بسم الله الرحمن الرحيم 1 2 acute versus chronic renal failure manal elshamaa, md...
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الرحمن الله بسمالرحيم
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Acute Versus Chronic Renal Failure
Manal Elshamaa , MD of pediatrics
National Research Centre
Acute Versus Chronic Renal Failure
Manal Elshamaa , MD of pediatrics
National Research Centre
Anatomy
2 Kidneys2 UretersBladderUrethra
Kidney Function
Detoxify bloodIncrease calcium absorption
– calcitriolStimulate RBC production
– erythropoietinRegulate blood pressure and electrolyte
balance – renin
Classifications
Acute versus chronicPre-renal, renal, post-renalAnuric, oliguric, polyuric
Acute Versus Chronic
Acute – sudden onset– rapid reduction in urine output– Usually reversible– Tubular cell death and regeneration
Chronic – Progressive– Not reversible– Nephron loss
75% of function can be lost before its noticeable
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Acute Renal Failure
Definition
Renal function is diminished to the point where body fluid hemostasis can no longer be maintained.
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Prerenal Causes The most common cause of acute renal failure. Hypovolemia Hemorrhage Gastroenteritis Hypoproteinemia Burns Renal or adrenal disease with salt wasting Hypotension Septicemia DIC Hypothermia Congestive heart failure Hypoxia RDS and pneumonia Aortic calmping
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Prerenal Azotemia In severe cases hypovolemic
shock. Oliguria is present in most individuals.
Normal or increased urine output indicates either
Aminogycoside or ATNnephrotoxicity
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Prerenal ARF of Newborns and Infants Causes Peri-natal hemorrhage - Twin-twin
transfusion, complications of amniocentesis, birth trauma
Neonatal hemorrhage - Severe intra-ventricular hemorrhage, adrenal hemorrhage.
Perinatal asphyxia and hyaline membrane disease.
Other causes as NIC &renal vein thrombosis
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Prerenal ARF of Children The most common cause of ARF Prerenal ARF: The most common cause of hypovolemia in
children is gastroenteritis.Congenital and acquired heart diseases
are important causes of ARF in this age group.
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Intrinsic Renal Failure GlomerulonephritisLocalized intravascular coagulation
Acute tubular necrosisAcute interstitial nephritisTumorsDevelopmental abnormalitiesHereditary
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Intrinsic Renal Failure Glomerular diseases: The most
common causes in older children
Nephritic syndrome of hematuria and edema is synonymous with a glomerular etiology of ARF.
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Intrinsic Renal Failure *Localized intravascular coagulation
Acute dehydration HUS
The most common causes of ARF in toddlers
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Acute Tubular Necrosis
Tubular diseases: Acute tubular necrosis(Absence of arterial or glomerular lesions).
There are major histologic changes that take place in ATN:
(1) tubular necrosis with sloughing of the epithelial cells
(2) occlusion of the tubular lumina by casts and by cellular debris
(3)Back leak of filtrate
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Major Causes of Acute Tubular Necrosis
Renal Ischemia:
* Severe pre-renal disease from any cause. Exposure to Nephrotoxins: * Amphotericin B • Aminoglycosides * Heme Pigments * NSAID's
(hemoglobinuria/myoglobinura) • Require a period of dialysis before spontaneous resolution
occurs.
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Intrinsic Renal Failure Interstitial diseases * Acute interstitial nephritis, drug reactions * infiltrative disease (lymphoma) * infectious agents.
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Intrinsic ARF of Children
Hemolytic uremic syndrome (HUS) is the most common cause of ARF in children.
The disease is associated with a diarrheal prodrome caused by Escherichia coli
Children usually present with microangiopathic anemia, thrombocytopenia, colitis, mental status changes, and renal failure.
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Post-renal ARF
Obstructive uropathy
Uretropelvic junction
Uretrocele
Urethral valves
Tumors
Vesicouretral reflux
Acquired Stones
Blood clots
Symptoms of ARF
Decrease urine output (70%) Edema, esp. lower extremity Mental changes Heart failure Nausea, vomiting Pruritus Anemia Tachypenic Cool, pale, moist skin
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Diagnostic Evaluation:
Urinalysis shows proteinuria, hematuria, casts.
Serum creatinine and BUN levels are elevated; arterial blood gas levels, serum electrolytes may be abnormal.
Renal untrasonography rules out treatable obstructive uropathy.
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Laboratory Findings in the Differential
Diagnosis of Acute Renal Failure:
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FeNa
Calculation of fractional excretion of sodium (FeNa)
FeNa = (urine Na/plasma Na)/(urine creatinine/plasma creatinine)
FeNa <1 % = prerenal ARF FeNa >1% = ATN
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Therapeutic and Pharmacologic Interventions:
Surgical relief of obstruction .Correction and control of biochemical imbalances.Restoration and maintenance of blood pressure Low protein diet with supplemental amino acids
and vitamins.Initiation of dialysis, or continuous renal
replacement therapy for patients with progressive azotemia .
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Continuous Hemofiltration (HF)It is useful in patients with ARF.
Continuous AVHF Continuous VV HF
Blood is pumped By a pump
through fillter
by patient heart
ARF: Life Threatening Conditions
HyperkalemiaVolume overloadVascular access
Hyperkalemia Symptoms
WeaknessLethargyMuscle crampsParesthesiasDysrhythmias
Hyperkalemia & EKG K > 5.5 -6 Tall, peaked T’s Wide QRS Prolong PR Diminished P Prolonged QT
Hyperkalemia Treatment
KayexalateCalcium gluconate (carbonate)Sodium BicarbonateInsulin/glucoseLasix AlbuterolHemodialysis
Chronic Renal Failure
150–200 cases per million people = new cases each year
Chronic renal failure and ESRD affect more than 2 out of 1,000 people in the U.S
Mortality = 20%
Chronic Renal Failure Causes
Glomerular diseases 40% (after 5 yrs old)Anatomic abnormalities 20% (under 5 yrs
old)Hereditary renal diseases 15% (after 5 yrs
old)Pylonephritis with reflux nephropathy 15%Miscellaneous10%: Vascular, HUS, JDM,
wilms tumor.
CRF Symptoms
Growth failureWeaknessFatigueNeuropathyCHFAnorexiaNauseaVomiting
SeizureConstipationPeptic ulcerationDiverticulosisAnemiaPruritusJaundiceAbnormal hemostasis
Problems Related to ESRD
Metabolic – K/CaVolume overloadAnemia, platelet disorder, GI bleed PericarditisPeripheral neuropathy, dialysis dementiaAbnormal immune function
Dialysis
½ of patients with CRF eventually require dialysis
Diffuse harmful waste out of bodyControl BPKeep safe level of chemicals in body2 types
– Hemodialysis– Peritoneal dialysis
Hemodialysis
3-4 times a weekTakes 2-4 hours Machine filters
blood and
returns it to
body
Types of Access
Temporary site AV fistula
– Surgeon constructs by combining an artery and a vein– 3 to 6 months to mature
AV graft– Man-made tube inserted by a surgeon to connect artery
and vein– 2 to 6 weeks to mature
Temporary Catheter
AV Fistula & Graft
What This Means For You
No BP on same arm as fistulaProtect arm from injuryControl obvious hemorrhage
– Bleeding will be arterial– Maintain direct pressure
No IV on same arm as fistulaA thrill will be felt – this is normal
Access Problems
AV graft thrombosis AV fistula or graft bleedingAV graft infectionSteal Phenomenon
– Early post-op– Ischemic distally– Apply small amount of pressure to reverse
symptoms
Peritoneal Dialysis
Abdominal lining filters blood3 types
– Continuous ambulatory– Continuous cyclical– Intermittent
Dialysis Related Problems
Lightheaded –give fluidsHypotensionDysrhythmiasDisequilibration Syndrome
– At end of early sessions– Confusion, tremor, seizure– Due to decrease concentration of blood versus
brain leading to cerebral edema
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Thank you