Transcript The Renal Patient

The Renal Patient
Cecilia Rademeyer
October 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 fx
ARF = 50%  GFR
Or 50%  in Cr from baseline
Acute Renal failure
Pre-renal
N tubular and Glom fx
GFR  due to RBF
Renal
Disease of Glomerulus, interstitium or tubule
Ass with release of renal vaso constriction
Post renal
Obstx  tubular pressure  GFR
Pre-renal
40-80%
Precursor to Ischemic and
nephrotoxic causes Intrinsic RF
Hypovolemia
Hypotension
Cardiac, sepsis, volume depletion
Renal (Intrinsic)
11-45% (more in children)
Tubular – ATN (90%)
75% Ischemia
25% 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 on
Restoration of the RBF asap
(restoration of circulating BV )
Clearance of toxins
Rapid relief from Obstx
History in ED
Pre-renal
Thirst
 Urine output
Dizziness and orthostatic hypotension
+++ Vomiting, urination, bleeding and
sweating
Third spacing ( burns and liver failure)
History
Renal
Hematuria, oedema, Hpt (Nephrotic sndr)
Recent throat, skin infections
ATN – hypotension 2nd to CVS arrest, bleeding,
sepsis, drug OD
Medications , radio contrast, rhabdo myolysis
Evidence of multisystem disease -arthritis,
rash, haemoptysis, nose bleeds
Post-renal
Usually obvious
Physical exam
Volume status – VERY IMPORTANT
Hypotension, tachycardia, orthostatic hypotention
JVP, weight change
Mucosae, skin turgor
Skin
CVS
Eyes
Lungs
CNS
?Distended bladder
Special investigations
MSU
Urea level
Creatinine
[140-age (yrs) X Wt(kg)] X 0.85
[Cr (mg/dl) X 72]
ECG
Electrolytes
CXR
Imaging
Renal biopsy
Management
Fluid balance
IDC
Stop Nephrotoxic drugs
Diuretics
Renal vasodilators
Dopamine 1-5g/kg/min
Dialysis –
Hemodialysis
Call the renal team
Indications for dialysis
Unresponsive to medical Treatment
Metabolic acidosis
Severe electrolyte 
Ureamic Sx
Refractory fluid overload
Drugs
Chronic renal failure
Irreversible loss of fx
Uremia “contamination of blood with urine”
Clinical syndrome
Universally fatal without renal replacement therapy
Uremia
CNS
PNS
CVS
Lungs
Immune
Blood
Skin
bone
CAPD - Peritoneal dialysis
CAPD Peritonitis
Catheter site infection
Staph and Pseudomonas
Hernias
High risk incarceration
Signs and Symptoms
Cloudy dialysate
Abd pain
Rebound tenderness
Abd discomfort, N, V, D
Chills
Fever
Other
99%
80-95%
60%
7-36%
12-23%
33%
15%
Anorexia, malaise,
Drainage problems, Increased catabolic rate
The Cloudy bag
The most constant finding
Usually sudden onset
Turbidity 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 syndrome
Neutrophilia
Blood
Fibrin filaments
Other intra-abdominal path
Cholecystitis, pancreatitis, appendicitis, salpingitis,
Ischemic gut etc
Bugs
Gram positives
S. Epidermides
S. Aureus
Streptococci
Other
Gram Negatives
Pseudomonas
Enterobacter
Other
Fungi (mainly Candida)
Other organisms
Culture Negative
30-40%
15-20%
10-15%
2-5%
5-10%
5-20%
2-5%
10-30%
2-5%
What should we do??
Appropriate Micro work-up
PF to lab for urgent gram stain, MSU
Bloods FBC, U&E’s, B.cultures
Swabs from exit site
Start Abx ASAP
Protocol
Vancomycin only if known MRSA
Pt’s on IP Actrapid
Change dose to SC - 1/2 IP Dose
CAPD peritonitis protocol
Therapy A (no prev MRSA)
Cephazolin
Cephradine
Gentamycin
10mg
1.5G IP
250 mg QID PO
0.6mg/kg Rounded nearest
(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 fistula
Bridge own a and v
Shunt care!!
Synthetic shunt
PTFE
Complications
Stenosis and Thrombosis
Infections
Bleeding
Aneurysms
Vascular insufficiency
High output CVS failure
Blocked shunt
Grafts >> natives
No Bruit/Thrill
Not acute emergency
Natives vascular surgeons
Grafts  radiology for thrombolysis
with urokinase
Infection
Most common portal for infection
Esp PTFE
Endocarditis
Systemic illness
Staph Aureus or Gram Neg’s
Rx
Fluclox/Augmentin plus Gentamycin
Vancomycin plus Gentamycin if MRSA
Bleeding
Can be severe
Digital pressure
Check coags/platelets
Tourniquet
Call the vascular surgeon
Protamine sulphate
Aneurism
Repeated puncture
Mostly Asx
Pain
Nerve impingement sndr
Rarely rupture
Vascular insufficiency
Steal syndrome
1%
Exercise pain
Non-healing ulcers
Cool, pulse less digits
Dx Doppler
Rx Surgery
Hemodialysis complications
Hypotension
Air embolism
Large electrolyte shifts
Fluid overload
Hemodialysis complications
Hypotension – 10-30%
Rx
Excessive ultra filtration
Underestimation of dry weight
Pre-dialysis volume deficiency
Stop HD, Trendelenberg
Asses volume status
N/S 100-200ml bolus
Look for
CVS failure
Pericardial tamponade
Infection
GIB
Air embolism
Position
Erectcerebral  ICP
Supine  RV lungs 
pulmonary hypertension
systemic hypotension
Patent F.Ovale  MI, CVA
Air embolism
Sx
Rx
Acute SOB, chest tightness
BP, CVS Arrest
LOC
Clamp the venous bloodline
Supine
Trendelenberg w L side down
Hyperbaric chamber
Percutaneus aspiration from RV
IV steriods, full heparinsation
Fluid overload
Non-compliance with fluid restriction
failure, or MI
Rx
Oxygen
ECG
Trop T
Diuretics
Dialysis – call renal team
In extremis - venesection
In ED - History
Etiology ESRF and PMHx
Recent complications
Missed dialysis and why
Baselines – target weight, labs, vital Sx
Usual weight gain inter-dialysis
Do they normally make target weight
Sx of uremia
Native kidney function
Many intra dialysis BP? (IHD, Peritamponade)
Examination
Vascular access CVS
JVP/ BP
CHF
Peritamponade
Murmers
CNS
PR ?Melena
patency, infx
Hyperkalemia
This is an emergency
ECG changes
Peaked T waves
Wide QRS
VT/VF
Check acid-base status
K+ >> 6 Rx
Stop drugs contributing
Ca Gluconate 10%
Over 5 minutes if ECG N
Repeat 30-60m if required
50ml 50% dextrose +10U Actrapid
Salbutamol neb 5-10mg rpt 20min
Telemetry
IV Sodabic if PH <7.25
Drugs causing  K+
K+ supplements
ACEI
Angiotensin II inhibitors
Losarten, Candesarten
NSAIDS
K sparing diuretics
Amiloride, Spironolactone
Drugs in kidney Dx
Modify
Aminoglycosides
Cephalosporins
Cimetidine,Ranitidine
Digoxin
Procainamide
B-Blockers
Avoid
Tetracyclines
Co-trimoxazole
Nitrofurantoin
Nalidixic acid
K-sparing diuretics
Except low dose
NSAIDS
Morphine
Pain relief in renal Pt’s
NO MORPHINE
Fentanyl as per protocol
Tramadol (up to 300mg/day)
Hyperglycemia
100 units Actrapid:500mls 5% Dextrose
Hourly capillary blood glucose
Capillary
blood
glucose
<5
Insulin
units/hr
ml/hr
0
0
5-7.9
1
5
8-11
2
10
>11
3
15
Transplant patients
Immuno suppressed
Fever
Discuss with the team asap.
The End
References
Tintinalli
RMO handbook
Nephrology secrets – Hrick,Miller,Sedor
Helen Pilmore – Renal consultant
Kushma Nand – Renal research fellow