Transcript
Renal Failure: acute, chronic &ESRD
Saeed M.G. Al-Ghamdi,FRCPS,FACP
Faculty of Medicine King Abdulaziz University
Hospital
RF: Items for Discussion Definitions of ARF, CRF & ESRD Classification & causes of RF Statistics Presentations Investigations Treatment
ARF: Definition
Abrupt decline of Glomerular filtration rate which is potentially reversible
ARF: Statistics Prevalence:
In 5% of medical-surgical ward admission
In 25% of non-emergent surgery In 15% of ICU admission
Mortality: Oliguric ARF: 50-80% Non-Oliguric ARF: 15-40% Risk of death: 6.2 folds
ARF: Classification & Causes
Pre-renal ARF: 40-80% Renal ARF: 20-30% Post-renal ARF: 2-10%
Pre-renal Causes: 1) Extra-renal fluid loss:
Vomiting Continuous un-replaced NG suctioning Continuous un-replaced drainage Diarrhea , intestinal fistula Pancreatitis Intestinal obstruction Excessive Sweating & heat
stroke ,burns
Pre-renal Causes:
2) Renal fluid loss Osmotic Diuretics: hyperglycemia,
mannitol Loop and thiazide diuretics Un-replaced post-obstructive diurecis
3) Change in renal hemodynamics ACEI in bilateral Renal Artery Stenosis NSAIDS in patient with dehydration or
CHF
Pre-renal Causes4) Cardiac causes Due to renal hypo-perfusion
In severe systolic heart failure (EF <15%)
Severe valvular heart disease Arrhythmias: Complete Heart Block Cardiac temponade Right Ventricular Infarction Severe core pulmonale
ARF: Pre-renal Causes
5) Peripheral vasodilatation: Anti-hypertensive drugs
6) Hepato-Renal Syndrome Due to renal vaso-constrictors & third
spacing In advanced irreversible liver disease Other causes of ARF should be ruled out Very low urine sodium (<10)
Renal Causes of ARF
1) acute tubular necrosis (ATN) Septic syndrome (with & without
hypotension) Significant bleeding leading to
prolonged hypotension Severe dehydration leading to
prolonged hypotension Cardiogenic shock Severe PET & ET
Renal Causes of ARF (Cont..)
2) Toxic and pigment-induced ATN Aminoglycoside nephrotoxicity Amphotericin-induced nephrotoxicity Contrast-nephropathy Hemoglobinuria (severe intravascular
hemolysis) Myoglobinuria (Rhabdomyolysis)
Renal Causes of ARF (Cont..)
3) Glomerular diseases and systemic vasculitis Rapidly progressive
Glomerulonephritis (RPGN) Immune-complex nephritis: (post-
infectious GN, lupus nephritis, HSP, ..Etc.) Anti-GBM disease Pauci-immune nephritis: Wegener's
Granulomatosis
Renal Causes of ARF (Cont..)
4) acute interstitial nephritis Drug-induced (NSAIDS, beta lactam
antibiotics,rifampicin, furosemide, allopurinol ..Etc.)
Auto-immune (SLE, Sjogren syndrome, HES )
Infection-related (Legionella, salmonella ,..Etc.)
Sarcoidosis Idiopathic
Renal Causes of ARF (Cont..)
5) Acute Pyelonephritis In transplant kidney In single functioning kidney
6) Acute Allograft Rejection 7) Lymphomatous Infiltration of the
kidneys In HIV+ve Patients PTLD
ARF: Renal Causes
8) renal vasular & Ischemic disorders Vasculitis Scleroderma renal crisis Malignant HTN TTP, HUS, DIC Renal artery thrombosis Renal vein thrombosis Cholesterol Athero-embolic disease
ARF: Renal Causes (contin..)
9) acute cortical necrosis (ACN) In association with hypotension and
DIC Abruptio placenta, placenta previa IUFD
Presentation: Loin pain Anuria Gross hematuria Cortical calcification (after healing)
Renal Causes of ARF (Cont..)
10) acute papillary necrosis Acute Pyelonephritis in diabetic Sickle cell disease Phenacetin-induced nephropathy
Pesentation: Loin pain Oligo-anuria Passage of tissues (papillae)
ARF: Presentation (Cont..) Features suggest renal causes of ARF
History of arthritis and or arthralgia Recent drug exposure Recent surgery and or intervention Recent URTI or tonsillitis Peri-orbital and facial edema HTN and absence of signs of
hypovolemia Vasculitis or livedo reticularis
ARF: Post-renal Causes Intra-renal (tubular) obstruction :
(medical) Acute uric acid nephropathy Calcium oxalate Crystalluria: ethylene glycol
poisoning or high dose vitamin C Myeloma cast nephropathy IV Methotrexate crystalluria IV acylovir and oral Indinavir crystalluria Sulfonamides crystalluria (sulfadiazine, SMZ)
Post-renal Causes of ARF Extra-renal (tubular) obstruction
(surgical) Ureteral/pelvic
Intrinsic: tumor, stone, clot, papilla Extrinsic: retroperitoneal and pelvic
malignancies , fibrosis and ligation Bladder: stones, clots, tumor,
neurogenic, BPH, Prostatic ca, post-operative
Uretheral: PUV, stone …etc
ARF: Causes
Pre-Renal Renal Post-renal
Renal & extra-renal fluid loss
ATN Intra-tubular obstruction
Systemic vaso-dilatation
Interstitial nephritis
Surgical obstruction
Severe cardiac failure
Acute GN
ACEI & NSAID in
predisposed patients
Vasculitis & thrombosis & CAED
Renal Artery Thrombosis In hyper-coagulable states Presentation:
Severe loin pain Gross hematuria Complete anuria if bilateral
Diagnosis by Doppler, IVP & Angiogram Treated by thrombolysis and or
heparin
Renal Vein Thrombosis: S&S
Loin pain Macro and or Microhematuria Proteinuria ARF if bilateral or single kidney Diagnosed by
U/S Doppler Spiral CT Renal venography
RVT: Predisposing Factors Severe dehydration in neonates Severe nephrotic syndrome
(S.Alb.<20 g) Hypercoagulable states
Protein S or C deficiency Anti-Phospholipids antibody syndrome Homocysteinuria Malignancies
Cholesterol Athero-embolic Disease
Predisposing factors Follows intravascular intervention May follow bellow renal vascular
surgery May occur after anti-coagulation May occur spontaneously
CAED: Presentation 3-6 weeks after vascular
instrumentation Progressive rise of S.Creatinine Livedo Reticularis Gangrenous toes and peripheral skin Thrombocytopenia Eosinophilia Hypocomplementemia Diagnosed by kidney biopsy
ARF: Presentation Features suggest pre-renal.
Vomiting, diarrhea , NGT ..Etc. Uncontrolled DM. Diuretic use. Exposure to sun and hot weather. Postural hypotension and tachycardia. Low JVP. Dry axilla and mucous membranes.
ARF: Investigations Rapidly rising S.Cr. & hyperkalemia U/S kidneys & bladder Urine analysis
RBCs and RBC casts suggest GN WBCs and WBC casts suggest AIN or
acute pyelonephritis Brown granular casts suggest ATN
ARF: Investigations (Cont..)
Urine Eosinophils : In AIN Urine myoglobulin : in Rhabdomyolysis Urine hemoglobin : in Hemoglobinuria Urine sodium :
<10 mmol/l, suggest pre-renal Na+ Excretion Fraction:
<1% suggest pre-renal > 3% suggest ATN
ARF: Investigations Fractional excretion of sodium:
UNa X PCr FENa: ----------------- X 100 =
PNa X Ucr
< 1%: Pre-renal > 3%: ATN
ARF: Investigations (Cont..) Positive ANA & Anti-dsDNA in lupus
nephritis Low C3 & C4 in :
Lupus nephritis Pos-infectious GN MPGN
Falsely positive RF in cryoglobulinemia
ARF: Investigations (Cont..) Positive ANCA.
Wegener's Granulomatosis. Microscopic Poly-Angiitis. Poly-Arteritis Nodosa.
Positive Anti-GBM in Good Pasture’s syn.
Monoclonal band in Serum and or urine electrophoresis in patients with paraprotein.
ARF: Investigations (Cont..) CBC
Neutrophilic Leucocytosis in infection Eosinophilia in allergic interstitial
nephritis Leucopenia & Thrombocytopenia
suggest SLE Prolonged PT & PTT and low
fibrinogen in DIC and sepsis Prolonged uncorrectable PTT in
SLE
ARF: Treatment
First: Treatment of the underlying cause
Second: Conservative treatment of established ARF
Third: Dialysis if indication (s) arise
I) Treatment According to the
Cause of ARF Pre-Renal Failure: Hydration Post-Renal Failure:
Relieve obstruction Catheterization DJS Nephrostomy
Dialysis if indication arises Replace urine output ( Post-Obstructive
Diurecis)
I) Treatment According to the Cause of ARF(contin..)
ATN and sepsis: IV Fluids (colloids & crystalloid) Inotropes (Dopamine, Norepinephrine) Antibiotics Furosemide In established ARF: Conservative
treatment If indication for dialysis: CRRT
I) Treatment According to the Cause ARF (contin..)
Drug-induced ATN: Discontinue the offending drug (s) Avoid nephrotoxins Conservative treatment of established
ARF Recovery is the rule If indication for dialysis arises: HD, PD
or CRRT
I) Treatment According to the Cause of ARF (contin..)
Rhabdomyolysis (early with non-oliguria) Urine alkalinization with Na bicarbonate Mannitol Furosemide
Rhabdomyolysis (late with oliguria) Conservative treatment of established
ARF Hemodialysis if indications arise
II) Conservative Treatment of Established ARF
Daily Fluid Intake : the previous 24 h urine output + insensible water loss
Hyperkalemia: Low K+ diet Calcium resonium Insulin + dextrose Inhaled Beta agonist Calcium gluconate iv (in EKG changes)
II) Conservative Treatment of Established ARF (contin..)
Metabolic acidosis: IV Sodium bicarbonate (in severe cases) oral Na bicarbonate (in mild to moderate
cases) May cause volume overload
Protein intake: if catabolic, low protein diet Medications:
Adjust the dose to Cr. clearance Avoid nephrotoxins
I) Treatment According to the Cause of ARF(contin..)
Allergic Interstitial Nephritis Stop the offending drug Prednisolone 1mg/kg/d for 6 weeks Hemodialysis if indication arise
Acute Pyelonephritis Hydration Amp+genta in uncomplicated Ceftazidime or ciproflox. + genta
(complicated)
CRF:definition
Chronic, slow, indolent, progressive deterioration of Glomerular filtration rate which is irreversible
CRF: Causes DM: 30% HTN: 26% Glomerulonephritis : 14% Other causes: 30%
Chronic interstitial diseases Obstructive Uropathy ADPKD
CRF: Causes in Children Congenital renal hypoplasia and
dysplasia. Vesico-Ureteric Reflux. Congenital cystic diseases.
ARPKD. Multicystic disease. MCD (Juvenile Nephronophthasis).
Obstructive diseases: PUV, etc....
CRF: Causes in Children Congenital glomerulonephritis
Alport’s syndrome Congenital FSGS
Glomerulonephritis Unresponsive GN DMS
HUS Congenital HUS Post-diarrheal HUS
CRF: PresentationIn mild to moderate disease; GFR >40
ml/min. Asymptomatic. Incidental discovery of high urea &
Cr. Discovery of concomitant or
causative disease, e.g... PKD, etc.... Hypertension.
CRF: Presentation (Cont...)
In moderate to moderately severe CRF: GFR> 15 mls/min and < 40 mls/min Polyuria & polydepsia Generalized fatigue Sexual dysfunction Bruiritis Bone pain and muscle weakness
CRF: Diagnosis
Requires three perquisites: Co-existence of disease that cause
CRF Evidence of Progressive Renal
Dysfunction Evidence of Extra-renal uremic
organ dysfunction
CRF: Diagnosis Coexistence of disease that cause CRF
Long standing DM (>10 years) Long standing uncontrolled HTN Remote history of hematuria or proteinuria Recurrent upper UTI Recurrent nephrolithiasis Painful conditions with chronic analgesic
abuse Family history of PKD
CRF: Diagnosis (contin.)
Evidence of Progressive Renal Dysfunction Previously documented elevated
serum creatinine Radiological evidence of signs of
chronicity by U/S Hyperechoic cortices Small shrunken kidneys
CRF: Diagnosis (Continued)
Evidence of Extra-renal organ dysfunction Anemia of chronic disease (due to decrease
EPO & decrease RBC survival) Renal Osteodystrophy:
Decrease S. Ca++
Increase S. PO4--
Increase ALP & iPTH Sub-periosteal bone resumption (MCP, Phalanges,
and clavicles)
CRF: Investigations S. Creatinine: ( > 120 mic.mol/l) S. potassium: (usually normal) S. calcium: (normal or low) S. phosphorus: (usually high) Alkaline phosphatase: (usually high) CBC:
Normochromic normocytic anemia
CRF: Investigations (Continued)
Urine analysis: Specific gravity: (1.010) RBCs: (only in patients with Chronic
GN) Casts: (granular casts)
Urine is bland (benign)
CRF: Investigations (Continued)
Ultrasound kidneys: (signs of chronicity) Hyperechoic cortices Poor cortico-medullary differentiation Small sized kidneys (< 9 cm) EXCEPT
Diabetic Nephropathy Malignant Hypertension Amyloidosis PKD
CRF: Monitoring Renal Function Serum creatinine: (70-120 mic.mol/l)
Affected by muscle mass, sex & protein intake
Cr.clearance = CrU × V(urine volume)/CrP
(80-120 mls/min) Affected by:
Muscle mass, sex, and protein intake Increase tubular secretion of creatinine in RF Decrease tubular secretion by cimetidine &
CoTMZ
CRF: Monitoring Renal Function Cockroft & Gault equation: Cr Cl.= (140- age) × wt /Cr P
Reliable in steady state
Clearance of 125 I-isothalamate, 99Tc-DTPA: rapid and accurate
Uremic Osteodystrophy: Pathogenesis Hyperphosphatemia: Due to
Decrease GFR leads to decrease PO4-- excretion
Hypocalcemia: due to Binding with P leads to precipitation
of Ca-P byproduct Decrease calcium absorption from gut
due to low level of calcitriol
Uremic Osteodystrophy:Pathogenesis (contin.)
Low level of active Vit D (1,25-dihyroxy-cholecalciferol) Due to: unavailability of alpha hydroxylase This lead to hypocalcemia and
unsuppressed Parathyroid gland High PTH: due to:
Low level of calcitriol (1,25 DHCC) Hypocalcemia
Uremic OsteodystrophyHyperphosphatemia Low 1,25 DHCC
Hypocalcemia
Hyperparathyoidism
CRF: Treatment Aggressive treatment of the underlying
disease Aggressive control of blood sugar (DCCT 93) Optimal control of BP Discontinue all nephrotoxins Relieve Urinary Tract Obstruction Treat underlying auto-immune disease Suppress UTI in recurrent upper UTI
CRF: Treatment (Continued)
Attenuate the hyperfiltration ACE Inhibitors and Angiotensin
Receptors Antagonists (especially in DM)
Low Protein Diet; 0.8g/kg BW (MDRD) Avoid all Nephrotoxins
NSAIDS Aminoglycosides
CRF: Treatment (Continued)
Treat Uremic Bone Disease Lower serum Phosphate
Low Phosphate diet Calcium carbonate, or Calcium acetate, or
Renagel with meal (phosphate binders)
Suppress PTH & increase Ca++ absorption Calcitriol or alfacalcidol (0.25-1.0 mic.g/day)
Treat. Uremic Osteodystrophy
Calcitriol orAlfacalcidol
Calcium Carbonate
Low PhosphateDiet
+ +
CRF: Treatment (Continued)
Treat anemia of CRF Iron sulfate or fumarate rh-Erythropoeitin
Usually when GFR <15mls/minute Only if Hgb significantly low (<9g) After replacing Iron stores Target Hgb level (11.0-12.0g, Hct 33-36)
Folic acids and multivitamins
CRF: Treatment (Continued)
Prepare Patient for Renal Replacement Therapy (when GFR < 15 ml/minute) AVF for hemodialysis PD catheter (Tenkhoff’s catheter ) for PD Transplant workup
Urological & medical assessment Radiological investigations Tissue matching (ABO, HLA & LYMPHOCYTE)
ESRD:definition
Permanent loss of GFR to the extent where renal replacement therapy is to be instituted
ESRD: Statistics 330,000 patients on RRT worldwide
70% on HD 9% on PD 21% has functioning renal transplants
Incidence in USA: 240 PMP Incidence in KSA: 139-215 PMP Mortality:
ESRD: Presentation Euremic Enchephalopathy
Nausea & vomiting & hiccup Lethargy, sleepiness, drowsiness and
coma Myoclonic jerks & seizures
Uremic Pericarditis Chest pain Pericardial rub Pericardial effusion and temponade
RRT: Modalities Hemodialysis Peritoneal Dialysis Renal Transplantation
Living-Related, Living-Unrelated Cadaveric
CRRT CAVH, CVVH, SCUF CAVHD,CVVHD, CAVHDF, CVVHDF
RRT: Absolute Indications for Dialysis Fluid Overload Hyperkalemia Severe Metabolic Acidosis Uremic Pericarditis Uremic Enchephalopathy Intoxication: Methanol, ethylene
glycol ASA, & Lithium
RRT: Relative Indications for Dialysis Uremic Neuropathy Malnutrition of CRF Correct bleeding time before
surgery Cr. clearance <10 ml/minute Level of urea & creatinine ??
Arterial blood fromPatient
Venous blood to patient
IncomingDialysate solution
Hemodialysis: Dialyzer
Hemodialysis: Principles Solutes are effectively removed by
diffusion Water is removed by convection
(UF) Both mechanisms contribute to
solute removal
Peritoneal Dialysis: Types Continuos Ambulatory Peritoneal
Dialysis (CAPD) 4 cycles of 2 liter of dialysate
Intermittent Peritoneal Dialysis (IPD) Whole day or night for 2-3 times/ week
Continuos Cyclic Peritoneal Dialysis (CCPD) Eight , 2 liters exchanges during night
Peritoneal Dialysis: Principle Diffusion: for solutes
From high concentration gradient to low concentration gradient
Osmosis: for water Depends on concentration of sugar in
the dialysate fluid The fluid and solute removal can be
enhanced by increasing the volume of dialysate and the number of exchanges
Peritoneal Dialysis: CAPD, IPD
PD dialysate solution
PD Catheter
Hanger
Connectionset
PD: Advantages A more normal life-style Better residual renal function Less stringent fluid and diet
restriction Stable solutes concentration (no dysequilibrium) Better hemoglobin level More economic: 2/3 of HD cost
PD: Complications CAPD PERITONITIS
Abdominal pain Fever Turbid effluent WBC in effluent >400 Organisms:
Staph. aureus and epidermedis Gram negative: Klebseilla, pseudomonas Candida
CAPD PERITONITIS: Treatment 3 flushes in & out Loading dose Intraperitoneal
antibiotics: Cefazoline and Tobramycin Or Vancomycin & Tobramycin
Maintenance dose IP antibiotics: Change antibiotics according to
sensitivity
CAPD: Complications & Treat. Tunnel infection
Pain and swelling at tunnel site Fever Treatment: Vancomycin IV
Exit site infection Redness at exit site with discharge Cloxacillin or Vancomycin
CAPD: Complications & Treat. Catheter leak
Treatment: Temporary conversion to HD
Catheter dysfunction: causes Constipation: laxatives Fibrin: IP heparin Omental wrap May require replacement
CAPD: Complications Obesity & hypertriglyceridemia
Due to excessive absorption of glucose
Protein loss & hypoalbuminemia Loss with the effluent
Bloody Effluent: Ruptured corpus leutium (ovulation) Endometriosis
CRRT: Types CAVH: UF only CVVH: UF only SCUF: slow UF CAVHD: Dialysis CVVHD: Dialysis CAVHDF: UF & Dialysis CVVHDF: UF & Dialysis
CRRT: Principle Ultrafiltration: The main driving
force Diffusion: slow and efficient only
with time Patient need replacement of fluid
loss up to 18 liters/ day (in CAVH, CVVH, CAVHDF & CVVHDF)
CRRT: CAVH
ArterialVenous
UF
Replacement
Qb=50-100 ml/minQf= 8-12 ml/min
CRRT: CAVHD
Arterial Venous
Dialysate out
Qb=50-100 ml/minQd=10-20 ml/minQf= 1-3 ml/min
Dialysate In
CRRT: CVVH
Venous Venous
UF
Replacement
Qb=50-200 ml/minQf= 10-20 ml/min
Pump
CRRT: CVVHD
Venous Venous
Dialysate out
Qb=50-200 ml/minQd=10-30 ml/min Qf= 1-5 ml/min
Dialysate In Pump
CRRT: Indications Acute Renal failure in
hemodynamically unstable patient & MOF
Volume control in septic patient with no Renal failure
Removal of mediators of sepsis Refractory Congestive Heart Failure ARF in acute and chronic liver disease Tumor lysis syndrome, lithium intox.?
RF: Natural History
RF: Differences
ARF CRF ESRDGFR Rapid decline
Reversible Slow,progressive,irreversible
Permanent no function
Urine output Anuria, oliguria on non-oliguria
Polyuria Polyuria or normal
Urine analysis
Sp.gr.:>1.020May be active sediment
Sp.gr.: 1.010Bland sediment
1.010Bland Sediment
Serum K+ Usually high May be normal
Usually lowMay be normal or high
Usually lowMay be normal or high
Uremic bone disease
Not present Usually present Always present
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