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40 Cards in this Set
- Front
- Back
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syndrome defined by a sudden loss of renal function over several hours to several days.
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ARF
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ARF definition
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syndrome defined by a sudden loss of renal function over several hours to several days.
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RPGN (Rapidly Progressive Glomerulonephritis) definition
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is a syndrome defined by the rapid loss of renal function over days to weeks due to acute glomerulonephritis
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is a syndrome defined by the rapid loss of renal function over days to weeks due to acute glomerulonephritis
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RPGN (Rapidly Progressive Glomerulonephritis)
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What constitutes the syndrome of ARF?
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Accumulation of nitrogenous waste products.
Increased Scr. Derangement of extracellular fluid balance. Acid-base disturbance. Electrolyte and mineral disorders. |
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What Constitutes Uremia? Symt:
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Renal failure
Lethargy Anorexia Dysgeusia Pericarditis Neuropathy Nausea and vomiting Pruritis Dyspnea |
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elevated blood urea nitrogen not from an intrinsic renal disease (not from kidney injury)
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Azotemia:
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Azotemia:
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elevated blood urea nitrogen not from an intrinsic renal disease
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Oliguria:
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urine output less than 500cc/24hr
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urine output less than 500cc/24hr
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Oliguria:
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urine output greater than 500cc/24hr
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Nonoliguria:
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Nonoliguria:
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urine output greater than 500cc/24hr
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urine output less than 50cc/24hr.
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Anuria:
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Anuria:
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urine output less than 50cc/24hr.
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Outpatients
Epidemiology |
cases/million/year
140-209 general population 17 adults < 50 yr 949 adults 80-89 yr |
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Inpatients
Epidemiology |
1% all admissions
2-5% all hospitalizations 4-15% post cardiopulmonary bypass ≤20% all ICU patients |
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Etiology of ARF among Outpatients MC and others
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prerenal 70% MC
Obstruction (17%) intrarenal (11%) idiopathic (2%) |
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Etiology of ARF among Inpatients MC and others
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ATN- intrarenal (45%) MC
Prerenal (21%) ARF on CKD (13%) Obstruction (10%) GN/vasc (4%) AIN (2%) Atheroemboli (1%) |
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Natural History of ARF- ICU pt's, inpt, etc
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48% ICU pts require dialysis
58% inpt mortality among patients who develop ARF in the ICU 36 % mortality among all inpts with ARF 20% of survivors received dialysis |
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% ICU pts require dialysis
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48%
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% inpt mortality among patients who develop ARF in the ICU
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58%
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% mortality among all inpts with ARF
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36%
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% of survivors received dialysis
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20%
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Mortality of ARF
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50%
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Predictors of Dialysis in ARF
Who gets dialysis with ARF? |
Oliguria:
<400cc/24hr 85% will require dialysis >400cc/24hr 30-40% will require dialysis Mechanical ventilation Acute myocardial infarction Arrhythmia Hypoalbuminemia ICU stay Multi-system organ failure |
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Factitious ARF
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-Interference with laboratory measurement of Scr (Jaffe Method)
Cefoxitin ketoacids -Competitive inhibition of creatinine secretion in the proximal tubule cimetidine trimethoprim -Increased production of creatinine fenofibrate |
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Prerenal ARF (decreased renal blood flow) result in:
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-Hypotension
Sepsis, cardiogenic, medication -Cardiogenic -Vascular Vasculitis, renal artery compromise, AAA, atheroemboli -Third Spacing Bowel obstruction, cirrhosis, nephrotic syndrome, major surgery, -Volume depletion GI losses: vomiting, diarrhea Skin losses:burns, sweat Renal losses: DKA, DI, Addison’s, Na wasting -Drug-induced NSAID, CsA, FK506, ACE, ARB |
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Tubular Toxins
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Antimicrobials: aminoglycosides, vancomycin, foscarnet, pentamidine, amphotericin B
Chemotherapeutics: cisplatin, mitomycin C, ifosfamide Immunotherapy: IVIG Complex Sugars: maltose, sucrose, mannitol Heavy metals Sepsis, hypoxia Radiocontrast agents |
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Stepwise Diagnostic Approach to Acute Renal Failure
Step 1 |
History
Record review Physical examination Volume status assessment Bladder evaluation Urinalysis |
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Stepwise Diagnostic Approach to Acute Renal Failure
Step 2 |
Urinary indices
Renal/urinary imaging Additional volume status measures Renal vascular status Blood and urine lab tests |
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Stepwise Diagnostic Approach to Acute Renal Failure
Step 3 |
Consider therapeutic trials
Volume challenge Foley placement Hemodynamic support |
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Stepwise Diagnostic Approach to Acute Renal Failure
Step 4 |
Consider renal biopsy
Consider empiric therapy |
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The Three Pivotal Bedside Tests
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Orthostatic Vital Signs
Fluid Challenge Foley Placement |
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Treatment of ARF
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Eliminate the toxic insult
Hemodynamic support Respiratory support Fluid management Electrolyte management Medication dose adjustment Dialysis |
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Treatment of Acute Renal Failure
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Eliminate toxic insult- medications(NSAIDS, aminoglycosides, ACR/, ARB, other antihypertensives in the face of hypotension)
Hemodynamic support- ICU monitoring with CVP if necessary Respiratory support- pulmonary toilet, respirator Fluid management- avoid over zealous fluid resuscitation Electrolyte management- watch K and Na levels especially in the oliguric patient Acid-Base- supplement with bicarb as needed for acidosis Medication dose adjustment- K supplements, antibiotics, lanoxin,and many medications require dose adjustment in renal failure Dialysis when needed |
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Prevention of ARF
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1. Diminish risk of nosocomial infection
conservative use of IV catheters judicious use of antibiotics hand-washing 2. Prevention of nephrotoxicity avoid/reduce nephrotoxins IV NS N-acetylcysteine, sodium bicarbonate correct hypokalemia, hypomagnesemia correct/treat other systemic diseases 3. Pharmacology avoid overlapping nephrotoxins follow drug levels closely 4. Attention to fluid status Regular weights, I & O |
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Best treatment for ARF is _____
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prevention
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Acute Renal Failure- Conclusions
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1. Best treatment is prevention
2. Use alternative imaging methods whenever possible 3. Adequate hydration remains the key 4. Clinical examination of the patient to assess volume status is of upmost importance |
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Clinical examination of the patient to ____ is of upmost importance
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assess volume status
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Urine sediment showing multiple muddy brown granular casts.
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Acute tubular necrosis
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