The Renal Patient

Cecilia RademeyerOctober 2003

Renal failure

Acute Renal failure

A deterioration in Renal function over hours or days resulting in the accumulation of toxins and loss of internal homeostasis

Chronic renal failure

(ESRF)The irreversible loss of renal function resulting in the accumulation of toxins and loss of internal homeostasis

Renal function

GFR = index of Renal fxARF = 50% GFR

Or 50% in Cr from baseline

Acute Renal failure

Pre-renalN tubular and Glom fxGFR due to RBF

RenalDisease of Glomerulus, interstitium or tubuleAss with release of renal vaso constriction

Post renalObstx tubular pressure GFR

Pre-renal

40-80%Precursor to Ischemic and nephrotoxic causes Intrinsic RF

HypovolemiaHypotension

Cardiac, sepsis, volume depletion

Renal (Intrinsic)

11-45% (more in children)Tubular – ATN (90%)

75% Ischemia25% Nephrotoxins

Interstitial – Acute interstitial nephritis

Glomerular – Acute GN

Vessels - Vasculitides

Post-renal

2-5%

- Renal calculi, prostate Ca

- Cervical Ca

- Congenital malformations Urethral valves Vesico-urethral reflux

Recovery

Depends onRestoration of the RBF asap

(restoration of circulating BV )

Clearance of toxinsRapid relief from Obstx

History in ED

Pre-renalThirst Urine outputDizziness and orthostatic hypotension+++ Vomiting, urination, bleeding and sweatingThird spacing ( burns and liver failure)

History

Renal Hematuria, oedema, Hpt (Nephrotic sndr)Recent throat, skin infectionsATN – hypotension 2nd to CVS arrest, bleeding, sepsis, drug ODMedications , radio contrast, rhabdo myolysisEvidence of multisystem disease -arthritis, rash, haemoptysis, nose bleeds

Post-renalUsually obvious

Physical exam

Volume status – VERY IMPORTANTHypotension, tachycardia, orthostatic hypotentionJVP, weight changeMucosae, skin turgor

SkinCVSEyes LungsCNS?Distended bladder

Special investigations

MSUUrea levelCreatinine

[140-age (yrs) X Wt(kg)] X 0.85 [Cr (mg/dl) X 72]

ECGElectrolytesCXRImagingRenal biopsy

Management

Fluid balance IDCStop Nephrotoxic drugsDiureticsRenal vasodilators

Dopamine 1-5g/kg/min

Dialysis – Hemodialysis

Call the renal team

Indications for dialysis

Unresponsive to medical TreatmentMetabolic acidosisSevere electrolyte Ureamic SxRefractory fluid overload Drugs

Chronic renal failure

Irreversible loss of fxUremia “contamination of blood with urine”

Clinical syndrome Universally fatal without renal replacement therapy

Uremia

CNSPNSCVSLungsImmuneBloodSkinbone

CAPD - Peritoneal dialysis

CAPD PeritonitisCatheter site infection

Staph and Pseudomonas

HerniasHigh risk incarceration

Signs and Symptoms

Cloudy dialysate 99%Abd pain 80-95%Rebound tenderness 60%Abd discomfort, N, V, D 7-36%Chills 12-23%Fever 33%Other 15%

Anorexia, malaise,Drainage problems, Increased catabolic rate

The Cloudy bag

The most constant findingUsually sudden onsetTurbidity may not be easily recognized

NB Patient education – hold up to a light, magazine

Not synonymous with infection

Differential cloudy bag

Infection WCC>100x106/l AND >50%PMN

Peritoneal eosinophilia syndromeNeutrophiliaBloodFibrin filamentsOther intra-abdominal path

Cholecystitis, pancreatitis, appendicitis, salpingitis, Ischemic gut etc

Bugs

Gram positivesS. Epidermides 30-40%S. Aureus 15-20%Streptococci 10-15%Other 2-5%

Gram NegativesPseudomonas 5-10%Enterobacter 5-20%Other 2-5%

Fungi (mainly Candida) 10-30%Other organisms 2-5%Culture Negative

What should we do??

Appropriate Micro work-upPF to lab for urgent gram stain, MSUBloods FBC, U&E’s, B.culturesSwabs from exit site

Start Abx ASAPProtocol Vancomycin only if known MRSA

Pt’s on IP ActrapidChange dose to SC - 1/2 IP Dose

CAPD peritonitis protocol

Therapy A (no prev MRSA)Cephazolin 1.5G IPCephradine 250 mg QID POGentamycin 0.6mg/kg Rounded nearest 10mg (Max 60mg)

Therapy B (known MRSA)Vancomycin 30mg/kg IP (to nearest 500mg, max 3g)Gentamycin 0.6mg.kg IP (to nearest 10mg, max 60mg)

Hemodialysis

Native fistulaBridge own a and v

Shunt care!!

Synthetic shuntPTFE

Complications

Stenosis and ThrombosisInfectionsBleedingAneurysmsVascular insufficiencyHigh output CVS failure

Blocked shunt

Grafts >> nativesNo Bruit/ThrillNot acute emergency

Natives vascular surgeonsGrafts radiology for thrombolysis with urokinase

Infection

Most common portal for infectionEsp PTFEEndocarditisSystemic illnessStaph Aureus or Gram Neg’sRx

Fluclox/Augmentin plus GentamycinVancomycin plus Gentamycin if MRSA

Bleeding

Can be severeDigital pressureCheck coags/plateletsTourniquetCall the vascular surgeonProtamine sulphate

Aneurism

Repeated punctureMostly Asx

Pain Nerve impingement sndrRarely rupture

Vascular insufficiency

Steal syndrome1%

Exercise painNon-healing ulcersCool, pulse less digits

Dx DopplerRx Surgery

Hemodialysis complications

HypotensionAir embolismLarge electrolyte shiftsFluid overload

Hemodialysis complications

Hypotension – 10-30%Excessive ultra filtrationUnderestimation of dry weightPre-dialysis volume deficiency

RxStop HD, TrendelenbergAsses volume statusN/S 100-200ml bolusLook for

CVS failurePericardial tamponadeInfectionGIB

Air embolism

PositionErectcerebral ICPSupine RV lungs

pulmonary hypertensionsystemic hypotension

Patent F.Ovale MI, CVA

Air embolism

Sx Acute SOB, chest tightnessBP, CVS ArrestLOC

Rx Clamp the venous bloodlineSupineTrendelenberg w L side down Hyperbaric chamberPercutaneus aspiration from RVIV steriods, full heparinsation

Fluid overload

Non-compliance with fluid restrictionfailure, or MIRx

OxygenECGTrop TDiuretics Dialysis – call renal teamIn extremis - venesection

In ED - History

Etiology ESRF and PMHxRecent complicationsMissed dialysis and whyBaselines – target weight, labs, vital SxUsual weight gain inter-dialysisDo they normally make target weightSx of uremiaNative kidney functionMany intra dialysis BP? (IHD, Peritamponade)

Examination

Vascular access - patency, infx

CVSJVP/ BPCHFPeritamponadeMurmers

CNSPR ?Melena

Hyperkalemia

This is an emergencyECG changes

Peaked T wavesWide QRSVT/VF

Check acid-base status

K+ >> 6 Rx

Stop drugs contributingCa Gluconate 10%

Over 5 minutes if ECG NRepeat 30-60m if required

50ml 50% dextrose +10U ActrapidSalbutamol neb 5-10mg rpt 20minTelemetryIV Sodabic if PH <7.25

Drugs causing K+

K+ supplementsACEIAngiotensin II inhibitors

Losarten, Candesarten

NSAIDSK sparing diuretics

Amiloride, Spironolactone

Drugs in kidney Dx

ModifyAminoglycosidesCephalosporinsCimetidine,RanitidineDigoxinProcainamideB-Blockers

AvoidTetracyclinesCo-trimoxazoleNitrofurantoinNalidixic acidK-sparing diuretics

Except low dose

NSAIDSMorphine

Pain relief in renal Pt’s

NO MORPHINEFentanyl as per protocolTramadol (up to 300mg/day)

Hyperglycemia100 units Actrapid:500mls 5% DextroseHourly capillary blood glucose

Capillary blood glucose

Insulin units/hr

ml/hr

<5 0 0

5-7.9 1 5

8-11 2 10

>11 3 15

Transplant patients

Immuno suppressedFeverDiscuss with the team asap.

The End

References

TintinalliRMO handbookNephrology secrets – Hrick,Miller,Sedor

Helen Pilmore – Renal consultant

Kushma Nand – Renal research fellow