14 ri acute nonoliguric renal failure

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Acute nonoliguric re Acute nonoliguric re nal failure nal failure Ri Ri 黃黃黃 黃黃黃 2003/10/27 2003/10/27

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Page 1: 14 Ri   Acute Nonoliguric Renal Failure

Acute nonoliguric renal failuAcute nonoliguric renal failurere

Ri Ri 黃正憲黃正憲2003/10/272003/10/27

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Acute Renal FailureAcute Renal Failure Definitions:Definitions:

An increase in the An increase in the serum creatinine of serum creatinine of 0.5 0.5 mg/dl over baseline valuemg/dl over baseline value

An increase in the serum creatinine of more than An increase in the serum creatinine of more than 50% over base line value50% over base line value

A reduction in the calculated creatinine clearance A reduction in the calculated creatinine clearance of 50%of 50%

A decrease in the renal function that results in A decrease in the renal function that results in the need for dialysisthe need for dialysis

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Category Category

1. urine output1. urine outputAnuric: <100 mL/dAnuric: <100 mL/dOliguric: 100-500 mL/dOliguric: 100-500 mL/dNonoliguric: >500 mL/d

2. the more common 2. the more common Pre-renalPre-renal IntrinsicIntrinsicPost-renalPost-renal

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Acute Renal FailureAcute Renal Failure

Pre Renal CausesPre Renal Causes - Intravascular volume depletion from vomiting - Intravascular volume depletion from vomiting

diarrhea, diarrhea, poor fluid intake, fever, use of diureticspoor fluid intake, fever, use of diuretics - Decreased glomerular perfusion in the setting of - Decreased glomerular perfusion in the setting of renal artery atherosclerotic disease with decreased renal artery atherosclerotic disease with decreased systolic head of BP, use of ACE inhibitors or NSAIDSsystolic head of BP, use of ACE inhibitors or NSAIDS - Decreased effective arterial blood volume in CHF, - Decreased effective arterial blood volume in CHF,

liver dysfunction, septic shock, anesthesialiver dysfunction, septic shock, anesthesia

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Acute Renal FailureAcute Renal Failure

Pre Renal CausesPre Renal Causes

Post Renal CausesPost Renal Causes - External compression to the outflow tract from tumors, - External compression to the outflow tract from tumors,

increased intra abdominal pressure, retroperitoneal fibrosisincreased intra abdominal pressure, retroperitoneal fibrosis

- Intrinsic blockage from tumor, calculi, blood clots, - Intrinsic blockage from tumor, calculi, blood clots,

papillary necrosispapillary necrosis

- Intratubular obstruction from crystals and myeloma chains- Intratubular obstruction from crystals and myeloma chains

- Blocked Foley catheter- Blocked Foley catheter

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Acute Renal FailureAcute Renal Failure

Pre Renal CausesPre Renal Causes

Post Renal CausesPost Renal Causes

Intrinsic causesIntrinsic causes

Tubulo- Glomerular VascularTubulo- Glomerular Vascular InterstitialInterstitial

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Acute Renal FailureAcute Renal Failure

Pre Renal CausesPre Renal Causes

Post Renal CausesPost Renal Causes

Intrinsic causesIntrinsic causes

Tubular Interstitial AcuteTubular Interstitial Acute necrosis nephritis necrosis nephritis glomerulonephritisglomerulonephritis (10% of cases) (5% of cases)(10% of cases) (5% of cases)

Ischemia ToxinsIschemia Toxins(50% of cases) (35% of cases)(50% of cases) (35% of cases)

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Ischemic Acute Renal FailureIschemic Acute Renal Failure Intravascular volume depletion and hypotension Gastrointestinal, renal, dermal losses, hemorrhage, shock

Generalized or localized reduction in renal blood flow

IschemicIschemic Acute Renal FailureAcute Renal Failure

Decreased effective intravascular volume: CHF, cirrhosis, nephrosis, peritonitis

Medications: ACE inhibitors, NSAIDS, radiocontrast agents, Ampho B, Cyclosporin

Hepatorenal syndrome

Large vessel renal vascular disease: Renal artery thrombosis or embolism, operative arterial cross clamping, renal artery stenosis

Small vessel renal vascular disease:Atheroembolism, vasculitis, malignant hypertension, hypercalcemia, transplant rejection

SepsisSepsis

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Toxin induced Acute Renal FailureToxin induced Acute Renal Failure

Reduction in renal perfusion thrReduction in renal perfusion through alteration of intra renal heough alteration of intra renal hemodynamicsmodynamics

Direct tubular injuryDirect tubular injury

Heme pigment induced ARFHeme pigment induced ARF

Intratubular obstructionIntratubular obstruction

Allergic Interstitial NephritisAllergic Interstitial Nephritis

Hemolytic Uremic SyndromeHemolytic Uremic Syndrome

NSAIDs, ACE inhibitors, CyclosporiNSAIDs, ACE inhibitors, Cyclosporin, Tacrolimus, IV contrast, Ampho Bn, Tacrolimus, IV contrast, Ampho B

Aminoglycosides, IV contrast, CycloAminoglycosides, IV contrast, Cyclosporin, Cisplatin, Ampho B, Heavy sporin, Cisplatin, Ampho B, Heavy metals, IV immunoglobulinsmetals, IV immunoglobulins

Rhabdomyolysis, Hemolysis, CocaiRhabdomyolysis, Hemolysis, Cocaine, Ethanol, Statinsne, Ethanol, Statins

Acyclovir, Sulfonamides, Ethylene glAcyclovir, Sulfonamides, Ethylene glycol, myoglobinycol, myoglobin

Penicillins, Cephalosporins, SulfonaPenicillins, Cephalosporins, Sulfonamides, Rifampin, Cipro, NSAIDs, Thimides, Rifampin, Cipro, NSAIDs, Thiazides, Cimetidine, Allopurinolazides, Cimetidine, Allopurinol

Cyclosporin, Cocaine, Mitomycin, QCyclosporin, Cocaine, Mitomycin, Quinineuinine

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Categories of anuria, oliguria, and nonoliguria Categories of anuria, oliguria, and nonoliguria may may bebe useful in differential diagnosis of ARF. useful in differential diagnosis of ARF.

AnuriaAnuria - Urinary tract obstruction, renal artery ob - Urinary tract obstruction, renal artery obstruction, RPGN, bilateral diffuse renal cortical nstruction, RPGN, bilateral diffuse renal cortical necrosisecrosis

OliguriaOliguria - Prerenal failure, hepatorenal syndrome - Prerenal failure, hepatorenal syndrome Nonoliguria Nonoliguria – AIN, AGN, partial obstructive neph– AIN, AGN, partial obstructive neph

ropathy, nephrotoxic and ischemic ATN, radiocoropathy, nephrotoxic and ischemic ATN, radiocontrast-induced ARF, and rhabdomyolysisntrast-induced ARF, and rhabdomyolysis

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Nonoliguric ARFNonoliguric ARF

Oliguria is a frequent but not invariable clinOliguria is a frequent but not invariable clinical feature (~50%). ical feature (~50%).

Harrison’s 15ed

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Nonoliguric ARFNonoliguric ARF

ATN: aminoglycoside, ATN: aminoglycoside, streptomycinstreptomycin, polymyxin B,, polymyxin B, lithium, or cisplatin nephrotoxicity. lithium, or cisplatin nephrotoxicity.

Case report:Case report: Celecoxib-induced Celecoxib-induced nonoliguric acute renal failure

Annals of Pharmacotherapy. 36(1):52-4, 2002 Jan.Annals of Pharmacotherapy. 36(1):52-4, 2002 Jan.

Lupus nephritisLupus nephritis American Journal of the Medical Sciences. 321(6):381-7, 2001 Jun.American Journal of the Medical Sciences. 321(6):381-7, 2001 Jun.

Isoniazid-induced Isoniazid-induced crescentic glomerulonephritis Omeprazole-induced Omeprazole-induced acute interstitial nephritis..

…………..

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Nonoliguric ARFNonoliguric ARF

Glomerular alterations in experimental oliguric and nonoliguric acute renal failure.

tubular damage was more pronounced in olig was more pronounced in oliguric kidneys…. There was uric kidneys…. There was no significant difference in these glomerular changes between oli in these glomerular changes between oliguric and nonoliguric kidneys. guric and nonoliguric kidneys.

The findings suggest that less reduction in the The findings suggest that less reduction in the whole-kidney GFR in nonoliguric ARF kidneys whole-kidney GFR in nonoliguric ARF kidneys is ascribed largely to is ascribed largely to less pronounced tubular damage rather than to less severe glomerular morphologic alterations.

Renal Failure. 15(2):215-24, 1993.

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Nonoliguric ARFNonoliguric ARF

Acute renal failure: clinical outcome and causAcute renal failure: clinical outcome and causes of death.es of death.

Higher mortalityHigher mortality was observed in was observed in oliguric patieoliguric patientsnts (62.9%) than nonoliguric (34.5%) (p < 0.0 (62.9%) than nonoliguric (34.5%) (p < 0.05) and in 5) and in ischemic renal failureischemic renal failure (56.7%) when (56.7%) when compared to nephrotoxic renal failure (14.7%) compared to nephrotoxic renal failure (14.7%) (p < 0.05).(p < 0.05).

Renal Failure. 19(2):253-7, 1997 Mar

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Nonoliguric ARFNonoliguric ARF

Acute renal failure in a teaching hospital.

…Compared with nonoliguric patients, oliguric patients had higher mortality (56.3% vs 18.9%, p < 0.01), and needed dialysis more frequently (43.8% vs 12.9%, p < 0.01)

Singapore Medical Journal. 36(3):278-81, 1995 Jun.

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Conclusion Conclusion

Nonoliguric acute renal failure Although the causes of nonoliguric renal failure vAlthough the causes of nonoliguric renal failure v

aried, aried, nephrotoxic failure occurred more frequent occurred more frequently in nonoliguric than in oliguric subjects (P <0.0ly in nonoliguric than in oliguric subjects (P <0.01). 1).

As compared to oliguric patients, those without oAs compared to oliguric patients, those without oliguria had significantly lower urinary sodium conliguria had significantly lower urinary sodium concentrations (P<0.05) and FENa (P < 0.02), had scentrations (P<0.05) and FENa (P < 0.02), had shorter hospital stay (P < 0.01), had fewer septic horter hospital stay (P < 0.01), had fewer septic episodes, neurologic abnormalities, gastrointestiepisodes, neurologic abnormalities, gastrointestinal bleeding and acidemia, required dialysis less nal bleeding and acidemia, required dialysis less frequently (P < 0.001) and had lower mortality rafrequently (P < 0.001) and had lower mortality rate (P < 0.05). te (P < 0.05).

NEJM. 296(20):1134-38,1977 May

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Management of acute renal Management of acute renal failure failure

Management of volume homeostasisManagement of volume homeostasisManagement of electrolyte homeostasisManagement of electrolyte homeostasisManagement of acid- base homeostasisManagement of acid- base homeostasisManagement of uremia Management of uremia Nutritional management in acute renal Nutritional management in acute renal

failure failure Dialysis in acute renal failure Dialysis in acute renal failure

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Management of volume Management of volume homeostasishomeostasis

Record I/O Record I/O Physical examination Physical examination Fluid = urine output + 300-500Fluid = urine output + 300-500Sodium intake<2 g/daySodium intake<2 g/dayDiureticsDiureticsLow dose dopamin ( 0.3 ug/kg/min)Low dose dopamin ( 0.3 ug/kg/min)CVP or pulmonary capillary wedge pressurCVP or pulmonary capillary wedge pressur

e e

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Management of electrolyte homManagement of electrolyte homeostais eostais

Hypernatremia and hyponatremiaHypernatremia and hyponatremiaHyperkalemiaHyperkalemiaHypocalcemia Hypocalcemia Hypomagnesemia Hypomagnesemia Hyperphosphatemia Hyperphosphatemia

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Management of acid- base Management of acid- base homeostasishomeostasis

Dietary protein restriction 0.8-1.0g/kg of bDietary protein restriction 0.8-1.0g/kg of body weight 30 kcal /kg/day ( except hyperody weight 30 kcal /kg/day ( except hypercatabolism )catabolism )

Look for cause of acidosis Look for cause of acidosis Sodium bicarbonate Sodium bicarbonate Dialysis Dialysis

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Management of uremiaManagement of uremia

Fatigue, lethargy, mental dullness, norexia Fatigue, lethargy, mental dullness, norexia and nausea and nausea

More serious– myoclonus, confusion, deliriMore serious– myoclonus, confusion, delirium or coma, seizure and pericarditis um or coma, seizure and pericarditis

Diet protein controlDiet protein controlCheck GI bleeding Check GI bleeding Hemodialysis Hemodialysis

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Nutritional management in Nutritional management in acute renal failure acute renal failure

Minimal recommand protein intake0.6-0.8gMinimal recommand protein intake0.6-0.8g/kg/day/kg/day

Carbohydrate and lipid should maximal witCarbohydrate and lipid should maximal with a target of providing 30-65kcal /kg/dayh a target of providing 30-65kcal /kg/day

Limit fluid volume potassium , magnesium, Limit fluid volume potassium , magnesium, and phosphorus should avoid.and phosphorus should avoid.

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Indications for dialysisIndications for dialysis

Absolute indicationsAbsolute indications

uremic symptomsuremic symptoms

uremic pericarditisuremic pericarditis Relative indicationsRelative indications

volume overlosdvolume overlosd

hyperkalemiahyperkalemia

metabolic acidosismetabolic acidosis

Other electrolyte abnormalitiesOther electrolyte abnormalities

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Drug management in acute Drug management in acute renal failure renal failure

Stop nephrotoxic drugsStop nephrotoxic drugsAdjust medication doseAdjust medication doseCheck drug level Check drug level

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Thanks for your attentionThanks for your attention