Professional Documents
Culture Documents
SIS_IX_271109
Review
Serum Creatinine (mg/dl)
9.0
8.0
7.0 6.0
5.0
4.0 3.0 2.0
1.0
0
20
40
60
Definitions
Anuria: No UOP Oliguria: UOP<400-500 mL/d Azotemia: Incr Cr, BUN May be prerenal, renal, postrenal Does not require any clinical findings Chronic Renal Insufficiency Deterioration over mos-yrs ( usually >3 months) ESRD = GFR <5%
Definition
Acute Kidney Injury:
an abrupt decrease in kidney function characterized by a rise in serum creatinine of more than or equal to 0.3 mg/dl or an increase to more than or equal to 1.5 fold from the baseline or normal creatinine level or a urine output of less than 0.5 ml/kg/hr for more than 6 hours with exclusion of chronic kidney insufficiency.
Definition of Acute Kidney Injury (AKI) based on Acute Kidney Injury Network
Stage 1 Increase in Serum Creatinine 1.5-2 times baseline OR 0.3 mg/dl increase from baseline 2-3 times baseline 3 times baseline OR 0.5 mg/dl increase if baseline>4mg/dl OR Any RRT given Urine Output <0.5 ml/kg/h for >6 h
2 3
<0.5 ml/kg/h for >12 h <0.3 ml/kg/h for >24 h OR Anuria for >12 h
stage Increase in serum creatinine of more than or equal to 0.3 mg/dl ( 26.4 mol/l) or increase to more than or equal to 150% to 200% (1.5- to 2-fold) from baseline Increase in serum creatinine to more than 200% to 300% (> 2- to 3-fold) from baseline Increase in serum creatinine to more than 300% (> 3-fold) from baseline (or serum creatinine of more than or equal to 4.0 mg/dl [ 354 mol/l] with an acute increase of at least 0.5 mg/dl [44 mol/l]) Less than 0.5 ml/kg per hour for more than 6 hours Less than 0.5 ml/kg per hour for more than 12 hours Less than 0.3 ml/kg per hour for 24 hours or anuria for 12 hours
2b
3c
aModified
from RIFLE (Risk, Injury, Failure, Loss, and End-stage kidney disease) criteria. The staging system proposed is a highly sensitive interim staging system and is based on recent data indicating that a small change in serum creatinine influences outcome. Only one criterion (creatinine or urine output) has to be fulfilled to qualify for a stage. b200% to 300% increase = 2- to 3-fold increase. cGiven wide variation in indications and timing of initiation of renal replacement therapy (RRT), individuals who receive RRT are considered to have met the criteria for stage 3 irrespective of the stage they are in at the time of RRT. Mehta et al. Critical Care 2007 11:R31 doi:10.1186/cc5713
Chronic Kidney Disease: a long-standing, progressive deterioration of renal function, kidney damage for more than 3 months, defined by structural or functional abnormalities of the kidney, with or without decreased GFR.
In the presence of increased serum creatinine, the following features will diagnose CKD and hence will exclude subjects from enrollment:
Past documents: increased serum creatinine History: uraemic symptoms > 2 months (any 2 or more of the below mentioned):
Nausea/vomiting Pruritus Nocturia Leg and/or facial swelling
Ultrasound Abdomen:
Decreased size Decreased cortical thickness Increased echogenicity Scarring Multiple cyst
Normochromic anemia in absence of systemic inflammatory conditions Renal osteodystrophy Serum creatinine > 10mg/dl with normal urine output
Pre-renal Causes
Redistribution of ECF
Third space accumulation (pancreatitis, Cirrhosis) Edematous disorders (Reduction of effective circulating volume e.g. CCF, NS, Cirrhosis)
Prerenal ARF
Volume depletion: vomiting, diarrhea, decreased intake, diuretics, third-spacing
Hypotension: sepsis, drugs, blood loss Decreased cardiac output Renal artery stenosis, embolism, or thrombosis
Renal
Vascular: Hypertension, Wegeners, PAN
Glomerular: Post-strep GN, Lupus, RPGN, Hepatitis related, IgA nephropathy, Tubular: Acute Tubular Necrosis (ATN) Medication toxicity, toxins Interstitial: Acute Interstitial Nephritis (AIN)
Exogenous Toxins
Antibiotics (e.g., aminoglycosides, amphotericin B) Radiocontrast agents Heavy metals (e.g., cis-platinum, mercury) Poisons (e.g., ethylene glycol)
Postrenal
BPH Stones (usually unilateral with single kidney) Tumor (lymphoma, ovarian, prostate)
Urethral stricture
Neurologic (i.e. overflow incontinence)
Review
RBF ~
Review
Raff
RAP
Reff
PGC
Physical Exam
Volume Status Mucus membranes, orthostatics Cardiovascular JVD, rubs Pulmonary Decreased breath sounds Rales Rash (Allergic interstitial nephritis) Large prostate Extremities (Skin turgor, Edema)
Infections
Bacterial Viral
Sarcoidosis
Develops 3-7 days after exposure Fever, Rash , and eosinophilia common U/A reveals WBC, WBC casts, + Hansel stain Often resolves spontaneously Steroids may be beneficial ( if Scr>2.5 mg/dl)
Atheroembolic ARF
Associated with emboli of fragments of atherosclerotic plaque from aorta and other large arteries Diagnose by history, physical findings (evidence of other embolic phenomena--CVA, ischemic digits, blue toe syndrome, etc), low serum C3 and C4, peripheral eosinophilia, eosinophiluria, rarely WBC casts Commonly occur after intravascular procedures or cannulation (cardiac cath, CABG, AAA repair, etc.)
Cholesterol Embolization
Chlosterol embolization is an often unrecognized cause of acute renal failure which may be indistinguishable from the bland variety of allergic interstitial nephritis except by biopsy. In addition to ARF, other manifestations of the occlusion of small arteries by atheroembolic material include skin mottling (livedo reticularis), blue toes and distal digital infarcts with intact peripheral pulses. Transient eosinophilia, hypocomplementemia, and an elevated sedimentation rate are sometimes also seen.
Your 68yo male inpatient with baseline Cr=1.2 had negative cardiac cath 4 days ago, now Cr=1.8 and blanching rash.
A. Renal Artery Stenosis B. ContrastInduced Nephropathy C. Abdominal Aortic Aneurysm D. Cholesterol Atheroemboli
Contrast-Induced ARF
Prevalence
Less than 1% in patients with normal renal function Increases significantly with renal insufficiency
Contrast-Induced ARF
Risk Factors
Renal insufficiency Diabetes mellitus Multiple myeloma High osmolar (ionic) contrast media Contrast medium volume
Contrast-induced ARF
Clinical Characteristics
Onset - 24 to 48 hrs after exposure Duration - 5 to 7 days Non-oliguric (majority) Dialysis - rarely needed Urinary sediment - variable Low fractional excretion of Na
Contrast-induced ARF
Prophylactic Strategies
Use I.V. contrast only when necessary Hydration Minimize contrast volume Low-osmolar (nonionic) contrast media N-acetylcysteine, fenoldopam
Rhabdomyolytic ARF
Diagnose with serum CPK (usu. > 10,000), urine dipstick (+) for blood, without RBCs on microscopy, pigmented granular casts Common after trauma (crush injuries), seizures, burns, limb ischemia occasionally after IABP or cardiopulmonary bypass Treatment is largely supportive care. Alkalinization of urine .
Acute Glomerulonephritis
Rare in the hospitalized patient Most common types: acute post-infectious GN, crescentic RPGN Diagnose by history, hematuria, RBC casts, proteinuria (usually non-nephrotic range), low serum complement in post-infectious GN), RPGN often associated with antiGBM or ANCA Usually will need to perform renal biopsy
Extra-renal Obstruction
Renal pelvis or ureter (e.g., stones, clots, tumors, papillary necrosis, retroperitoneal fibrosis) Bladder (e.g., BPH, neuropathic bladder) Urethra (e.g., stricture)
Radiologic studies
Monomorphic
Dysmorphic
UOsm (mOsm/L)
(U/P)Cr
UNa (mEq/L)
RFI
FENa
Hydronephrosis
Hydronephrosis
Hydronephrosis
Management Principles
Establish urine output (fluids diuretics) Remove nephrotoxins, dose-adjust medications Careful volume and electrolyte management (using free daily weights, VS, I&Os, and labs) Ca, Mg, P also useful Provide nutrition (low K, low P)
Water and sodium restriction Protein restriction Potassium and phosphate restriction Adjust medication dosages Avoidance of further insults
BP support Nephrotoxins
Hyperkalemia
Highly Arrhythmogenic
Usually with progressive EKG changes
Peaked T waves ---> Widened QRS--> Sinus wave
K> 5.5 meq/L needs evaluation/intervention Usually in setting of Decrease GFR but:
medication also a common cause
ACEI NSAIDS Septra, Heparin
More FeNa
FeNa 1%-2% 1. Prerenal-sometimes 2. ATN-sometimes 3. AIN-higher FeNa due to tubular damage
FeNa >2% 1. ATN Damaged tubules can't reabsorb Na
A 22yo male with sickle cell anemia and abdominal pain who has been vomiting nonstop for 2 days. BUN=45, Cr=2.2.
A. ATN B. Glomerulonephritis C. Dehydration D. AIN from NSAIDs
Prerenal ARF
Hyaline casts can be seen in normal pts
NOT an abnormal finding
UA in prerenal ARF is normal Prerenal: causes 21% of ARF in hosp. pts Reversible Prevent ATN with volume replacement
Fluid boluses or continuous IVF Monitor Uop
Prerenal causes
Intravascular volume depletion Hemorrhage Vomiting, diarrhea Third spacing Diuretics Reduced Cardiac output Cardiogenic shock, CHF, tamponade, huge PE.... Systemic vasodilation Sepsis Anaphylaxis, Antihypertensive drugs Renal vasoconstriction Hepatorenal syndrome
Intrinsic ARF
1. 2. 3. 4. Tubular (ATN) Interstitial (AIN) Glomerular (Glomerulonephritis) Vascular
You evaluate a 57yo man w/ oliguria and rapidly increasing BUN, Cr.
A. B. C. D.
ATN
Muddy brown granular casts (last slide) Renal tubular epithelial cell casts (below)
More ATN
Broad casts (form in dilated, damaged tubules)
ATN Causes
1. Hypotension Relative low BP May occur immediately after low BP episode or up to 7 days later! 2. Post-op Ischemia Post-aortic clamping, post-CABG 3. Crystal precipitation 4. Myoglobinuria (Rhabdo) 5. Contrast Dye ARF usually 1-2 days after test 6. Aminoglycosides (10-26%)
ATNWhat to do
Remove any offending agent
IVF Try Lasix if euvolemic pt is not peeing Dialysis
U Na, FeNa
UA Response to volume BUN/Cr
UNa>40 FeNa >2% epi cells, granular casts Cr wont Cr improves improve with IVF much 10-15:1 >20:1
ATN
B. Spec grav 1.010, 1-3 WBC, 5-10 renal tubular cells, many granular casts, occasional renal tubular cell casts, no eos Dilute urine: failure to concentrate urine No RBC casts or WBC casts in ATN Eos classically in AIN or renal atheroemboli, but nonspecific
56yo woman with previously normal renal function now has BUN=24, Cr 1.8. Which drug is responsible?
A. Indinavir for her HIV Gentamicin for her SBE Motrin for her OA Cyclosporin for her SLE
B.
C. D.
WBC Casts
Cells in the cast have nuclei (unlike RBC casts) Pathognomonic for Acute Interstitial Nephritis
AIN Management
Remove offending agent Most patients recover full kidney function in 1 year Poor prognostic factors
ARF > 3 weeks Advanced age at onset
You evaluate a 32yo woman with HTN, oliguria, and rapidly increasing Cr, BUN. You spin her urine:
Acute Glomerulonephritis
RBC casts: cells have no nuclei Casts in urine: think INTRINSIC renal dz If she has Lupus w/recent viral prodrome, think Rapidly Progressive Glomerulonephritis If she had a sore throat 10 days ago, think Postinfectious Proliferative Glomerulonephritis
Glomerular Dz
Hematuria (dysmorphic RBCs) RBC casts Lipiduria (increased glomerular permeability) Proteinuria (may be in nephrotic range) Fever, rash, arthralgias, pulmonary sx Elevated ESR, low complement levels
Hematuria, HTN, edema, proteinuria Positive antistreptolysin O titer (90% upper respiratory and 50% skin) Treatment is supportive
Screen family members with throat culture and treat with antibiotics if necessary
A 19yo woman with Breast Cancer s/p chemo in the ER has weakness, fever, rash. WBC=15.4, Hct 24, Cr 2.9, LDH 600, CK=600. UA=3+ prot, 3+blood, 20 RBC. What next test do you order? Whats her likely dx?
A. Nephrotic Syn B. Systemic Vasculitis C. Acute Glomerulonephritis D. Hemolytic-Uremic Syn E. Rhabdomyolysis
TTP
Order blood smear to r/o TTP TTP associated with malignancy, chemo TTP may mimic Glomerulonephritis on UA (RBCs, WBCs) Thrombocytopenia, anemia not consistent with nephrotic or nephritic syndrome Need CK in the thousands to cause ARF
Microvascular ARF
TTP/HUS HELLP syndrome Platelets form thrombi and deposit in kidneysGlomerular capillary occlusion or thrombosis Plasma exchange, steroids, Vincristine, IVIG, splenectomy....
Macrovascular ARF
Aortic Aneurysm Renal artery dissection or thrombosis Renal vein thrombus Atheroembolic disease
New onset or accelerated HTN? Abdominal bruits, reduced femoral pulses? Vascular disease? Embolic source?
Your 68yo male inpatient with baseline Cr=1.2 had negative cardiac cath 4 days ago, now Cr=1.8 and blanching rash.
A. Renal Artery Stenosis B. ContrastInduced Nephropathy C. Abdominal Aortic Aneurysm D. Cholesterol Atheroemboli
Renal Atheroembolic Dz
1% of Cardiac caths: atheromatous debris scraped from the aortic wall will embolize Retinal Cerebral Skin (Livedo Reticularis, Purple toes) Renal (ARF) Gut (Mesenteric ischemia) Unlike in Contrast-Induced Nephropathy, Cr will NOT improve with IVF Diagnosis of exclusion: will NOT show up on MRI or Renal U/S; WILL show up on renal bx Tx: supportive
Post-Renal ARF
Urethral obstruction: prostate, urethral stricture. Bladder calculi or neoplasms. Pelvic or retroperitoneal neoplams. Bilateral ureteral obstruction (neoplasm, calculi). Retroperitoneal fibrosis.
You admit this pt to telemetry and aggressively hydrate her. You recheck labs 6h later and BUN=85, Cr=4.2. Suddenly the pt starts to seize. Now what?
UremiaSo what?
General
Fatigue, weakness Pruritis Uremic encephalopathy Seizures Asterixis Anorexia, early satiety, N/V,
GI disturbance
A pt with chronic lung disease has acute pleuritic pain and desats to 92%RA. You want to r/o PE but her Cr=1.4. Can you get a CT with IV contrast?
A. B. C. D. E. F. Send her for Stat CT with IV contrast Send her for Stat CT without IV contrast Just give her heparin Begin IV hydration Begin pre-procedure Mannitol Get a VQ scan instead
Contrast-Induced Nephrotoxicity
Cr increases by 25% or >0.05 postprocedure Contrast causes renal vasoconstriction renal hypoxia Iodine itself may be renally toxic If Cr>1.4, use pre-procedure prophylaxis
Pre-Procedure Prophylaxis
1. IVF ( 0.9NS) 1-1.5 mg/kg/hour x12 hours prior to procedure and 6-12 hours after 2. Mucomyst (N-acetylcysteine) Free radical scavenger; prevents oxidative tissue damage 600mg po BID x 4 doses (2 before procedure, 2 after) 3. Bicarbonate (JAMA 2004) Alkalinizing urine should reduce renal medullary damage D5W with 3 amps HCO3; bolus 3.5 mL/kg 1 hour preprocedure, then 1mL/kg/hour for 6 hours postprocedure 4. Possibly helpful? Fenoldopam, Dopamine 5. Not helpful! Diuretics, Mannitol