acute renal failure课件

ACUTERENALFAILURE ShahzadQureshiM D DivisionofNephrologyLoyolaUniversityMedicalCenter Objectives DefineandreviewclassificationofARFEpidemiologyofARFMeasurementofkidneyfunctionPathophysiologyofARFManagementandtreatmentofARFReviewclinicalcases WhatisARF A IncreaseinserumCreatinine0 5mg dL B AnincreaseinserumCreatinineofmorethen50 frombaseline C AreductioninthecalculatedCreatinineClearanceof50 RIFLEClassification 2004ADQIgroupclassificationRisk R IncreaseCrx1 5orDecreaseGFRx25 orUO 0 5ml kg hrx6hrsInjury I IncreaseCrx2 0orDecreaseGFRx50 orUO 0 5ml kg hrx12hrsFailure F IncreaseCrx3 0orDecreaseGFRx75 oranuriax12hoursLoss L PersistentARF completelossofkidneyfunctionx4weeks needingRRT EndStageKidneyDisease E Lossofkidneyfunctionx3months MeasurementofKidneyFunction SerumCreatinine SerumcreatinineisareflectionofcreatinineclearanceCreatinineproductionisdeterminedbymusclemassandmustbeinterpretedwithrespecttopt sage weightandsex CreatinineisfilteredandsecretedandtendstooverestimateGFR CertaindiseasesandmedicationsinterferewithcorrelationbetweenserumCrandGFR i e Acuteglomerulonephritis trimethoprim cimetidine SerumCreatinine cont Cockcroft GaultequationCrCx 140 agey weightkg 0 85iffemale 72Xserumcreatininemol L MDRD ModifiedDietandRenalDisease GFR inmL minper1 73mm2 186 3X serumcreatinine exp 1 154 X Ageexp 0 203 X 0 742iffemale X 1 21ifAfricanAmerican SerumCreatinine cont NoneoftheequationsaccuratelydetermineGFRinARF AssumeCrisstable MoreaccuratetechniquesinvolvenuclearmedicinestudiesandGFRscans Newbiochemicalmarkersinvestigated i e CystatinC Epidemiology 5 ofhospitalizedpatientsdev ARF 0 5 ofthesepatientsrequiredialysis 20 ofcriticalcareadmissionsdev ARF HospitalacquiredARFusuallydevelopsinthesettingofICUsecondarytomultisystemorganfailure CausesofARFinHospitalizedPatients 45 ATNIschemia Nephrotoxins21 PrerenalCHF volumedepletion sepsis10 Urinaryobstruction4 Glomerulonephritisorvasculitis2 AIN1 Atheroemboli Mortality Morbidity Mortalityratesrangefrom7 80 dependingonpatientsothercomorbidities Thisratehasremainedunchangedsincetheadventofdialysisbecauseofincreasingageandcomorbidconditions MostcommoncauseofdeathassociatedwithARFaresepsis cardiacfailureandrespiratoryfailure Mortalityratesarelowerfornonoliguric 400ml day thenoliguricARF 400ml day Pathophysiology 1 Asanadaptiveresponsetoseverevolumedepletionandhypotensionwithstructurallyandfunctionallyintactnephrons Prerenalazotemia 2 Inresponsetocytoxicorischemicinsultstothekidneywithstructuralandfunctionaldamage IntrinsicRenalfailure 3 Withobstructiontopassageofurine Postobstructiveuropathy History Nausea Vomiting Diarrhea Hxofheartdisease liverdisease previousrenaldisease kidneystones BPH Anyrecentillnesses Anyedema changeinurination Anynewmedications Anyrecentradiologystudies Rashes PhysicalExam VolumeStatusMucusmembranes orthostaticsCardiovascularJVD rubsPulmonaryDecreasedbreathsoundsRalesRash Allergicinterstitialnephritis Livedoreticularis LargeprostateExtremities Skinturgor Edema WorkupforARF BMPUrineUrinesediment U A casts cells proteinUrineelectrolytes UNaandUUN andurineCrtocalculateFeNa FeUreaUrineosmolarityUrineproteinUrineeosinophilsKidneyU S r ohydronephrosis A75yoman NHresident withAlzheimer sdementiaadmittedforaspirationpneumonia BUN50andCr2 6 A ATNfromAbxB Glomerulo nephritisC DehydrationD AINfromNSAIDs HyalineCasts PreRenalAzotemia Impairedrenalbloodflowasaresultoftrueintravasculardepletion decreasedeffectivecirculatingvolumetothekidneys oragentsthatimpairrenalbloodflow UrineandbloodstudiesarehelpfulindiagnosingprerenalARF Hyalinecastscanbeseen Notanabnormalfinding TreatwithfluidbolusesorcontinuousIVF monitorurineoutput PrerenalCauses IntravascularvolumedepletionHemorrhageVomiting diarrhea Thirdspacing DiureticsReducedCardiacoutputCardiogenicshock CHF tamponade hugePE SystemicvasodilationSepsisAnaphylaxis AntihypertensivedrugsRenalvasoconstriction HepatorenalsyndromeMedications ACE I NSAIDS UrineIndicesinARF PreRenal IntrinsicATN PostRenal Uosm Na meq L Bun Cr mg dL FENa Sediment FEUrea AcuteRenalFailureUrinaryIndices UOsm mOsm L U P Cr UNa mEq L FENa ATN ATN ATN ATN PR PR PR PR 1 0 350 500 40 20 40 20 WhatisFENa Thefractionoffilteredsodiumexcretedintheurine FeNa urineNaxplasmaCr plasmaNaxurineCr ARFsyndromeswithLowFENA PrerenalARFVasoconstrictionMediatedIntrinsicRenalFailure Tacrolimus cyclosporine cocaine Hepatorenalsyndrome RadiocontrastInjury Rhabdomyolysis Sepsis early burninjury AcuteGlomerulonephritis CalculatingFeNaafterpthasgottenLasix CautionwithcalculatingFeNaifpthasgottenLoopDiureticsinpast24 48hLoopdiureticscausenatriuresis incrurinaryNaexcretion thatraisesUNa evenifptisprerenalSoifFeNa 1 youdon tknowifthisisbecauseptiseuvolemicorbecauseLasixincreasedtheUNaSohelpfulifFeNastill1 1 FractionalExcretionofLithium endogenous 2 FractionalExcretionofUricAcid3 FractionalExcretionofUrea Nursepagesyouandstatesyourpatienthasnoturinatedin8hours Whatdoyouwanttodo Examinept Dry Septic vasodilated CheckI Os hasptbeendrinking InsertFoleyandmeasurePVRFlushfoley sedimentcanobstructoutflow GiveIVBOLUS 250 500ccIVF seeifpturinatesinnext30 60minIfpturinates thentheptwasdryIfptdoesn turinate thenpt seitherREALLYdryorinrenalfailureCheckUA urinelytes urineosmolarity BMPConsiderRenalU Sifreasonable PostObstructiveUropathy Occursifbothurinaryoutflowtractsareobstructedoroutflowtractofsolitarykidneyisobstructed PatientswithSUDDENONSETofanuriaarelikelytohavepostobstructiveuropathy PrimarycausesincludeBPH prostateandcervicalcancer stones stricturesandretroperitonealfibrosis BladdercatheterizationandRenalU Stoassesshydronephrosis Canhaveobstructionw ohydronephrosisonU SMonitorforpostobstructivediuresis hemorrhagiccystitis Youevaluatea60yomanwhoundergoesfem popbypassforseverePVDnowwitholiguriaandrapidlyincreasingBUN Cr A ATNB AcuteglomerulonephritisC ContrastInducedNephropathyD Post Obstructiveuropathy Brown Muddy casts IntrinsicAcuteRenalFailure Tubular ATN Interstitial AIN Glomerular Glomerulonephritis Vascular ATN MostcommoncauseofARFinhospitalizedpatientsContrastandaminoglycosidesmostoftenassociatedwithnonischemicATN 3phases 1 Initiationphase Renalinjurylastinghourstodays 2 Maintenancephase Lastsdaystoweeks GFRandU Oatlowest 3 RecoveryPhase Postacutetubularnecrosisdiuresis Canstillexp uremiaandhypovolemiaastubularfunctionnotcompletelyrestored Thadhani R etal NEnglJMed1996 334 1448 1460 Tubular CellInjuryandRepairinIschemicAcuteRenalFailure Treatment ReverseunderlyingcausesandcorrectfluidandelectrolytebalancesTreatmentissupportive Drugssuchasmannitol loopdiuretics dopamineandCCBsuccessfulinpromotingdiuresisinanimalsbutnotinhumans Dialysisasneeded IHDvs CRRT 60yowomanwithh oOAhaslabsdrawnBUN 24 Cr1 8 U Areveals20WBC nobacteria WhatisthecauseofARF PrerenalazotemiasecondarytoUTIATNsecondarytoAbxAINsecondarytoNSAIDuseAcuteglomerulonephritis WBCCAST AcuteInterstitialNephritis 70 Drughypersensitivity30 Antibiotics PCNs Methicillin Cephalosporins CiproSulfadrugsNSAIDsAllopurinol 15 InfectionStrep Legionella CMV otherbact viruses8 Idiopathic6 AutoimmuneDz Sarcoid Tubulointerstitialnephritis Uveitis AINfromDrugs RenaldamageisNOTdose dependentMaytakewksafterinitialexposuretodrugUpto18mostogetAINfromNSAIDS Butonly3 5dtodevelopAINaftersecondexposuretodrugFever 27 SerumEosinophilia 23 Maculopapularrash 15 BlandsedimentorWBCs sterilepyuriamostcommonlyseenWBCCastsarecommonUrineeosinophilsonWright sorHansel sStain AlsoseeurineeosinRPGN renalatheroemboli Treatmentistoremoveoffendingagents Mostpatientsrecovercompletekidneyfunctionw Ioneyear Youevaluatea32yowomanwitholiguria hematuriaandrapidlyincreasingBUN CrafewdaysafterexperiencingaviralURI U Areveals ATNAcuteglomerulonephritisAcuteinterstitialnephritisPrerenalAzotemia RBCCASTS AcuteGlomerulonephritis NephroticSyndromes1 Disorders MinimalChangeDisease MembranousNephropathy FSGS2 Disorders DM SLE HepatitisB Amyloid Heroin NephroticSyndromes Edema Anasarca Proteinuria 3 5gm 24hrs LipidemiaCanhavenormalserumcreatinine Notoliguric UsuallydoNOTseeRBCcasts NephriticSyndromes Type1 Anti GBMdz AntiGBMAbpositive Goodpasture sDiseaseAnti GBMType2 Immunecomplex Lowcompliment elevatedESR IgAnephropathy NormalComplimentlevels PostinfectiousglomerulonephritisLupusnephritisMixedcryoglobulinemiaMPGNIBEType3 Pauci immune ANCApositive assocwithvasculitis Wegner sDiseaseMicroscopicPolyangitisChurg Strauss NephriticSyndromes FeverOliguriaHematuriaHtnRBCcastsProteinuria 1 2gramsusually Treatmentvariesbasedonunderlyingdisease 68y omalewithbaselineCr 1 2underwentangiogram3dayspriorforACS NowpthasCr 2 0andblanchingrash RenalArteryStenosisContrast InducedNephropathyC AbdominalAorticAneurysmD CholesterolAtheroemboli RenalAtheroembolicDz 1 ofCardiaccaths atheromatousdebrisscrapedfromtheaorticwallwillembolizeRetinal