RenalFailure

AcuteRenalFailure b) Intrinsicfever,edema,changeinweight,syncope,AMS,
Definition:Suddendecreaseinkidneyfunction,resultinginaninability seizures
tomaintainacidbase,fluidandelectrolytebalancesand i) TeacoloredurinefromATN(rhabdo)
excretion/accumulationofnitrogenouswastes ii) **AINTRIAD:fever,maculopapularrash,eosinophils
c) Postrenaldistendedbladder,CVAtenderness,enlarged
1) Epidemiology prostate,oliguria
a) 5%hospitaladmissions 5) SymptomsofARFingeneralcouldbeasx
b) ARFdevelopsin25%ofhospitalizedpts a) Confusion,asterixis
c) Riskfactors b) Nonspecific,diffuseabdominalpain
i) Age c) N/V/D
ii) Familyhistory d) Anorexia
iii) HTN e) Fatigue
iv) DM f) Oliguria/anuria
v) Obesity g) Possibleseizures
vi) Dyslipidemia h) Weakness,pain,edemainmusclesifrhabdo
vii) Smoking i) Fever,rash,arthralgia,oliguriaifAIN
2) Etiology j) Nocturia,hesitancy,frequencyifBPH
a) Prerenalm/ccauseofrenalfailure 6) Diagnosis
i) Causes:decreasedcirculatingvolume,lowCO,altered a) Labs
systemicresistance i) CBCanemia
b)
Intrinsicrenal ii) CMP
i) Acutetubularnephritis(ATN) (1) ElevatedBUN(>20mg/dL)
(1) Exogenoustoxins(m/c): (2) Elevatedcreatinine(>1.2mg/dL)
(a) Aminoglycosides,vancomycin,cyclosporine, (3) BUN/Crratio
contrastdye,chemo (a) Prerenalandpostrenal(initially)>20:1
(2) Endogenoustoxins: (b) Intrinsicandpostrenal(late)<20:1
(4) Hyperkalemiawithaniongap(metacidosis)
(a) Myoglobinuria(rhabdo),hyperuricemia(TLS)
(5) Hyperphosphatemia
(3) Ischemic
(6) Hypocalcemia
(a) Uncorrectedprerenalstate,prolonged
b) EKG
hypotension,vasoconstriction
i) PeakedTwaves
ii) Acuteinterstitialnephritis(AIN)
ii) PRprolongation
(1) Drugsm/cPCN,sulfa,Bactrim iii) QRSwidening
(2) Infections,autoimmune,idiopathic iv) LongQT
iii) Glomerulonephritis(GN) c) UA
(1) GABHS,Goodpastures,Wegners i) Prerenal
c) Postrenal (1) FENa<1%,elevatedspecificgravity
i) Urinaryoutflowobstruction ii)
Intrinsicrenal
(1) Urolithiasis,BPH,neurogenicbladder,foley (1) FENa>1%
ii) Anticholinergics
(2) ATNmuddybrowngranularcasts
3) Pathophysiology
(3) AINwhitecellcasts,eosinophils
a) Prerenal:lowerGFRbutNOparenchymaldamage
iii)
Postrenal
i) DecreasedrenalperfusionSNSandRAASsystem
(1) US,renalbladderscan,CT/MRItodx
activatedreleasingNEandangiotensinII
7) Treatment
aldosteronestimulationvasoconstrictionNaand
a) Correctunderlyingcause
H2Oresorption
b) Assessvolumestatus
ii) LowbloodvolumeADHreleaseincreasedtubular
c) MonitorelectrolytesespeciallyK
H2Oreabsorption
d) Prerenal
b) Intrinsic:renalparenchymaldamageduetoischemia,
i) Treatthecausemaintain:
decreasedperfusionandinflammation
(1) CirculatingvolumeIVNSS
i) ATN:decreasedrenalperfusionandsevereHOTNand
(2) LowCOinotrope,pericardiocentesis,
hypoxemiatubularischemia
(3) Dec.SVRvasoconstrictor
ii) AIN:interstitialinflammatoryresponsew/edemaand
(4) SerumK+(3.55mmol/L)
possibletubularcelldamage
e) Intrinsicsameasaboveplus
(1) Infiltrationoftubulointerstitiumbyeosinophilsand
i) Stopoffendingdrug
macrophages
ii) Convertoliguriatononoliguria
c)
Postrenal
(1) ThiazidediureticifGFR30:
i) 1orbothkidneysareobstructed
(a) Hydrochlorothiazide25100mg/dPO
ii) compensatedbyincreasedrenalbloodflowbut
(2) LoopdiureticifGFR<30
constrictioncausesdecreasedGFR
(a) Furosemide20320mg/dPO
4) Signsmayreflectunderlyingcause
iii) AIN:
a) PrerenalHOTNandtachycardia
(1) Corticosteroids
(a) Methylprednisolone0.51g/dayIVx14days
 (b) Prednisone60mg/dayPOx12weeks 5) Symptoms
iv) WithHTNorDMuseanACEI a) Remainasymptomaticuntilstages34
(1) Lisinopril1040mgPOQD b) Generalfatigue,weakness,malaise,HA
v) RestrictdietaryNa,K,andprotein c) Skinpruritus;easybruising
vi) DialysisifserumCr>10mg/dL d) PulmSOB
f) Postrenal e) CardioDOE,pleuriticCP
i) Reliefofobstructionwithcatheters,stents f) GIN/V,metallictaste,hiccups
(1) Watchforpostobstructivediuresis g) Neuroirritability,difficultyconcentrating,insomnia,subtle
memorydefects,restlesslegs,twitching
6) Diagnosis
8) Complications a) GFRdecreased<60x>3mos
(a) Lifethreateningelectrolytedisturbances(hyperkalemia) b) IncreasedBUNandSCr
(b) Volumeoverloadnotresponsivetodiuresis c) CBCanemia(normocytic,normochromic)
(c) Worseningacidosis d) CMP
(d) Encephalopathy i) Hypocapnia(lowbicarb)
(e) Pericarditis e) Electrolytes
(f) Seizures i) Hypocalcemia
(g) Death ii) Hyperphosphatemia
iii) Hypermagnesemia
ChronicRenalFailure f) IncreasedINR,PTH,serumuricacid
g) Urinalysis
Definition:theprogressivelossofkidneyfunction,asdefinedbyGFR, i) Specificgravitymaybedecreased
leadingtotheinabilityofkidneystoproperlyexcretemetabolicproducts ii) Proteinuria
andregulateacid/baseandelectrolytebalance.Thereare5stages: iii) RBCcasts
- Stage1normalorGFR90mL/min iv) Urinarysediment,broadwaxycasts
- Stage2diminishedrenalreserveGFR6089mL/min h) EKGpeakedTwaveswithhyperkalemia
- Stage3renalinsufficiencyGFR3059mL/min i) KidneyUSsmall,atrophickidneys!Dx!
- Stage4severeinsufficiencyGFR1529mL/min 7) Treatment
- Stage5kidneyfailureGFR<15mL/min a) Treatreversiblecausesandcomorbidities
b) NonPharmacological
1) Epidemiology i) Renaldietjustenoughproteintopreventmalnutrition
a) About20millionAmericans ii) lowphosphateandlowsodiumdiet
b) 6%ofUSpopulationhasstage1or2 c) Pharmacological
c) 4.5%ofUSpopulationhasstage3or4 i) Stage1
d) MostcommonlyseeninDMandHTN(>40,obese, (1) ControlHTN<130/80w/ACEI
minorities) (a) Lisinopril1040mgPOQD
2) Etiology (2) Controlglucose:A1c<7%
a) About70%ofcasesduetoDMandHTN ii) Stage2estimateprogression
i) #1causeisDM iii) Stage4txcomplications
b) APOL1geneassociatedw/increasedriskinAA (1) AnemiaEPOtomaintainHgb<11
c) Alsoprogressionofuntreated: (a) Epogen50100units/kgSCorIV3x/wk
i) Acuterenalfailure iv) Stage5dialysis
ii) Polycystickidneydisease d) Hemodialysisorperitonealdialysis
iii) Collagenvasculardisease i) Indications
iv) Obstruction (1) Diabetics
3) Pathophysiology (a) GFR15ml/min
a) Initialinrenalmasshypertrophyoftheremaining (b) Creatinine6mg/dL
nephronsw/hyperfiltration (2) NonDM
b) Increasedburdenontheremainingnephronsglomerular (a) GFR10ml/min
sclerosisandinterstitialfibrosis (b) Creatinine8mg/dL
c) inGFRaccumulationofnitrogenouswastes (3) A=acidosis
d) GFR<15mL/minelectrolyteandacidbaseregulationis (4) E=electrolytes(hyperkalemia)
deranged (5) I=ingestion(ASA,methanol)
4) Signs (6) O=volumeoverload
a) Ptappearscachecticwt.loss,musclewasting (7) U=uremiacausingendorgandamage(pericarditis,
b) Skinpallororyelloww/ecchymosis encephalopathy
c) Pulmrales,Kussmaulsrespirations e) TransplantationifESRD
d) CardioHTN,pericardialfrictionrub 8) Complications
e) GUnocturia,impotence a) ESRD,death
f) Neuroperipheralneuropathy,alteredmentalstatus, b) HTN
myoclonus,asterixis,seizures,coma,decreasedvibratory c) Arrhythmia
sensation d) CHF
g) Uremicfetorfishbreath e) Anemia
h) PVSperipheraledema f) Uremicsyndromeencephalopathy,pericarditis