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ACUTE RENAL FAILURE

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ACUTE RENAL FAILURE

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  1. ACUTE RENAL FAILURE INTERN EMERGENCY LECTURE SERIES 2005

  2. ABRUPT DECREASE IN RENAL FUNCTION RESULTING IN THE ACCUMULATION OF NITROGENOUS COMPOUNDS SUCH AS UREA AND CREATININE DEFINITION

  3. A

  4. Acute vs Chronic Renal Failure • History • Known Chronic • Recent Toxic Exposure • Recent Hypoxic Insult • Recent Trauma • Known Diseases Associated with ARF • Prev. Abnormal Lab Results Suggesting Chronic

  5. Acute vs Chronic Renal Failure • Rapidly Rising Creatinine = Acute • Kidney Size • Small = Chronic • Renal Ultrasound • Increased Echogenicity = Chronic • Urine Flow Rate • Oliguric or Anuric usually = Acute

  6. ACUTE RENAL FAILURE CLASSIFICATION BY URINE VOLUME OLIGURIC: <400 CC/ 24 Hrs NON-OLIGURIC: >500 CC/24 Hrs ANURIC <50 CC/24 Hrs

  7. ETIOLOGY OF ACUTE RENAL FAILURE • PRE-RENAL 55-60% • POST RENAL <5% • RENAL 35-40%

  8. PRE-RENAL ACUTE RENAL FAILURE • MOST COMMON CAUSE OF ARF • RESULTS FROM DECREASED RENAL PERFUSION • TREATMENT OF THE CAUSE RESTORES RENAL FUNCTION TUBULAR FUNCTION INTACT * • PROLONGED PRE-RENAL FAILURE MAY LEAD TO ATN

  9. CAUSES OF PRE-RENAL AZOTEMIA • Intravascular volume depletion • Decreased cardiac output • Systemic vasodilation • Antihypertensives • Sepsis • Renal vasoconstriction • Drugs impairing autoregulation • Ace inhibitors NSAID

  10. MECHANISMIS OF PRE RENAL ARF

  11. POST-RENAL ACUTE RENAL FAILURE • ACCOUNTS FOR 2-15% OF ALL ARF • OBSTRUCTION TO URINE FLOW • INCREASED TUBULAR PRESSURE • VASOCONSTRICTION • DECREASED RENAL BLOOD FLOW • MUST BE BILATERAL TO RESULT IN ARF • UNLESS : SINGLE KIDNEY OR PRIOR CHRONIC RENAL FAILURE

  12. POST RENAL ACUTE RENAL FAILURE • SUSPECT OBSTRUCTION IN ANURIA • ETIOLOGY MAY BE AGE DEPENDENT • YOUNG = CONGENITAL ABNORMALITY • OLDER MALE = PROSTATIC ENLARGEMENT • ARF MOST OFTEN ASSOCIATED WITH LESIONS IN: • BLADDER, PROSTATE OR URETHRA

  13. RENAL-ACUTE RENAL FAILURE • VASCULAR DISEASE • VASCULITIS (SLE, POLYARTERITIS ETC.) • SCLERODERMA • THROMBOEMBOLIC DISEASE • MALIGNANT HYPERTENSION

  14. RENAL--ACUTE RENAL FAILURE • GLOMERULAR DISEASE • ACUTE GLOMERULONEPHRITIS • POST INFECTIOUS GN • CRESCENTIC GN • ANCA POSITIVE DISEASES • GOODPASTURE’S DIS. • ANTI- GLOMERULAR BASEMENT ANTIBODY

  15. RBC CAST

  16. PENICILLINS SULFONAMIDES CEPHALOSPORIN RIFAMPIN ( 2ND TIME) QUINOLONES NSAID (FENOPROFEN) ALLOPURINOL PHENYTOIN THIAZIDES FUROSEMIDE CIMETIDINE ACUTE INTERSTITIAL NEPHRITISDRUG INDUCED

  17. Acute Interstitial Nephritis • Fever • Rash • Eosinophilia • Pyuria • Eosinophiluria • WBC Casts

  18. WBC Cast

  19. RENAL --ACUTE RENAL FAILURE • ACUTE TUBULAR NECROSIS • ISCHEMIC INJURY • TOXIC INJURY • ENDOGENOUS TOXINS • HEMOGLOBINURIA • MYOBLOBINURIA (RHABDOMYOLYSIS) • ENDOTOXEMIA

  20. RENAL-- ACUTE RENAL FAILURE • ACUTE TUBULAR NECROSIS • EXOGENOUS TOXINS • AMINOGLYCOSIDES • RADIOGRAPHIC CONTRAST • HEAVY METAL COMPOUNDS • ETHYLENE GLYCOL • METHANOL • CARBON TETRACHLORIDE • CIS PLATIN

  21. HIGH RISK SETTINGS FOR ATN CLINICAL SETTING FREQUENCY • GEN.MED. --SURG. 3-5% • INTENSIVE CARE 5-25% • OPEN HEART SURG 5-20% • AMINOGLYCOSIDE 10-30% • BURNS 20-60% • RHABDOMYOLYSIS 20-30% • CIS-PLATIN 15-25%

  22. ATN SEDIMENT

  23. DIAGNOSTIC APPROACH TO ARF • HISTORY • PHYSICAL EXAMINATION • ASSMENT OF URINE VOLUME • URINE ANALYSIS • BLOOD CHEMISTRY • BLOOD AND URINE INDICES • RADIOLOGIC STUDIES

  24. Treatment of ARF

  25. Hyperkalemia • Never occurs in the absence of renal excretory problem • Pseudohyperkalemia • Leukocytosis • Thrombocytosis • Prolonged Application of Tourniquet

  26. Hyperkalemia • Significance of urine output • Role of increased catabolism or tissue breakdown • Factors affecting shift of Potassium out of cells • Etiololgy of the renal failure

  27. Treatment of Hyperkalemia • Urgency • Role of the EKG in making the decision • Clinical setting in which it occurs • Acute renal failure • Chronic renal failure

  28. Table 5-3. Treatment of hyperkalemia Medication Mechanism of action Dosage Peak effect Calcium Antagonism of 10-30 ml of 10% solution IV -5 min gluconate membrane over 2 min Insulin and Increased K+entry Insulin, 10 U IV bolus 30-60 min Glucose into the cells followed by 0.5 mU/kg of body weight per minute in 50 ml of 20% glucose Sodium Increased K+entry 44-50 mEq IV over 5 min; 30-60 min bicarbonate into the cells can be repeated within 30 min Albuterol Increased K+entry into the cells 20 mg in the nebulized form 30-60 min Kayexalate Removal of the 20 g of resin with 100 ml of 2-4 hr excess K+ 20% sorbitol; can be repeated every 4-6 hr Hemodialysis Removal of the Dialysis bath K+ concentration 30-60 min excess K+ variable

  29. INDICATIONS FOR DIALYSIS IN ACUTE RENAL FAILURE UREMIC SYMPTOMS ~ nausea ~neurologic SEVERE FLUID OVERLOAD REFRACTORY ELECTROLYTE DISORDERS ~hyperkalemia SEVERE REFRACTORY ACIDOSIS

  30. INDICATIONS FOR DIALYSIS IN ACUTE RENAL FAILURE • PERICARDITIS • NEUROPATHY • MENTAL STATUS CHANGE • SEIZURES • BLEEDING • TOXINS----ETHYLENE GLYCOL, METHANOL • PROPHYLACTIC ~recent studies fail to document benefit

  31. MORTALITY ASSOCIATED WITH SETTING OF ATN • OVERALL MORTALITY 40-60% • POST TRAUMATIC 70-90% • MEDICAL CAUSE 15-40% • SURGICAL CAUSE 40-80% • NON-OLIGURIC 26% * • OLIGURIC 50% *

  32. CAUSES OF DEATH IN ATN