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Approach to azotemic patients Case presentation

Approach to azotemic patients Case presentation. Shiva Seyrafian. Approach to azotemic patients. At the end of this class, you should be able to Diagnose acute kidney injury (AKI) Define the etiologies of AKI Describe the evaluation of AKI Diagnose chronic kidney disease (CKD)

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Approach to azotemic patients Case presentation

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  1. Approach to azotemic patients Case presentation Shiva Seyrafian

  2. Approach to azotemic patients • At the end of this class, you should be able to • Diagnose acute kidney injury (AKI) • Define the etiologies of AKI • Describe the evaluation of AKI • Diagnose chronic kidney disease (CKD) • Define the stages of CKD • Describe the evaluation of CKD • Discuss CKD risk factors and management of them.

  3. Evaluation of Renal Failure Is the renal failure acute or chronic? • laboratory values do not discriminate between acute vs. chronic • Oliguria supports a diagnosis of acute renal failure • History of renal disease and azotemia helps to diagnose CKD. Clues to chronic disease • Pre-existing illness – DM, HTN, age, vascular disease. • Uremic symptoms – fatigue, nausea, anorexia, pruritus, altered taste sensation, hiccups. • Small, echogenic kidneys by ultrasound.

  4. 5 Key Steps in Evaluating Acute kidney Injury • Obtain a thorough history and physical; review the chart in detail • Do everything you can to accurately assess volume status • Always order a renal ultrasound • Look at the urine • Review urinary indices

  5. Case 1 • A 42 year old male is admitted to the SICU after sustaining multiple trauma. His course is complicated by Enterobacter sepsis with profound hypotension requiring support with intravenous dopamine. The urine output has gradually decreased to only 300 ml per day. The urine sodium is 78.

  6. Ischemic Acute Renal Failure • A form of ATN often following a prerenal insult • Late proximal tubule and medullary thick ascending limb most susceptible • Severity of renal failure correlates with duration of insult • Treatment is to optimize renal perfusion, avoid additional nephrotoxic insults and other supportive measures

  7. Risk Factors for Ischemic Tubular Injury • Volume depletion • Aminoglycosides • Radiocontrast • NSAIDs, Cox-2 inhibitors • Sepsis • Rhabdomyolysis • Pre-existing renal disease • HTN • Diabetes mellitus • Age > 50 • Cirrhosis

  8. Case 2 • A 56 y.o. male presents with complaints of persistent fever, chills, sore throat, and myalgias for the past 14 days. Ten days ago he started taking amoxicillin. • His physical exam is remarkable for fever to 38.6oC, an exudativepharyngitis and a diffuse maculopapular rash.

  9. Laboratory Data Result Normal Range • Serum • Na 134 mEq/L 135-145 • K 5.7 mEq/L 3.5-5 • Cl 106 mEq/L 100-111 • Total CO2 14 mEq/L 24 • BUN 46 mg/dL 4-15 • Creatinine 3.8 mg/dL 0.6-1.0 • Glucose 96 mg/dL 60-100 • Whole blood • WBC 12 x109/L 4.5-11.0 • Hgb 11 gm/dL 13.5-17.5 • Hct 33 % 41.0-53.0 • Platelets 216 x109/L 150-440 • Urine • Specific gravity 1.010 1.002-1.036 • Protein 2+ Negative • Blood Trace Negative • Glucose Negative Negative • The urine sediment shows 3-5 RBC’s/h.p.f., 20-25 WBC’s/h.p.f., coarse granular and white cell casts, and rare red cell casts.

  10. Case 3 • A 58 y/o woman referred to clinic due to abdominal pain, anorexia, fever and icterus. She had hx of HTN and DM. BP= 100/70, BW= 68 kg.T= 38.8 In US there was a common bile duct stone. • Lab: WBC= 20,000, Hb= 14.5, plt= 260000, BilT=5, Bill D= 4, AST= 70 ALT= 75, AlPh= 289, BUN= 25, Cr= 1.4 • The physician admitted her and ordered gentamycin 80 mg tid for 7 days. • Patient recovered from fever and pain but 10 days later she developed nausea, vomiting, and edema. BP=160/100

  11. Lab values

  12. What is the cause of vomiting? • How much is her eGFR? (First and last)

  13. Calculations • Cockcroft-Gault • Men: CrCl (mL/min) = (140 - age) x wt (kg) • SCr x72 • Women: multiply by 0.85 • MDRD • GFR (mL/min per 1.73 m2) = 186 x (SCr x 0.0113)-1.154 x (age)-0.203 x (0.742 if female) x (1.12 if African-American

  14. eGFR: (F, age= 58, BW= 68) • Cr= 1.4 Cr=5.4 • CG 1= 47 ml/min CG 2= 12 ml/min • MDRD 1= 41 ml/min MDRD 2= 8.6 ml/min • What is the cause of azotemia? • Which kind of renal failure has she developed? • What is your prescription? • What would be her prognosis?

  15. AminoglycosideNephrotoxicity • Generally presents 1 week after exposure • Non-oliguric • Low trough levels do not guard against nephrotoxicity • Incidence of ATN • 10% after 1 week • 40% after 2 weeks • Risk factors for ATN • Advanced age - Superimposed sepsis • Liver disease - Hypotension • CKD (DM-HTN)

  16. Case • A 60 Y/O male patient with Hx of HTN and IHD, his cardiologist recommended coronary angiography due to recent chest pain. • Before angio: BUN= 23, Cr= 1.3, Na=138, K=4.5, Hb= 14. • 3 days after angiography he developed edema, nausea and BP= 170/95, BUN=55 Cr=4.3 K=5.2 Na=132 U/A: SG= 1.011, Blood 1+, Pr 1+, WBC=5-7, RBC= 4-6, R epithelial cell= 3-4, cast granular+ • What’s your diagnosis? • And what is his prognosis?

  17. Case • A 60 Y/O male patient with Hx of HTN and IHD, his cardiologist recommended coronary angiography due to recent chest pain. • Before angio: BUN= 23, Cr= 1.3, Na=138, K=4.5, Hb= 14. • 3 days after angiography he developed edema, nausea and BP= 170/95, BUN=55 Cr=4.3 K=5.2 Na=132 U/A: SG= 1.011, Blood 1+, Pr 1+, WBC=5-7, RBC= 4-6, R epithelial cell= 3-4, cast granular+ • What’s your diagnosis? • And what is his prognosis?

  18. Case • Radiocontrast-induced acute renal failure • 10 days later: his sCr= 1.8, BUN= 25, K= 4.5

  19. Radiocontrast-Induced Acute Renal Failure • Induces renal vasoconstriction and direct cytotoxicity via oxygen free radical formation • Risk factors: • Renal insufficiency - Diabetes • Advanced age - > 125 ml contrast • Hypotension • Usually non-oliguric ARF; irreversible ARF rare

  20. Case 4 • A 24 y/o renal transplant woman admitted to hospital for fever, tender vesicular rash on left side of abdomen and back in the spinal nerve root, from 4 days ago. T= 38.5, BP= 135/85 Her Cr= 1.8 mg/dl, BUN=28 mg/dl, WBC= 15000, Hb= 12g/dl. U/A: WBC= 3-4 RBC= 4-5 • She received acyclovir 500 mg IV tid. After 5 days became anorectic and developed vomiting, but fever recovered. • Now Cr= 6 mg/dl, BUN= 67, Na= 135, K= 5.3, Ca=8.2, P= 4.7, Alb=3.4, U/A: RBC= 8-10, WBC= 10-14, Cast granular=3-4.

  21. Acute Renal Failure due toIntratubular Obstruction • Crystalluria • Ethylene glycol: Calcium oxalate • Tumor lysis: Urate and Calcium phosphate • Medications • Acyclovir • Methotrexate • Sulfonamides • Anti-retroviral agents • Myeloma cast nephropathy

  22. Case 5 • A 35-year-old female presents with a one month history of periorbital and lower extremity edema. Over two days prior to presentation she has experienced arthralgias in her wrists and elbows. On physical examination she is in no acute distress. Blood pressure is 162/94, temperature 37.4 . Her skin exam is significant for a malarerythematousrash. The heart and lungs are normal. There is 3+ edema to the thighs bilaterally.

  23. Laboratory Data Result Normal Range • SerumNa 138 mEq/L 135-145 • K 4.2 mEq/L 3.5-5 • Cl 108 mEq/L 100-111 • Total CO2 17 mEq/L 24 • BUN 75 mg/dL 4-15 • Creatinine 3.5 mg/dL 0.6-1.0 • Glucose 83 mg/dL 60-100 • Anti-nuclear antibody1:160 Negative • Whole blood • WBC 5.9 x109/L 4.5-11.0 • Hgb 11.9 gm/dL 13.5-17.5 • Hct 34 % 41.0-53.0 • Platelets 153 x109/L 150-440 • Urine • Specific gravity 1.015 1.002-1.036 • Protein 3+ Negative • Blood 3+ Negative • RBC >50/h.p.f . 0-4 • Sodium 10 mEq/L Variable

  24. Acute Glomerulopathies RPGN most commonly seen with: • Lupus nephritis (DPGN, class IV) • Pauci-immune GN (ANCA associated) • Anti-GBM disease • less commonly: IgA, post-infectious Nephrotic presentations of ARF • Collapsing FSGS (HIV nephropathy) • Minimal change disease with ATN • Thrombotic microangiopathies (HUS, TTP, malignant hypertension, scleroderma kidney, pre-eclampsia)

  25. Atheroembolic Renal Disease • ARF in patient with erosive atherosclerosis. Often follows aortic manipulation (angiography, surgery, trauma) or anticoagulation. • Pattern is often an acute worsening of renal function due to showering of emboli, followed by more insidious progression over several weeks to months due to ongoing embolization of atheromatous plaques. Livedoreticularis. Nephritic sediment, eosinophilia, eosinophiluria, low C3. Poor prognosis

  26. LivedoReticularis

  27. Case • 47 y/o female presents for routine dental care • PMH: chronic renal failure, kidney transplant 4 yrs ago and doing well • Meds: prednisolone, cyclosporine, mycophenolatemofetil • VS: BP: 145/87, PR: 70

  28. What are the potential problems to consider in this patient? • Susceptibility to infection • Management recommendation: • Consultation with patient’s transplant doctor • Antibiotic prophylaxis • Daily antibacterial mouth rinses(chlorhexidine)

  29. Case • CKL is a 68 year-old woman with DM and HTN who presents for a routine visit. She complains of mild fatigue and leg swelling but is otherwise asymptomatic.

  30. Case… • On physical examination: • Weight 55 kg with BP 155/90 mm Hg • Funduscopy reveals AV nicking with cotton-wool exudates • Unremarkable cardiac exam with diffusely reduced peripheral pulses and a right femoral bruit • Trace pedal edema • Medications: • HCTZ 25 mg/d • Insulin

  31. Labs • 18 months ago, her serum Cr: 1.5 mg/dL • One year ago, sCr: 1.6 mg/dL • How can we assess her degree of kidney dysfunction?

  32. Calculations • Cockcroft-Gault • Men: CrCl (mL/min) = (140 - age) x wt (kg) • SCr x72 • Women: multiply by 0.85 • MDRD • GFR (mL/min per 1.73 m2) = 186 x (SCr x 0.0113)-1.154 x (age)-0.203 x (0.742 if female) x (1.12 if African-American

  33. What is CKD? • Presence of markers of kidney damage for three months, as defined by structural or functional abnormalities of the kidney with or without decreased GFR, manifest by either pathological abnormalities or other markers of kidney damage, including abnormalities in the composition of blood or urine, or abnormalities in imaging tests. • The presence of GFR <60 mL/min/1.73 m2 for three months, with or without other signs of kidney damage as described above.

  34. Stages of CKD • Stage 1*: GFR >= 90 mL/min/1.73 m2 • Normal or elevated GFR • Stage 2*: GFR 60-89 (mild) • Stage 3: GFR 30-59 (moderate) • Stage 4: GFR 15-29 (severe; pre-HD) • Stage 5: GFR < 15 (kidney failure) Am J Kidney Dis 2002; 39 (S2): S1-246

  35. Case cont. • Recheck her sCr: 1.7 mg/dL • CrCl (age 68 yrs; wt 55 kg): 27 mL/min • MDRD: 32 mL/min/1.73 m2 • How can we quantify CKD? • What next doc?

  36. Identify reversible causes • Think about volume contraction, urinary obstruction, or toxic effects of medications • Rx • ACEs/ARBs • NSAIDs • Aminoglycosides and amphotericin B • IV radiocontrast agents

  37. Other etiologies • Renovascular disease • Glomerulonephritis • Nephrotic syndrome • Hypercalcemia • Multiple myeloma • Chronic UTI

  38. Management • Identify and treat factors associated with progression of CKD • HTN • Proteinuria • Glucose control

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