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RENAL FAILURE

RENAL FAILURE. DR..M.H.MUMTAZ. TYPES. 1, REVERSIBLE DYSFUNTION (acute R.failure) 2, IRREVERSIBLE DYSFUNTION (Chronic R failure). ACUTE RENAL FAILURE. 1, PRE RENAL 2, RENAL

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RENAL FAILURE

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  1. RENAL FAILURE DR..M.H.MUMTAZ

  2. TYPES 1, REVERSIBLE DYSFUNTION (acute R.failure) 2, IRREVERSIBLE DYSFUNTION (Chronic R failure)

  3. ACUTE RENAL FAILURE • 1, PRE RENAL • 2, RENAL • 3, POST RENAL

  4. PRE RENAL FAILURE • CAUSES a,total body water depletion b,water redistribution ivs--------iss vasodilation,sepsis,anaphy. c,low CO--------low BP (S,M.D)

  5. RENAL a, Interstitial nephritis b, A.T.N. hypoperfusion chemical trauma , toxins sepsis

  6. PATHOLOGY T.obstruction T.damage T.backleakage

  7. DIAGNOSIS a,History oligurea,concentrated U b,Tests lab. Serum,urine radiodiagnostics C.T. MRI. Ultrasount

  8. ALTERNATIVE CLASS. Filteration failure Tubular dysfuntion Oliguric/non oliguric

  9. Acute diseases sepsis SIRS jaundice I.A.P. renal trauma transfusion DIC Anaphylaxis muscle injury thermal burn electrocution RISK FACTORS

  10. RISK FACTORS CHRONIC DISEASES advancing age diabetes mellitis renal disease vascular disease hyperuricaemia

  11. Physiological changes 1. ^ age 2. ^ HR hypotension ^ CVP, lowRVPP high or low co,svr abnormal OER olig/polyurea 3. Fluid balance Oedaema high/low protein intake RISK FACTORS

  12. RISK FACTORS Chronic drug therapy NSAIDS Diuretics Cyclosporins

  13. Acute drug therapy A. ATN aminoglycosides cephalosporins diuretics contra. rifampicin lithium cisplatin B. Interstitial nephritis cephalosporins diuretics aspirin,NSAIDS cemetidine captopril RISK FACTORS

  14. RISK FACTORS Proceedures a. Aortic/renal cross clamping b.Transfusion c. Major surgery

  15. RISK FACTORS IMPAIRED RBF hypotension/m.hypertension renal art. Occlosion hepatorenal failure endotoxaemia renal vein thrombosis renal venous hypertansion

  16. Metaboic causes 1. Electrilytes hyper-cal hypo-k hyper-phosphate 2. High oncotic P. 3. Metabolites Pigments bilirubin myoglobin haemoglobin RISK FACTORS

  17. Post-renal urethral/blader obs. bil.ureter obs. stones/clot/tumur papillary necrosis Retroperitoneal fibrosis Surgical ligation Blader rupture Renal pelvic trauma Urethral trauma RISK FACTORS

  18. ACUTE TUBULAR NECROSIS PHASES a,Initiation phase b,Maintenance phase

  19. ISCHAEMIA ^ symp.stimulation ^ renin activity PGE2 ANH inhibition ^ ADH ^ adenosine ^ endothelin NEPHROTOXINS Ischaemia increases the susceptibility to nephrotoxic agents INITIATION PHASE

  20. MANTENANCE PHASE • Factors acting to maintain filteration failure 1,tubular obstruction 2,tubular backleak 3,vasodilatation of efferent art. 4,decreased GMP

  21. Mechanism of oligurea a,glomerulo-tubular balance b,decreased GMP c,itratubular obstruction d,interstitial oedema e,cortical ischaemia

  22. A,oligurea absolute relative B, azotaemia normal solute load maximum in catabolic states in ARF ^ urea/d ^ cr/d Complications of ARF/ATN

  23. C,Biochamical ^NaCl/water ^ K ^ HPO4 hypocalcaemia ^ Mg ^ uric acid M.acidosis D,Haematological Anaemia Thrombocytopaenia Leukocyte dysf. Complications

  24. E,Immunosupression Lumphopaenia Reduced IgG Reduced comple. Impaired PMN R.I.response Drug effects Infections F,C.V.S. CCF Hypertention Arrhythmias Pericarditis Effusion Complications

  25. G, G.I.T. Anorexia,Nausea, Ileus,Hmge. H,Neurological Lethargy,somnolance Confusion, Convulsions ^ sensitivity to anaesthetics Complications

  26. Complications I,causes of pulmonary infilterates in ARF 1,LVF/CCF 2,bacterial pmeumonia 3,Atypical pneumonia 4,Septicaemia 5,ARDS 6,Autoammune diseases

  27. A,Tubular dysfuntion B,Glomerular dysfuntion C,Other causes low C.O. Resp.F Starvation Rhabdomyolysis Hyperkalaemia Organic acids Causes of Acidosis in ARF

  28. Biochemistry INVESTIGATIONS IN ARF

  29. INVESTIGATIONS

  30. Investigations-1, Biochemistry

  31. Definitions • RFI=RENA FAILURE INDEX • =urine(Na)/(U/P creatinine) • FEna=%fractional excretio Na • =(U/P Na).100/(U/P creatinine)

  32. Abnormal urea/creatinine ratio • Normal U:C ratio 100:1( R;70-150) • Pre-renal disease >200:1

  33. Abnormal urea/creatinine ratio • High Ratio • ^ urea .dehydration/hypovol. • .GIT.bleeding • .Catabolic state • .Hyperalimentation • .Drugs • low creatinie .elderly,low m. mass

  34. Abnormal urea/creatinine ratio • Low Ratio • low urea. Liver failure • hepato-renal synd • Malnutrition • High creatinie rhabdomyolysis • acute m.disease • ketones,drugs

  35. CREATININE CLEARANCE • 1, clearance(ml/min=(N-age[years])*BW(kg)/serum creat. N = 150 foe female N = 160 for male > 70 N = 170 for male < 70 2, clearance(ml/min)=UV*1000 /p*420 U=urine creatinine level V=urine volume (midnight &7 am) P= plasma creatinine level

  36. 2. Urinary sediment • .Cast types • i,hyaline casts, fever,diuretics,RD • ii,red cell casts glomerulonephritis • iii,w.cell casts pyelonephritis • iv,waxy casts chronic renal disease

  37. 3,Imaging • 1, Ultrasound • 2, CT scan • 3, IV pylogram • 4, radio-isotope perfusion scan • 5, renal angiogram

  38. 4,Renal biopsy • 1, glomerulonephritis • 2, vasculitis • 3, SLE • 4, Goodpasture syndrome • 5, TTP • 6, Interstitial nephritis • 7, oligurea lasting > 8 weeks

  39. Renal failureprophylaxis&protection • Methods • 1, physiological • 2,physical • 3,pharmacological • 4,replacement therapies

  40. Physiological methods • a, normalise blood volume • iv fluids,(Na containg) • b,optimise cardiac output • iv fluids.inotropes,vasopressors • c, optimise O2 delivery • Hb,Spo2,avoid acidosis • d, high sodium excretion

  41. Physical methods • Detection/management of IOH • Detection/management-post renal obs. • Limitation of aortic clamp times • Avoidance of embolisation • Minimise direct trauma

  42. Pharmacological methods • Avoid nephrotoxins • Avoid inhibitors of autoregulation • Diuretics • Renodilators • Other agents • free radical scavengers • Ca channel blockers

  43. Renal replacement methods • Haemo- filtration • Haemo-diafiltration • Haemodialysis • R. Transplant.

  44. Renal failure---Frusemide • Beneficial effects • Increased tubular&urine flow • Increase Na &osmolar clearance • Decreased tubular O2 demand • Stimulate vasodilator prostaglandins • Deleterious effects • Hypovolaemia • Hypokalamia,Hyponatraemia • Ototoxicity

  45. Uses in non renal failure • Fluid overload • Cerebral oedema • Hyperkalaemia • Renal protection • ( decreased O2 demand)

  46. Renal failure---Mannitol • 1,Osmotic diuresis • 2,Anti sludging ,tubular protect. • 3,renal vasodilatory PG synthesis • 4,Free radical scavenger • 5,Decreased T. swelling

  47. Renal failure---Dopamine • Increases Fe Na excretion • Increases urine out put • Does not increase creatinine clearance • Inotropic effect • Doesnot prevent ac.renal failure • Side effects, • gastric stasis,inhibition of • ant pit.hormones,hypoxic • drive depression.

  48. Renal failure---Nor-adrenaline • Increases perfusion pressure by increase • of efferent arteriolar resistance • more than afferent art.resistance

  49. Other therapies • 1,Calcium channel blockers • 2,Adenicine recepter antagonists • 3,Oxypentifylline • 4,Chlorpromazine • 5,Clonidine • 6,ATP-MgCl2 • 7,ANF

  50. Conclusion,Renal rescue therapy • Normalise;- • Blood flow • blood volume • blood pressure • O2 delivery • CO—CI • Blood Pressure, s,m,d.

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