 60 Urine OS= 400 GFR=? < 15 > =35 = 19 =125 =60 DIAG A= ATN B=PUMP FAILURE C= NORMAL RENAL FUNC D= INSU DATA FOR DIAG
    • RENAL CLEARANCE/GFR Practical issues regarding creatinine, clearance in SICU A. Estimate Creatinine Clearance CL Cr = (140 - age) x lean BW in Kg 72 x S Cr Female = Estimate Value x .85
    • Case Study Calculate G.F.R V.S Measured Creatinine Clearance Estimate GFR 140 - 86 x 40 = 19 72 x 1.6
    • Case Study GFR = Cr C 2h = 105 x .5 = 32 1.6 GFR = 32 is normal for this patient age, Diagnosis = normal kidney function; High BUN is due to GI bleeding
      • CLEARANCE and GFR
      • Plasma clearance is used to express the ability of the kidney to clean or “clear” the plasma of a substance. If a substance does not reabsorb and not exerted by the kidney then clearance = GFR
      • C = Uc x UV (per min)
      • Pc
      • Ideal Agent =
          • Non Toxin
          • Non Reabsorbent
          • Non Actively Excreted
    • GFR/CLEARANCE
      • ESTIMATE
      • INULIN
      • CREATININE 2H/ 24 H
      • IOTHALAMATE (radio active tracer) gold standard
    • RENAL CLEARANCE/GFR
      • ADVANTAGE :
        • easy to calculate
        • good for starting medication, antibiotics, etc in the patient in acute phase of ATN
        • cost is cheap
      • DISADVANTAGE:
        • extremely inaccurate in obese and overloaded patients, septic patients, tendency to overestimate.
        • Underestimate in small size old patient
    • RENAL CLEARANCE/GFR (cont) 24 Creatinine Clearance or 2 Hours = CL Cr = Ucr x UV(cc/min) S cr needs volume of urine (cc/min) urine concentration of creatinine ( lab reports total amount of creatinine per vol of urine) serum concentration of creatinine
    • GFR
      • example
      • 150 cc urine collected over two hours
      • U Cr is 40mg per dc/l
      • Scr is 2mg /dl
      • U volume 1.2 cc/min 40 X 1.2 =24
      • GFR= 24 2
      • Iothalamate Sodium I 125 Clearance
      • CL I TH = U ITH x UV/min
      • S ITH (1) + S ITH (2)
      • Extremely accurate
      • Eliminate weight problems
      • Fast, could be done within 3-4 hours
      • Expensive
      • Not available in smaller institution.
      • Gold standard
    • Case Study 4 (cont) Ccr = 140 - Age x B.W. = 140 - 43 x 105 = 110 72 x Pcr 72 x 1.4 Female correction = Ccr x .85 = 110 x .85 = 94
    • Case Study 4 ESTIMATED VS MEASURED CREATININE CLEARANCE 43 year old female; weight 105 kg; evaluated for possible renal disease. Plasma creatinine 1.4/DL Urine creatinine 62/DL Urine volume 24 hours 1080 cc Consider zosyn dose
    • case 4 C cr measured 24 hour urinary creatinine clearance Ccr = Ucr x Uv min = 62x .75 = 33 Pcr 1.4
    • Interpretation= GFR Dialysis <10 >6 End stage Aggressive hydration 40-60 2-6 Severe hypovolemia Diuretics/dialysis 10-20 2-4 ATN None,protection strategy 20-30 2-4 C.Renal insufficiency None 30-80 1-2 Age >60 None 80-120 1-2 Normal TX GFR Serum Cr condition
    •  
    •  
    • Case Study 2
      • 55 year old male admitted to I.C.U. after AAA operation: Aorta clamp time 45 minutes otherwise uneventful course. Urine output 250 cc/h PCWP = 19 C.I. 3.1 Patient I/O last 24 hour 11500/8500 Pcr 1.8 (Preop Cr 1.1) BUN = 30 Urine Na 65 Urine osm 200 Ur cr = 15 PNa = 130
      • Possible Diagnosis:
        • High Output A.T.N. Diabetes Insipidus
        • S.I.A.D.H. Over hydration
        • Fluid Mobilization
    • Case Study 2 (cont) FENa = UNa x Pcr x 100 = 65 x 1. 8 x 100 = 6% PNa x Ucr 130 x 15 2h urinary creatinine clearance Ccr = Ucr x UV (min) = 15 x 4 = 33 Pcr 1.8
    • CASE 2 ATN FENA 65 LOW GFR=33
    • Fractional excretion of Na Ratio of the Na excreted < 1% to Na reabsorbed 99%
    •  
    • FeNa
      • Inexpensive,easy in ICU
      • To identify pre renal from renal or hepato-renal
      • Could be used as follow-up during recovery phase
      • Little influenced by low salt diet or excess of salt intake
      • Diuretics should not be used at least 8 hours prior to test
      • Renal dose of dopamine although theoretically influence Na + excretion, but in practice it is usually ignored .
    • FRACTIONAL - EXCRETION NA +
      • EVALUATION OF TUBUL INTETEGRITY
      • FE Na = U/P Na + x P/U cr OR
      • FENA= Una + x P cr x 100
      • PNa + x U cr
    • FENA FENA= Una + x S cr x 100 S na X Ucr
    • FENA/NORMAL VALUE
      • U/sodium= 30
      • U cr =60
      • Scr =1.2
      • Sna =140
      • 30 X 1.2 X100 = 1.14
      • 140 x60
    • FRACTIONAL - EXCRETION NA +
      • FE Na >3% = Renal tubular dysfunction, A.T.N.P0S DIURETIC USE
      • FE Na <1% = Hypovolemia - low cardiac output
      • FE Na 1% - 2% = Not significant diagnostic value
          • FE Na are low in these conditions:
          • 10% - 15% A.T.N.
          • H.R.S. FENA LOW <1% NO RESPONSE TO VOLUME OR INOTROPIC AGENTS
    • Case Study 5 70 year old woman 80 kg in very good health admitted in ICU after surgical removal of her spleen. She has been hypotensive and on pressors in PACU for a period of 6 hours prior to ICU admission: BP 110/70 BUN = 20 Creat 1.6/L urine output 30cc/h CVP = 12 Lasix drip, 2 mg/h + Dopa renal dose Urine Na = 65 Urine osm = 320 Urine Creatinine 48 mg/L SN a=135 DIAGNOSIS A= ATN B= SIADH C= HYPOVOLEMIA D=INSU DATA FOR DIAGNOSIS
    • Case Study 5 (cont) Estimated Creatinine Clearance from Cock Croft - Gault Ccr = (140-age) x BW = 140 - 30 x 80 = 76 72 x PCr 72 x 1.6 Correction for Female .85 = 65
    • Case 5 Urinary Cr clearance 2 h Ccr= Ucr x UV (min) = 48 x .5 = 15 Pcr 1.6
    • Dx=ATN
    • ATN/VASOCONSTRICTION
      • HYPOVOLEMIA
      • PRESSORS
      • CONTRAST
      • LOW CARDIAC INDEX
      • HEPATO-RENAL
    • ATN/VASODILATATION
      • SEPSIS
      • 50% IN SEPTIC SHOCK
      • VASODILATION AND ^RBF
      • REDIST BLOOD FLOW FROM CORTEX TO MEDULLA
      • INCREASE NO PRODUTION
      • NOREPINEPHRINE MAY BE HELPFUL (renal dose Nor-epinephrine)
      • Intrarenal blood flow distribution in hyperdynamic septic shock: Effect of norepinephrine.
      • Di Giantomasso, David MBBS; Morimatsu, Hiroshi MD; May, Clive N. PhD; Bellomo, Rinaldo MD
      • [LABORATORY INVESTIGATIONS]
    • Dopamine Action
      • INCREASE CO/INC RENAL BLOOD FLOW
      •  NA EXEC LIKE DIURETICS
      • DOES NOT  GFR
      •  PULSE, PB
      •  T-CELL, MORE INFECTIOUS
      • A-FIB
      •  GROWTH HORMONE
    • Low Dose Dopamine Patients with Early Renal Dysfunction THE LANCET VOL 356 DEC 2000 AUSTRALIAN-NEW ZEALAND STUDY GROUP
      • PACEBO-CONTROL RANDOMIZED STUDY
      • MULTI-INSTUT
      • 3 YEARS IN 23 ICU's
      • 328 PATIENTS 2ug/K DOPAMINE
      • NO SIGNIFICATN RENAL PROTECTION IN TWO GROUPS
      • Lancet 2000;356
    • Rhabdomyolysis
      • Major crush injury/compartment synd
      • Muscle edema, ischemia, necrosis
      • Status epilepticus
      • Prolong positional pressure under anesthesia
      • Protracted fever
      • Prolong use of vasopressor/cross clamp
      • Cocaine, cracks/STATIN
      • Malignant hyperthemria
    • Mechanism of Rhabdomyolosis Release of myoglobin, which is 25% of HG size rapidly filtering by glomerlus, precipitate as an acid ferrihematin in proximal tubes, hypovolemia, urine pH<6 low urine output enhancing the process
    • Rhabdomyolysis Diagnosis
      • Clinical High Index of Suspicion
      • Serum Myoglobin >400 ug/l
      • Urine Myoglobin >1000 mg/c
      • Negative Test are Frequent
      • CPK >1000
    • Rhabdomyolisis
      • CPK over 10000 associated higher incidence ARF
    • Strategy for Renal Protection, Recovery
      • Enhance DO 2  CI Hg preload, maintain perfusion pressure
      • Renal vasodilatation
        • Dopamine
        • Fenoldapam
      • Maintenance Tubular Flow u/o 100-200 cc/h
      • Mannitol
      • Loop Diuretics
    • Rhabdomyolysis Treatment
      • High Urine Volume >200/h
      • Mannitol
      • Sodium Bicarb 25 meq/h
      • Urine pH>6
      • Diuretics
      • Hydration
    • Mechanism CIARF
      • Renal vasoconstriction  leading to medullary ischemia  GFR
      • Direct cytotoxic injury mediated by O2 free radical
      • Intratubular obstruction
    • Risk factor contrast CIARF
      • Odd ratio=5.5
      • Prior renal insufficiency
      • Diabetes
      • Large dose,multi-dose ,
      • Dehydration
      • Bp<100i
      • CHF
      • NSAID ,ACE I
      • Multiple myeloma
    • Prevention CIARF
      • Hydration 1-3cc/kg saline 12 hours prior and post contrast
      • Manitol 25 Gr 1 or lasix 80 mg hour prior to contrast
      • Acetylcystrine 600mg bid day before and after of contrast ( Tepel NEJM 2000) reduce CIARF 2% vs. 21% control (Diaz- Sandoval 2002 AJC) 8%vs45 %
      • Fenoldopam 1ug/kg/min 4 hours prior and after contrast (Tumlin 2002 AHJ) 21%vs45%
    • Case Study 7
      • 48 WF acute brain hemorrhage
      • Intra abdominal bleed, massive fluid intake, transfusion of 40 units blood product urine output 180 cc/h, SCr = 2, Urine OSM = 325, Serum OSM = 340, SRNa = 160, Urine Cr = 10
      • Diagnosis
      • A=DI B=ATN C=EXCESS Na INTAKE
    • CASE
      • UV-3 cc/minXUCr-10
      • GFR= ----------------------- =15
      • S Cr-2
    • Case Study 7 (cont) FENA UNa - 111  Sr cr - 2 SNa - 160  Ucr - 15 x 100 = 9%
    • CASE
      • DIAGNOSIS = ATN
      • D .I . URINE OUT PUT MUCH HIGHER, UOSM IS <100 SG<1020 fena not high
    • Case Study 45 year old male with Cirrhosis and large acites admitted in I.C.U.for hypotension and low urine out put Patient urinary output 20 cc/h C.I. 5L/min PCWP = 20 BP = 130/70 P Na= 130 U Na = 5 meq/l Urine osmo = 580 Pcr 2.6 BUN = 60 meq/l Urine Cr = 92
    • Case Study (cont)
      • Possibilities:
        • S.I.A.D.H. Syndrome
        • Hypovolemia
        • A.T.N.
        • Hepato - Renal Syndrome
        • None of above
    • Case continue
      • Cl Cr =GFR= Ucr x UV/min = 92 x .3 = 11
      • S Cr 2.6
    • Case study cont
      • FENa = U Na x Pcr = 100 = 5 x 2.6 = 0.10
      • PNa x Ucr 130 x 92
    • Case 3 DX= HRS LOW GFR =11 LOW FENA=.1 H/O LIVER DISEASE
    • Pathology in Hepato Renal Symptoms
      • Cortical vasoconstriction due to decreased effective blood volume
      • The role of angiotensin and mediators not well-defined
      • Although the hemodynamic values are not compatible with hypovolemia or congestive heart failure the renal functions are very similar to pre-renal dysfunction
      • Not responsive to volume and pressor therapy
      • Liver transplant in a definitive treatment in the patients with primary liver pathology
      • Support the patient with CVVHD or hemodialysis
    • Hepato Renal Syndrome
      • Primary Pathology in liver, e.g. CIRRHOSIS
      • No clinical evidence of low C.O. or hypovolemia
      • No response to therapy, volume loading or Pressors
      • Good response to liver transplant
      • S Cr 3-5 GFR=20-10
    • Hepato-Renal
    • URINARY INDICES IN HEPATO-RENAL SYNDROME
    • Case
      • 71 /Y/MALE 50 Kg IN PACU POST PNUMONECTOMY FOR LUNG CA BLOOD LOSS 3 LITER
      • TRANSFUSE 5 RBC 2 FFP 4 LITER LR
      • URINE 15-20 CC/H LAST 4-6 HOURS NO RESPONSE TO LITER HEXTAN AND  IV FOLEY OK
      • Bp=130/60 pulse=90 CVP=12 PCWP=16 CI=3.2 SNa=136 SCr=1.6 / BASELINE 1.6
    • case U Cr=80 UOS=750 UNA=65
    • Case Study (cont)
      • FENa = UNa x Pcr x 100 65 x 1.6 x 100 = 1.02
      • PNa x Ucr 136 x 80
      • DIAGNOSIS
        • 1. A.T.N.
        • 2. CHF
        • 3. HYPOVOLEMIA
        • 4. SIADH
        • 5.NORMAL POST OP /ACCEPTABLE U/O FOR HER SIZE
    • Case Study 1
      • DX= SIADH
      • High U/OSM (750)
      • LOW Sr /OSM
      • Low Serum Na (136)
      • High Urinary Na (65)
      • Mild Oliguria 15-20 cc/h
      • Clinical Presentation Lung CA
      • Positive Pressure Vent
    • SIADH IN ICU PATIENTS
      • ETIOLOGY
      • Pre-existing medical condition ( i.g ., lung tumors, brain tumors, CVA, et.)
      • Surgical procedure ( i.e., bone surgery, lung surgery, abdominal surgery)
      • Positive pressure ventilation
      • Pain and analgesic drugs
    • SIADH IN ICU PATIENTS
      • DIAGNOSIS
      • Relative hyponatremia serum Na + usually 130 - 140 mEq/L, normal S Na does not rule it out
      • Relative oliguria urine output <30 cc or significantly less than intake (75/80%)
      •  urinary Na + > 30 mEq/L Range: 30 - 120 mEq/L
      •  urine osmolality > 500
    • SIADH IN ICU PATIENTS
      • TREATMENT
      • DO NOT DO ANYTHING (most of cases)
      • Very low dose of lasix if renal function OK
      • (2-10 mg)
      • Rule out other condition
    • RX
      • 5 MG LASIX
      • URINE OUTPUT TO 90 CC/H
    • Free Water Clearance In a patient with prerenal oliguria, the urine flow may be 0.5 ml/min, serum osmolarity 300 mOsm/liter, and urine osmolarity 600 mOsm/liter: Cl OSM = (600)(0.5) = 1.0 ml/min (300) Cl H2O = urine flow (ml/min) _ Cl OSM = 0.5 - 1.0 = -0.5 ml/min
    • Free Water Clearance Cl H2O = Urine Volume/min - Cl OSM Example: Serum OSM = 300 MSO Urine OSM = 600 MSO Urine Value 120 cc/h Cl OSM = Uosm x UV = 600 x 2 = 4 S OSM 300 Cl H2O = UV = Cl OSM = 2- 4 = - 2 
    • Tests to Evaluate Tubular Dysfunction Osmolar Clearance CL OSM = Uosm x Uv SERUM OSO Refers to total number of osmotically active solute particles instead of single substance: If CL OSM in equal with urine volume means no solute, would be cleared by kidney.
    • Free Water Clearance Cl OSM = (0.5)(200) = 0.36 ml/min (280) Cl H2O = 0.5 - 0.36 = 0.14 ml/min . IF FREE WATER Cr POSITIVE MEANS LACK OF CONCENTRATION CAPABILTY
    • FILTERATION, EXCRETION, REABSOBTION ELCTROLYTES
    • Free Water Clearance Free-water clearance (Cl H2O ) is defined as urine volume per minute minus osmolar clearance and is normally negative. Isosthenuria (urine osmolarity the same as plasma) is one of the earliest and most consistent functional characteristics of ATN As urine osmolality falls, osmolar clearance also falls and free-water clearance becomes less negative. If urine osmolality falls below that of serum, free-water clearance becomes positive, a fall in osmolar clearance may occur, even before a fall in Cl cr or serum Cr . in some patients as ATN is developing.