Professional Documents
Culture Documents
Renal Failure in
Burn
Burn Unit
Ain Shams University
Faculty of Medicine
Renal Failure in Burn
Functions of the
Kidney
• Excretion (metabolic waste products: Urea, creatine).
• Regulation (pH of blood, electrolyte e.g. Na+ ,K+).
• Endocrinal functions.
– Erythropoietin.
– Renin.
– Vitamin D.
• Metabolic functions
– Degradation of peptides such as some hormones, in
fasting gluconeogenesis.
– Transformations of amino acids (glutamine to
NH4, synthesis of arginine and glycine).
Renal Failure in Burn
Renal Physiology
Gross structure of the kidney:
– Cortex.
– Medulla.
– Pyramids.
– Renal calyxes and pelvis.
– Ureter.
The nephron:
is the basic structural and functional unit.
1. Superficial nephrons (30%).
2. Midcortical nephrons (60%).
3. Juxtamedullary nephrons (10%).
functions: filtration, reabsorption, secretion.
Renal Failure in Burn
Renal Physiology
Renal Failure in Burn
Renal Physiology
Renal Physiology
Renal Physiology
The medullary loop of Henle
reabsorbs salts with little water
making the medullary
interstitium rich in solutes
(hyperosmolar) and delivers a
solute poor, dilute fluid to the
distal tubules. Thus the loop of
Henle initiates the processes of
urine concentration or dilution.
Renal Failure in Burn
Renal Physiology
Renal Physiology
Urine
reabsorption, and aldosterone
stimulated Na, K and H transport.
Renal Failure in Burn
Urine Formation =
Filtration +Secretion –
• Glomerular Filtration:Reabsorption
Filtering of
blood.
Urine Concentration
RBF = 1200ml/min
RPF = 660 ml/min = RBF x (1 – 0.HCT)
ERPF = 600 ml/min (Effective renal plasma flow)
Renal Failure in Burn
Glomerular Filtration
Rate
GFR = volume of plasma filtered every minute
= 20% ERPF = 125 ml/min
(i.e. entire plasma 3 L 180 L filtered per day)
Filtration depends on
– Size/ shape/ charge.
– No RBC/ WBC/ platelets.
– No proteins.
– Fluid composition otherwise identical in
glomerular capillary and proximal tubule.
– Blood pressure.
Renal Failure in Burn
Monitoring of Renal
Failure
• 24-hr urine volume, osmolarity and contents:
– Blood urea nitrogen.
– Serum creatinine.
– Creatinine clearance.
– Total urinary protein.
– Urinary microalbumin.
– Recent tests:
• 24-hr urinary nacetyl-d-glucosaminidase (NAG)
activity.
• Urinary malondialdehyde (MDA).
Renal Failure in Burn
Prognostic Factors
–The severity of the burns.
–The fluid resuscitation (quantity and quality).
–The criteria of renal failure such as:
•Urine volume (> 0.5 ml/min).
•Blood urea nitrogen (> 50 mg/dl).
•Serum creatinine level (> 2.0 mg/ dl).
•Proteinuria (quantity and quantity).
–The factors of age, burn surface area, day of onset
of ARF, and the duration of renal replacement
therapy are not significant.
Renal Failure in Burn
•Metabolic acidosis.
•Glomerulonephritis.
•Acute tubular necrosis.
•Medullary ischemia.
•Vasoconstriction.
•Tubular obstruction.
•Interstitial edema.
Renal Failure in Burn
Morphological
Changes
With an experience of post-mortem histopathology in burns,
there are two pattern of change in renal failure after burning:
(i) Distal tubular necrosis.
– Widespread distal tubular necrosis: (affecting
many nephrons, commonest in children and
young adults).
– Focal distal tubular necrosis: (affecting only
a few nephrons, was found in some patients,
mainly children).
(ii) Proximal tubular necrosis.
– Proximal tubular necrosis: was found mainly
in elderly cases who had nephrosclerosis.
Renal Failure in Burn
Prophylactic
Management
The initial resuscitation period (between 0 and 36 h),
characterized by ↓Na+ and ↑K+.
Prophylactic
Management
The early post-resuscitation period (between days and 6),
in which we consider ↑Na , ↓K , ↓Ca, ↓Mg and ↓Ph.
+ +
Fluid Resuscitation
It should be started within the first 24h post-
burn:
(1) Choice of resuscitation fluid
A. Crystalloid vs colloid (Demling's method).
B. Parkland vs Evans & Brooke formulae.
C. Hypertonic sodium solution (Monafo's method).
D. Modified Parkland formula.
(2) Resuscitation
A. Resuscitation in the first 24 hours.
B. Resuscitation in the second 24 hours.
(3) Monitoring resuscitation
A. Urine output (adult : 40-60 ml/h, child : 1 ml/kg body wt./h).
B. Pulmonary capillary wedge pressure.
C. Cardiac output.
D. Blood PH.
E. Systemic blood pressure.
Renal Failure in Burn
Management
Once the diagnosis of acute tubular necrosis
has been made, it is clearly indispensable to
begin immediately a therapy whose
foundations are:
– Clinical nutrition.
– Haemodialysis and Haemofiltration.
NB: No therapy to date has been shown to improve renal outcome and
diuretics may worsen pre-renal syndrome.
Renal Failure in Burn
Management) Clinical
nutrition(
• Infusion with glucose only may be associated with:
– The inhibition of lipogenesis.
– An increase in the oxydization of the glucose and of the glycogen
deposit.
– An increase of the catecholamines.
– Increased consumption of O2 and increased production of CO2.
• So, the use of glucose only is not advisable in the presence of
respiratory failure and in the case of patients in mechanical
ventilation.
• On the other hand, the combined glucose-lipids system has many
advantages:
– Less metabolic overload compared to the infusion of a single
substratum.
– The supply of the essential fatty acids,
– The diminished frequency of hyperglycaemia and hepatic
steatosis.
– A reduced production of CO2 and consumption of O2.
Management) Renal Failure in Burn
Haemodialysis(
Continuous Renal Replacement Therapy
(CRRT)
• The basic principle of action of CRRT is the elimination of
inflammatory mediators, urea, creatinine and uraemic toxins
with the maintenance of water and electrolytes balance.
• It depends on four physical principles: ultrafiltration,
convection, diffusion and adsorption.
• CRRT has the capacity to eliminate inflammatory mediators,
depending on the type of filter used, up to 30,000-50,000
Daltons (D).
Mediator Molecular weight (D)
Thromboxane A2 352
PAF 524
Leukotriens 600
Complement 3a 10000
Complement 5a 11200
Interleukin 1, 2 15000
Tumor necrosis factor
17000
alpha
Interleukin 6 25000
Endotoxin 100,000
Renal Failure in Burn
Management
• Types of haemofiltration:
– Pump-driven Haemofiltration system.
– Continuous Arterio-Venous
Haemofiltration (CAVH) system.
• The advantage of a Pump-driven Haemofiltration
system over a Continuous Arterio-Venous
Haemofiltration (CAVH) system, was related to
the faster elimination of toxic mediators with a
molecular weight of 800-1000 Daltons by high-
volume haemofiltration.
Renal Failure in Burn
Management
• Indications of haemodialysis or haemofiltration:
A. Renal:
• Oliguric renal failure.
• Massive myoglobulinuria (in electric burns).
B. Non-renal:
• SIRS to eliminate inflammatory mediators.
• Sepsis, septic shock.
• Refractory hyperpyrexia.
• Correction of electrolyte imbalance.
• Congestive heart failure not responding to diuretics.
• ARDS (adult respiratory distress syndrome).
• Some intoxications.
• Prevention of the tumour-lysis syndrome.
Renal Failure in Burn
Management
• Disadvantages and complications of CRRT
– Long-term interactions between blood and the
membrane with possible manifestations of material
incompatibility.
– Removal of substrate by filtration (glucose, amino
acids).
– Risk of haemorrhage during long-term anticoagulation.
– Loss of heat due to extracorporeal system.
– Complications associated with insertion of central
venous catheter.
– High price of materials.
– Some authors have doubts about the elimination of
mediators.
• Antioxidants???
Renal Failure in Burn
Conclusion
• Acute renal failure rarely occurs in cases where
adequate resuscitation is applied.
• In sever burns, a persistent renal tubular damage and
inflammation in spite of recovery of general renal
function after a transient acute renal dysfunction
usually occurs.
• An early intensive care of burn-induced renal damage
is necessary in order to prevent renal complications as
well as to lower the mortality in patients with major
burns.
Renal Failure in Burn
Thank You