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Acute renal failure

Acute renal failure. Prolonged,reversible abrupt loss of renal function Dr. Jumana Albaramki. Types of ARF. RIFLE classification based on Cr,urine output.(risk,injury,renal failure,renal loss,ESRD) AKIN prerenal,renal,postrenal Oliguric ( < .5ml/kg/h or <1ml/kg/h) ,nonoliguric.

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Acute renal failure

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  1. Acute renal failure Prolonged,reversible abrupt loss of renal function Dr. Jumana Albaramki

  2. Types of ARF RIFLE classification based on Cr,urine output.(risk,injury,renal failure,renal loss,ESRD) AKIN prerenal,renal,postrenal Oliguric (< .5ml/kg/h or <1ml/kg/h) ,nonoliguric

  3. Prerenal causes 1.intravascular volume depletion:bleeding,GIT losses,third spacing 2.low cardiac output:CHF 3.Sepsis Treatment: fluid management and restoration of effective circulatory volume

  4. Renal causes 1.ATN,acute cortical necrosis from drugs,ischemic vasoconstrictive injury 2.Glomerulonephritis:PSGN,SLE,HSP 3.HUS:Most common cause 4.Acute interstital nephritis

  5. 5.drug induced ARF: NSAID cause ischemic vasoconstriction,decrease GFR,ATN AG:direct tubular injury ACEI:decrease renal blood flow CNI:decrease GFR,HTN

  6. 6.pigment nephropathy:rhabdomyolysis myoglobinuria,result trauma,status epilepticus,hereditary tx with fluids,alkali,diuretics Tumor lysis syndrome:high uric acid,phosphate,low calcium.Tx allopurinol,alkalinazation of urine ph 7 8.renal artery,vein thrombosis

  7. Post renal ARF Obstruction at level of ureter till urethra Elevated tubular pressure decrease GFR Duration of obstruction affects recovery Congenital (PUJ,PUV),acquired (stones) Post obstructive diuresis:dilute urine with large Na losses,reduced excretion of H,K

  8. Important points in history : • Previous GE,previous throat infection • Fever,rash,joint pain • Urinary symptoms • Drug history • FH of renal disease • O/E: state of hydration,hemodynamic status

  9. Investigations Elevated urea,creatinine,spot Na FeNa=(Una X Pcr )/( Pna XUcr) X 100% FeNa < 1% in prerenal,2-3% renal FeNa unreliable in diuretics,neonate High in bartter,CRD. FBC: anemia usualy chronic

  10. Blood smear:schistocytes of HUS Electrolytes:high K,acidosis,CK Complements,ANA,antiDNAs,ANCA, Imaging:U/S ,Doppler (kidney size,echogenecity Renal biobsy

  11. Role of U/S in renal failure

  12. Urine analysis for proteinuria (glomerular,tubular) Urine sediment:RBC,WBC casts,crystals,myoglobin,red brown granular,tubular epithelial casts in ischemic,nephrotoxic ATN,eosinophiluria New kidney markers of injury:KIM 1,cystatin C

  13. Management Monitoring:weight,input/output chart,B.P Fluids:bolus of crystalloid,furosemide as indicated by hydration Fluid restriction to U.O.P and insensible losses at 400/m2 ?? Role of renal dose dopamine in reversing oliguria ?? Role of lasix in reversing oliguria Conservative: Recovery phase:polyuria

  14. Hyponatremia:dilutional,fluid restriction Na < 120, Tx with hypertonic saline= (125-measures) X .6 X wt over 2-4 h. High PO4,low Ca:diet restriction,phosphate binders Acidosis:correct Ca before,give I.V HCO3=.5 X wt x (22-measure) over 1-2 h

  15. HTN: fluid overload or vasoconstriction due hypovolemia Tx:diuretics,dialysis,nifedipine Hyperkalemia:low potassium diet,Ca gluconate,insulin and glucose,sodium biocarbonate,ventolin,oral resins Nutrition:fluid restriction,catabolism result in high urea,K,need sufficient calories

  16. Indications for renal replacement therapy Persistent hyperkalemia Diuretic resistant volume overload and associated hypertension and heart failure Refractory acidosis Severe uremia with risk of encephalopathy and /or pericarditis

  17. Choice of renal replacemnet thearpy 1.acute peritoneal dialysis: Peritoneal membrane is a semipermeable membrane with a large surface area Needs tenkoff catheter (rigid,permnant ) Use diffusion and convection by ultrafilteration PD fluids has electrolytes,glucose ( 1.5 %,4.25 % ),acid buffer of biocarbonate

  18. Peritoneal dialysis Volume of 10-50 ml/kg Dwell time of 20-60 min Used for young infants,avoids sudden shifts of fluid and metabolites,miminal fluid and dietary restrictions Complications : Infection :exit site,tunnel,peritonitis Blockage

  19. Dialysis Solution (Dialysate) • PD Solution • Sodium - 132 • Chloride = 98 • Lactate = 40 • Calcium = 1.2 - 1.75 • Mg = o.5 • DIFFUSION OF WASTE PRODUCTS • The movement of solid particles (across a semi permeable membrane) from an area of high concentration, to an area where the concentration is lower in order to achieve eventual equilibrium • Small amt of solute removal by convection

  20. Peritoneal Dialysis - Water Removal by Osmosis “The movement of water through a membrane from a higher to a lower water concentration area.” This is achieved by adding glucose to the dialysis solution, however alternative osmotic agents are the future of PD.

  21. Peritoneal Dialysis- FILL

  22. Peritoneal Dialysis - DWELL

  23. Peritoneal Dialysis - DRAIN

  24. Acute intermittent hemodialysis Needs vascular acsess and anticoagulation Rapid correction so contraindicated in hemodynamic instability Complication :hypotension,dialysis disequilibrium due to rapid correction of urea Requires greater fluid restriction CVVH

  25. TIN The absence of HTN,significant proteinuria,RBC casts,exposure to drugs,sterile pyuria,good urine output,evidence of tubular dysfunction favor TIN Present nonspecific with fever,flank pain,skin rash,arthralgia Leucocytosis,eosinophilia,high ESR,ARF Hematuria,non-nephrotic proteinuria

  26. Kidney U/S:enlarged echogenic kidneys Causes:drugs(NSAIDS,AB),infections Kidney Bx:interstitial cellular infiltrate,definite Dx. Treatment:stop drug,treat infection,steriods

  27. Interstitial Nephritis

  28. Eosinophils in acute interstitial nephritis

  29. HUS

  30. Most commom cause of ARF Triad:MAH,ARF,thrombocytopenia Pathology:endothelial cell injury microthrombi ,ischemic injury to multiple organs Kidney :glomerular,arterial thrombotic microangiopathy ,cortical necrosis

  31. Classification of HUS • Infectious (Stx) • E coli 0157:H7 • Shigella dysenteriae type I (D+ HUS) • Hereditary • Factor H deficiency, VWF proteinase def,ADAMTS-13 • Secondary • Pregnancy • Malignancy • Medication • CNIs

  32. Diarrhae + HUS D+HUS:follows STEC, shigella Transmitted undercooked hamburgers,milk,person to person O157:H7 E. coli most common serotype 5-15% of kids infected STEC develop HUS Risk of HUS increase with age <5y, WBC >13,000/mm3,antimotiliy drugs (retention of toxin Antibiotic can increase risk?? Release toxin

  33. Clinical Manifestations Diarrhea 3-7 d after exposure to STEC,mostly bloody Pallor,oliguria 4-7 d post diarrhoea GIT:severe colitis,transmural necrosis,perforation,stricture,rectal prolapse Hepatitis,jaundice 35%

  34. Progression of E coli O157:H7 infections in children

  35. Pancreatitis Glucose intolerance,IDDM CNS: 20% seizures,irritability,confusion Mycardium ischemia rare,rhabdomyolysis HTN,renal cortical necrosis, 50% are anuric,75% needs dialysis

  36. Investigations FBC,showes anemia and low platlets. LDH high,blood film shows schizocytes,fragmented RBC High urea and creatinine Elevated liver enzymes 40 % hematuria,proteinuria

  37. Microangiopathic hemolytic anemia

  38. Management Transfusion if severe hemolysis,slowly 4h Monitor fluid and electrolyte status Platlet if bleeding,can accelerate microthrombi formation RRT if ARF Synsorb Pk doesn’t decrease progression to HUS

  39. Outcome Duration of oliguria is best predictor of outcome,worse if more than one week 30% had adverse renal outcomes,HTN,renal impairment 5-10% develop ESRD RRT during acute phase,if recover risk of future renal disease

  40. RPGN 1.PSGN 2.MPGN 3.Lupus nephritis 4.Wegner,good pasture Treatment with high dose pulse steriods

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