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RENAL FAILURE

BY

E. D. YEABOAH (MA BCHIR MD (CANTAB) FRCS FWACS FICS FMCS FGA)

PROF.

UNIVERSITY OF GHANA MEDICAL SCHOOL

OBJECTIVES

1. 2. 3.

AETIOOLOGY.PATHOGENESIS. MANAGEMENT RENAL FUNCTIONS ASSESSMENT ACUTE RENAL FAILURE (ARF )DEFINITION AETIOLOGY PATHOGENESIS DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS MANAGEMENT COMPLICATIONS

4.

CHRONIC RENAL FAILURE (CRF) DEFINITION AETIOLOGIES PATHOGENESIS CLINICAL APPROACH DIAGNOSIS & DD COMPLICATIONS MANAGEMENT CONSERVATIVE DIALYSIS CAPD, HD, HF RENAL TRANSPLANTATION

RENAL FUNCTIONS

A. B.

MAINTENANCE OF HOMEOSTASIS FLUID AND ELECTROLYTE BALANCE EXTRACELLULAR VOLUME ACID BASE BALANCE BP HORMONES PRODUCTION - RENIN PROSTAGLANDINS KALLIKREIN VIT D ERYTHROPROIETIN HORMONE DETOXICATION /EXCRETION

A. EXCRETION NITOGENOUS AND WASTE PRODUCTS OF METABOLISM B. RENAL FUNCTION TESTS 1. CLINICAL RECOGNITION HISTORY

DISORDERS

DEHYDRATIONDIARRHOEA VOMITING BURNS DRUGS BURNS PAIN RENAL/URETERIC COLIC MALARIA,TYPHOID,ABORTION, BILHARZIASIS NEPHRITIDES, DM, SICKLE CELL CRISIS MULTIPLE INJURIES, CCF, CANCER, ALLERGY, THROMBOEMBOLISM MI, BITES-SNAKE, BEES INSECTS

OPERATIONS MAJOR CARDIOVASCULAR PELVIC GYNAECOLOGICAL INSTRUMENTATION

URINARY TRACT SYMPTOMS PAIN RENAL/ URETERIC COLIC LUTS (Lower Urinary Tract Symptoms) LUTO (Lower Urinary Tract Obstructive Symptoms)

EARLY LUTO NOCTURIA POOR URINE flow Bothersome bladder or prostate

LATE (LUTO) Intermittency, Hesitancy, Incomplete bladder emptying (residual urine), straining, POOR STREAM

IRRITATIVE SYMPTOMS NOCTURIA FREQUENCY URGENCY. IPSS 7 SYMPTOMS (EARLY) 4 OBSTRUCTIVE Intermittency. Weak Stream. Straining Incomplete Emptying

3 IRRITATIVE Frequency Urgency Nocturia SCORES 0-35 MILD 0-7 MODERATE 8-18 SEVERE 19-35 LATE SYMPTOMS ACUTE RETENTION OF URINE (ARU) CHRONIC RETENTION OF URINE (CRU) PROLONGED MICTURITON URINARY INCONTINENCE HAEMATURIA, UTI, CALCULI, DIVERTICULI, BILHAZIASIS

RECURRENT UTI esp. Males prostatitis Cystitis, Epididymoorchitis, Pyelonephritis, Bacteraemia Septicaemia.OTHER URINARY SYMPTOMS ANURIA OLIGURIA POLYURIA

DD ANURIA ARU, SEVERE ATN/CORTICAL NECROSIS, URETERIC OBSTRUCTION, OCCLUSION RENAL ARTERIES (THROMBOSIS.EMBOLI) RUPTURED BLADDER/URETHRA PHYSICAL EXAMINATION URAEMIA DEHYDRATION ABDOMINAL WOUND. CCF FIBRILLATION (AF) ANARSARCA PERITONITIS PANCREATITIS ABDOMEN

ATRIAL ACUTE

ABDOMINAL DISTENSION ASCITES INTESTINAL obstruction ABDOMINAL MASSES Kidneys Bladder Tumour ABDOMINAL VASCULAR DISORDERS BRUIT ANEURYSM. ATRIAL FIBRILLATION EXTERNAL GENITALIA Paraphimosis Phimosis Mental Stricture, Stigmata Urethral Stricture Urethral discharge, periurethral swelling, fistulae. Extravation of urine. Female Genital multilation caruncle.

CLINICAL EVALUATION AND INVESTIGATIONS

1. URINE (a) Hourly output INPUT OUTPUT CHART (b) Anuria oliguria Polyuria (Diuresis) (c) Inspection infected urine Haematuria Crystals (d) CHEMISTRY OSMOLARITY Proteins Sugar pH SG Urea Sodium electrolytes. Creatinine Bonce Jones protein (e) MICROSCOPY Casts RBC WBC Bacteria FUNGI Crystals S. Ova , Acid fast Bacilli Malignant cells (f) CRYSTALS pH Acid Uric acid PH alkali phosphates Uric acid oxalate Cystine Phosphates

(g) URINE CHEMISTRY PARAMETER Na Concrn Urea Creatinine PRERENAL Low 30mmol Low 30mmol >260-500 High

(2) BLOOD Hb PCV Sickling Eletrophoresis G6-PD Status, WBC culture Leucocytosis sepsis leukaemia Lymphoma eosinophilia allergy Interstitial Disease. ThrombocytopeniaABRNORMAL RBC Haemolytic uraemic Syndrome

Low platelets Thrombocytopenia, Haemolytic Uraemic syndrome WIDAL Typhoid

(3) BLOOD CHEMISTRY 1. Urea & Electrolytes 2. CREATININE LEVEL (a) Creatinine Clearance (b) Serial measurement of creatinine levels (c) Factors affecting creatinine Elevated Large body mass, Ageing. Trauma muscles, Collagen diseases. DRUGS Cimetidine, ,Cephalosporins Septrin ,Gentamicin

1. UREA (a) Rises RF, Blood in GIT, reabsorption of urine (GIT) Dehydration (b) Urea Low Liver disease (iv) Derangements blood Chemistry & others in RF (a) RISES (b) FALLS Creatinine Bicarbonate ACIDOSIS BUN Free Ca++ K+PO4= Mg++ RBC cell Mass Platelets GFR (4) GFR (1) Creatinine Clearance (ii) Radionucleotide scan

(5) IMAGING

(i)

Plain Xray Abdomen Fractures Metastases Osteoblastic/osteolytic Calculi Calcification Bladder Ureter kidneys AORTA Pancreas MASSES Kidney others Aorta. (ii) CHEST calcification. TB Cardiomegaly Metastses in ribs. (iii) ULTRASOUND ABDOMEN (a) Bladder Full/empty post void residual - Urine Calculi (b) Kidneys. Small+small cortex CRF Large Dilated calyces Normal/thin cortex Hydronephrosis. Absent abnormal positions etc. Calculi Tumors COLOUR DUPLEX USG Renal vessels Blood flow (iv) Radionucleotide renal scan (v) IVU with care in RF Non ionic contrast preferred. (vi) RENAL ANGIOGRAM/VENOGRAM Digital Subtraction angiogram

(6)

RENAL BIOPSY FNA Trucut USG/CT Guided (7) CT Scan/MR I (8) ENDOSCOPY Cystoscopy and retrograde Uretero pyelogram

ACUTE RENAL FAILURE

Acute/sudden onset of renal dysfunction with urine output less than 400mls/24h or less than 20mls/min resulting in accumulation of end products of metabolism such as urea, crentinine H+ phosphates and a complex life-threatening illness. (1) PRE-RENAL (EXTRARENAL) Ureamia without structural damage due to reversible renal hypoperfusion. (2) RENAL-ATN (Vasomotor nephropathy) and other parenchymal renal diseases. (3) Acute obstructive renal failure

DIAGNOSIS AWARENESS

OF FACTORS THAT LEAD TO ARF history of its signs. PRERENAL RENAL POST RENAL HISTORY Dehydration Haemorrhage Bites shock haemolysis diarrhoea vomiting. Anuria oliguria Polyuria operations. DRUG Hb SS/SC G6 PD Def

CLINICAL EXAMINATION Thorough, Dehydration CCF shock Rashes . Uraemia Prerenal Adequate urine flow after correction of dehydration & diuretics or replacement of blood. OBSTRUCTIVE ABDOMINAL USG Dilated calyces Hydronephrosis SPECIAL TESTS URINE BLOOD film Cultures Urine Blood Sputum IMAGING. PLAIN XRAY ABDOMINAL USG. CYTOSCOPY RETROGRADE URETEROPYEROGRAM. IVU CT MRI RADIONUCLEOTIDE

CLASSIFICATION OF CAUSES OF ACURE RENAL FAILURE

MANAGEMENT

PRERENAL Correct hypovolaemia Diuretics Frusemide 80mg in 70kg adult Mannitol 10-50g (50-100ml 20%) PREVENTION IntraoperativeBP, CVP, Urine output prevent hypotension and dehyradation Dopanine infusion 15mg/kg/min renal Vasodilator reverses loguria Treat underlying cause GOO, Burns Intestinal obstrucon peritonoitis etc. ACUTE TUBULAR NECROSIS (ATN)/RENAL RENAL FAILURE Rehydration and diruretics no effect. Conservative Fluid restriction 500-100mls plus losses. Low protein diet 20- 40g low electrolytes Daily weighing patient to loose 0.5kg/day.

DIALYSIS

Peritoneal charger

Haemodialysis (venuses cannulation/ shunts external expensive Haemofiltration less expensive INDICATIONS FOR DIALYSIS Blood Urea >30mmol/L (180mg %) Rapid rises K+ over 5.5 mmol Severe acidosis Pulmonary oedema anarsaca Uraemic symptoms Drowsiness, anaemia confusion fits( late presentation)

EMERGENCY Rx Hyperkalaemia IV 10% Ca gluconate 50G Dextrose/100mls +20 unit soluble insulin ii. Slow IV sodium bicarbonate 25-50mls 8.4% TREAT Surgical emergency operation etc ATN usually recover after 6 weeks Mortality depends on cause Medical good prognosis (over 70% of cases) Survival 80% Gynaecological/Obstetric (10-23% cases) Survival 1020% SURGICAL CAUSES Postoperative/post traumatic (1020% cases) survival usually under 40%

ACUTE OBSTRUCTIVE UROPATHY

A. (i)

Uraemia Treat as follows Bladder outlet obstruction/Acute Retention of Urine catheterisation Suprapubic stab

cystostomy

ii. Ureteric Obstruction (a) Cystosiopy double J stent insertion, ureteric catheterization) (B) PERCUTANEOUS NEPHROSTOMY (PCN) or occasionally open nephrostomig

URETERIC CALCULI PCN ESWL, Endoscopic lithotripsy or Open procedures ureterolithotomy, ureteropyelolithotomy

(D)

EXPLORATION AND SURGERY (i) Lower Ureteric obstruction Ureteroneocystostomy with or without BOARI Flap and Psoas hitch ii. Ureterioleal substitution ureteroileocystoplasty

ANAESTHESIA AND RENAL FAILURE (1) Prevention Proper monitoring and infusions to prevent renal hypoperfusion BP, CVP, Arterial BP, Urine output by bladder catheterisation

(2) ANESTHESIA IN URAEMIC PATIENTS (i) Hyoerkalaemia and Acidosis Correct by Insulin /glucose/calcium gluconate/ iv sodium bicarbonate (ii). INHALATIONAL anaesthesia may lend to cardiac arrestuse - nerve block, local infiltration regional or spinal anaesthesia. (iii) Blood transfusion Fresh blood preferred avoid citrate intoxication by 5ml 10% ca gluconate per unit of blood

(3) DRUGS THERAPY

Impaired drug excretions lead to accumulation and toxicity. Remove drugs by HD, HF or PD Know pharmacokinetics before prescribing a particular drug to ureamic patients (4) DRUGS (a) AVOID (i) Aminoglycosides (Gentamyin) Streptomycin ii. Analgesic Aspirin Paracetamol iii. Narcotics Morphine pethidrine poisoning

iv. Others Digoxin Inmunosuppressants. Heparin Warfarin. (b) Use with caution Chloramphenol, Ethombutal. Tetracyclines Cephalosporins

CHRONIC RENAL FAILURE

OBJECTIVES DEFINITION AETIOLOGY PATHOGENESIS CLINICAL APPROACH DIAGNOSIS DD COMPLICATIONS MANAGEMENT CONSERVATIVE DIALYSIS CAPD/HD TRANSPLANTATION

CHRONIC RENAL FAILURE

Results from progressive destruction of nephrons which leads to fluid and electrolyte disturbances with progressive azotaemia and systemic effects on major systems of the body, circulatory, respirator

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