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RENAL FUNCTION IN THE  ICU S. ESFANDIARI  MD, SURGICAL INTENSIVE CARE UNIT
RENAL FUNCTION IN ICU ,[object Object],[object Object],[object Object]
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
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
GFR/CLEARANCE ,[object Object],[object Object],[object Object],[object Object]
RENAL CLEARANCE/GFR ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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 ,[object Object],[object Object],[object Object],[object Object],[object Object]
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 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
FRACTIONAL - EXCRETION NA + ,[object Object],[object Object],[object Object],[object Object]
FENA FENA=  Una +  x  S  cr  x 100 S na  X  Ucr
FENA/NORMAL VALUE ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
FRACTIONAL - EXCRETION NA + ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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 ,[object Object],[object Object],[object Object],[object Object],[object Object]
ATN/VASODILATATION ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object]
Dopamine Action ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Low Dose Dopamine Patients with Early Renal Dysfunction THE  LANCET VOL 356 DEC 2000 AUSTRALIAN-NEW ZEALAND STUDY GROUP ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Rhabdomyolysis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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 ,[object Object],[object Object],[object Object],[object Object],[object Object]
Rhabdomyolisis ,[object Object]
Strategy for Renal Protection, Recovery ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Rhabdomyolysis Treatment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Mechanism CIARF ,[object Object],[object Object],[object Object]
Risk factor contrast CIARF ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Prevention CIARF ,[object Object],[object Object],[object Object],[object Object]
Case Study 7 ,[object Object],[object Object],[object Object],[object Object]
CASE ,[object Object],[object Object],[object Object]
Case Study 7  (cont) FENA UNa - 111    Sr cr - 2 SNa - 160    Ucr - 15 x 100 =  9%
CASE ,[object Object],[object Object]
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) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Case continue ,[object Object],[object Object]
Case study cont ,[object Object],[object Object]
Case 3   DX= HRS   LOW GFR =11  LOW FENA=.1   H/O LIVER DISEASE
Pathology in Hepato Renal Symptoms ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Hepato Renal Syndrome ,[object Object],[object Object],[object Object],[object Object],[object Object]
Hepato-Renal
URINARY INDICES IN HEPATO-RENAL SYNDROME
Case ,[object Object],[object Object],[object Object],[object Object]
case U Cr=80  UOS=750  UNA=65
Case Study  (cont) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Case Study 1 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
SIADH IN ICU PATIENTS ,[object Object],[object Object],[object Object],[object Object],[object Object]
SIADH IN ICU PATIENTS ,[object Object],[object Object],[object Object],[object Object],[object Object]
SIADH IN ICU PATIENTS ,[object Object],[object Object],[object Object],[object Object],[object Object]
RX ,[object Object],[object Object]
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.

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Renal Function Iin ICU

  • 1. RENAL FUNCTION IN THE ICU S. ESFANDIARI MD, SURGICAL INTENSIVE CARE UNIT
  • 2.
  • 3. 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
  • 4. 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
  • 5. Case Study Calculate G.F.R V.S Measured Creatinine Clearance Estimate GFR 140 - 86 x 40 = 19 72 x 1.6
  • 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
  • 7.
  • 8.
  • 9.
  • 10. 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
  • 11.
  • 12.
  • 13. 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
  • 14. 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
  • 15. case 4 C cr measured 24 hour urinary creatinine clearance Ccr = Ucr x Uv min = 62x .75 = 33 Pcr 1.4
  • 16. 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
  • 17.  
  • 18.  
  • 19.
  • 20. 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
  • 21. CASE 2 ATN FENA 65 LOW GFR=33
  • 22. Fractional excretion of Na Ratio of the Na excreted < 1% to Na reabsorbed 99%
  • 23.  
  • 24.
  • 25.
  • 26. FENA FENA= Una + x S cr x 100 S na X Ucr
  • 27.
  • 28.
  • 29. 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
  • 30. 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
  • 31. Case 5 Urinary Cr clearance 2 h Ccr= Ucr x UV (min) = 48 x .5 = 15 Pcr 1.6
  • 33.
  • 34.
  • 35.
  • 36.
  • 37.
  • 38.
  • 39. 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
  • 40.
  • 41.
  • 42.
  • 43.
  • 44.
  • 45.
  • 46.
  • 47.
  • 48.
  • 49. Case Study 7 (cont) FENA UNa - 111  Sr cr - 2 SNa - 160  Ucr - 15 x 100 = 9%
  • 50.
  • 51. 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
  • 52.
  • 53.
  • 54.
  • 55. Case 3 DX= HRS LOW GFR =11 LOW FENA=.1 H/O LIVER DISEASE
  • 56.
  • 57.
  • 59. URINARY INDICES IN HEPATO-RENAL SYNDROME
  • 60.
  • 61. case U Cr=80 UOS=750 UNA=65
  • 62.
  • 63.
  • 64.
  • 65.
  • 66.
  • 67.
  • 68. 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
  • 69. 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 
  • 70. 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.
  • 71. 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
  • 73. 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.