renal function evaluation and the approach to the patient with acute renal failure

7/23/2019 Renal Function Evaluation and the Approach to the Patient With Acute Renal Failure

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Chapter 133:Renal Function Evaluation and theApproach

to the Patient with Acute Renal Failure


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INTRODUCTION1! The "idne#$: %or the e&cretion o% end'product$

o% (eta)oli$( urea* creatinine* and uric acid!and %or control o% the concentration o% (an#)od# +uid con$tituent$ Na,* -,* Cl'* and .,!/

The 0lo(erular ltrate contain$ virtuall# noR2C$* and it$ co(po$ition i$ $i(ilar to that o%inter$titial +uid e&cept that it ha$ a protein

concentration onl# one two'hundredth that o%pla$(a/


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INTRODUCTION!

4ore than 556 o% the ltrate containin0 water*

elec'trol#te$* and $(all (olecule$ e/0/*0luco$e and uric acid! i$ rea)$or)ed )# thetu)ule$/

0lo(erular ltration rate 7FR!* avera0e$18(l9(in in adult (en/


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E4ER7ENC DEPART4ENTDIA7NO;TIC;


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Urine == (l9> hr/

Alternatin0 oli0uria and anuria i$ a cla$$icindicator o% inter(ittent o)$truction thatoccur$ a$ urine collect$ )ehind an o)$tructin0$tone or tu(or and then i$ allowed to +ow pa$ta$ the o)$tructin0 (aterial $hi%t$ po$ition/


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Urinal#$i$ dip$tic" $creenin0 %or he(e pi0(ent* protein*

0luco$e* "etone$* and p. and in $o(ela)oratorie$ leu"oc#te e$tera$e or nitritereduction!/

(icro$copic e&a(ination o% a $pun $peci(eno% %re$hl# voided urine/


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Urinal#$i$ .e(e

.e(e pi0(ent catal#?e$ the o&idation o%

ortho'tolidine )# pero&ida$e/ detect$ )oth %ree he(o0lo)in or

(#o0lo)in(ore $en$itive! and he(o0lo)incontained in R2C$/

%al$e'ne0ative: vita(in C* dilute urine and inurine containin0 lar0e a(ount$ o% protein/ A po$itive dip$tic" re$ult $hould pro(pt

(icro'$copic e&a(ination o% the urine/


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Urinal#$i$ Protein1!

The dip$tic" te$t u$in0 the color chan0e o%tetra')ro(ophenol )lue* can relia)l# #ieldpo$itive re'$ult$ when the concentration i$0reater than 3= (09dl/

3 to 8 ti(e$ (ore $en$itive to al)u(in than to0lo)ulin$ and i((uno0lo)ulin li0ht chain$/

Fal$e'po$itive: al"aline urine* he(aturia* or pro'lon0ed i((er$ion o% the dip$tic" in the urine/

Fal$e'ne0ative: dilute urine/


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Urinal#$i$ Protein!

The $ul%o$alic#lic acid ;;A! te$t i$ (ore$en$itive to proteinuria detectin0 8 (09dl o%

nonal)u(in or al)u(in protein!/ Fal$e'po$itive: radio0raphic contra$t a0ent$*

PCN* or $ul%on#lurea dru0$/ Fal$e'ne0ative: al"aline urine/

I% the ;;A re$ult i$ $i0nicantl# (ore po$itivethan the dip$tic"* a urine electrophore$i$ $hould)e per%or(ed to detect nonal)u(inprotein$ the li0ht chain$ a$$ociated with(ultiple (#elo(a!/


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Urinal#$i$ 4icro$copic E&a(ination1!

8 R2C9hp% i$ the thre$hold o% a)nor(alit#/

@ar0e nu()er$ o% pol#(orphonuclearleu"oc#te$: inter$titial nephriti$* papillar#necro$i$* and p#elo'nephriti$/

Uric acid cr#$tal$: uric acid nephropath#/

O&alic acid or hippuric acid cr#$tal$:eth#lene 0l#col in0e$tion/


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Urinal#$i$ 4icro$copic E&a(ination!

Ca$t$ are %or(ed %ro( urinar# Ta(('.or$%allprotein* a product o% the tu)ular epithelial cell$

(i&ed with al)u(in* red cell$* tu)ular cell$* orcellular de)ri$/

.#aline ca$t$devoid o% content$!: deh#dration*a%ter e&erci$e* or 0lo(erular proteinuriapre'renal a?ote(ia or o)$truction/

Red'cell ca$t$: 0lo(erular he(aturia0lo(erulo'nephriti$ or va$culiti$/

hite'cell ca$t$: renal parench#(alin+a((ation/


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Urinal#$i$ 4icro$copic E&a(ination3!

7ranular ca$t$cellular re(nant$ and de)ri$! andrenal tu)ular epithelial cell$ ATN/

Fatt# ca$t$li"e oval %at )odie$!:heav# proteinuriaand the nephrotic $#ndro(e0lo(erulardi$ea$e/

Eo$inophil'containin0 ca$t$ a%ter $tainin0 the

$edi(ent! aller0ic inter$titial nephriti$/ tele$coped $edi(enta co()ination o% cellular

ca$t$ and )road and wa ca$t$! on0oin0da(a0e o% the re(ainin0 nephron$/


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;eru( and Urine Che(ical Anal#$i$ Creatinine and 2UN1!

Creatinine clearance* parallel$ 7FR clo$el#*

can )e deter(ined %ro( a >'hour urinecollection* Clcr (l9(in! BurineCr(09dl!volu(e(l!9$eru(Cr(09dl!ti(e(in!/

The nor(al ran0e o% the $eru( creatininelevel e&tend$ %ro( =/8 (09dl to 1/8 (09dl/Clcr (l9(in!B1>=' a0e!I2 "0! 9$eru( Cr(09dl!=/G8 %or wo(en!


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;eru( and Urine Che(ical Anal#$i$ Creatinine and 2UN!

;puriou$ elevation$ can )e cau$ed )#

acetoace'tate which cro$$'react$ in theco((onl# u$ed a$$a#$! and )# certain(edication$/

A)rupt ce$$ation o% 0lo(erular ltration

cau$e$ the $eru( creatinine to ri$e )# 1 to(09dl9da#/ H1 (09dl9da#$o(e renal %unction pre$erved/ (09dl9da# rha)do(#ol#$i$


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;eru( and Urine Che(ical Anal#$i$ Creatinine and 2UN3!

2UN : Increa$ed protein inta"e* 7I )leedin0*and cata)olic eJect$ o% %ever* trau(a* in%ection*

or dru0$ $uch a$ tetrac#cline andcortico$teroid$/

2UN : liver %ailure or protein (alnutrition/ Once 0lo(erular ltrate ha$ )een %or(ed* renal

urea clearance i$ lar0el# a %unction o% +ow rate/Urea clearance i$ thu$ decrea$ed in patient$with prerenal a?ote(ia or acute o)$truction*de$pite pre$ervation o% tu)ular %unction theratio o% the 2UN to the $eru( creatinine 1=:1/


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;eru( and Urine Che(ical Anal#$i$ Urine ;odiu( and Fractional E&cretion o%

;odiu( Nor(all#* urine Na UNa! concentration

parallel$ Na inta"e/ @ow urine Na concentrationthu$ indicate$ not onl# intact rea)$orptive%unction )ut al$o the pre$ence o% a $ti(ulu$ tocon$erve Na

The FENa* dened a$ UNa9PNa!9UCr9PCr!1==* re+ect$ the %raction o% ltered $odiu(that e$cape$ rea)$orption and i$ e&creted inthe urine/


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;eru( and Urine Che(ical Anal#$i$ Urine ;odiu( and Fractional E&cretion o%

;odiu(


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;eru( and Urine Che(ical Anal#$i$ Urine ;odiu( and Fractional E&cretion o% ;odiu( Cau$e$ o% .i0h or @ow FENa and UNa in Patient$ with ARF

UNa H= (EK9@* FENa H16 : Prerenal a?ote(ia Acute 0lo(erulonephriti$ Acute o)$truction Contra$t'induced ATN ;o(e ca$e$! Rha)do(#ol#$i$'a$$ociated ATN $o(e ca$e$! Earl# $ep$i$ Nonoli0uric ATN 1=6 o% ca$e$!

UNa >= (EK9@* FENa 16 : ATN 5=6 o% ca$e$! Chronic o)$truction Diuretic dru0$ O$(otic diure$i$ Underl#in0 chronic renal %ailure


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I(a0in0 ;tudie$ Intravenou$ p#elo0raph# I


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I(a0in0 ;tudie$ Ultra$ono0raph#

Dilatation o% the collectin0 $#$te( i$

0enerall# apparent within > to 3M hour$ o%the on$et o% o)$truction/

Detectin0 intrarenal and ureteral calculi/


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I(a0in0 ;tudie$ Co(puted to(o0raph# CT $can! :

.#dronephro$i$ and dilated ureter$ can )e $een with'outcontra$t enhance(ent/

The cau$e o% o)$truction e/0/* l#(pho(a* retroperi'toneal he(orrha0e* (eta$tatic cancer* or retroperi'toneal)ro$i$! can )e delineated/


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APPROAC. TO .E4ATURIA


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APROAC. TO .E4ATURIA Painle$$ he(aturia i$ e$ti(ated to occur in the

0eneral population at an incidence o% 36 to >6/ The cau$e$ o% he(aturia can )e divided into

he(atolo0ic* renal 0lo(erular ornon0lo(erular!* and po$trenal cau$e$2o& 133'!/

The (o$t co((on cau$e$ o% he(aturia1/ "idne# $tone$

/ carcino(a o% the "idne# or )ladder

3/ urethriti$

>/ urinar# tract in%ection

8/ )eni0n pro$tatic h#pertroph# 2P.!

M/ 0lo(erulonephriti$/


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APROAC. TO .E4ATURIA


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APROAC. TO .E4ATURIA the Pattern and Character o% the .e(aturia

on initiation o% voidin0 a urethral $ource/ in the la$t %ew drop$ o% urine a pro$tatic or

)ladder nec" $ource/ Total he(aturia a $ource in the )ladder*

ureter* or "idne#/ 2rown or $(o"#'colored urine a renal $ource/

2lood clot$

a non0lo(erular renal or lowerurinar# tract $ource o% )leedin0/ c#clic or a$$ociated with (en$e$

endo(etrio$i$ o% the ureter or )ladder/


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APROAC. TO .E4ATURIA .i$tor#

A recentl# $ore throat P;7N/ A hi$tor# o% %orei0n travel or re$idence a)road$chi$to$o(ia$i$ or tu)erculo$i$/

4edication AIN * papillar# necro$i$* orhe(orrha0ic c#$titi$/

Anticoa0ulant u$e

Fa(il# hi$tor# pol#c#$tic or other %a(ilial"idne# di$ea$e* $ic"le cell di$ea$e* or renalcalculi/

A hi$tor# o% $trenuou$ e&erci$e


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APROAC. TO .E4ATURIA ;#(pto($

Flan" pain calculu$* neopla$(* renal

in%arction* o)$truction* or in%ection/ FreKuenc#* d#$uria* or $uprapu)ic pain

c#$titi$ or urethriti$/ In adult (en* perineal pain* d#$uria*and

ter(inal he(aturia

pro$tatiti$/ ;#(pto($ $u00e$tive o% a (ulti$#$te(

di$order e/0/* $#$te(ic lupu$er#the(ato$u$! $hould al$o )e $ou0ht/


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APROAC. TO .E4ATURIA ;i0nPE!

Endocarditi$ new heart (ur(ur! or atrial)rillation irre0ular rh#th(! renal e()oli$(/

C< an0le tenderne$$ p#elonephriti$ or $tonedi$ea$e/

A palpa)l# enlar0ed "idne# pol#c#$tic "idne#di$ea$e or renal (ali0nanc#/

The pro$tatic e&a(ination pro$tatiti$* 2P.* or

cancer/ E&a(ination o% the e&ternal 0enitalia a

urethral (eatal le$ion/ P< e&a(ination vulvova0inal $ource$/


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APROAC. TO .E4ATURIA Urinal#$i$

Red urine dip$tic"'ne0ative and %ree o% R2C$! in0e$tion o% )eet$* red )errie$* or %ood colorin0 )#

urate cr#$tal$ or )# dru0$ $uch a$ phena?o'p#ridineP#ridiu(! and ri%a(pin/ Red'cell ca$t$* other ca$t$* or lipiduria or $i0nicant

proteinuria , he(aturia intrin$ic renal di$ea$e$/ .e(aturia , p#uria or )acteriuria UTI

Even i% 2C'! or or0ani$($'!

do U9C to rule outhe(orrha0ic c#$titi$* e$p/ with lower tract $#(pto($/ Eo$inophiluria on ri0ht$ $tain or .an$el$ $tain!

AIN/


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APROAC. TO .E4ATURIA 7ro$$ he(aturia c#$to$cop#/

R9O renal colic or other di$order$ o% the upperurinar# tract e/0/* pol#c#$tic "idne# di$ea$e*tu(or* or o)$truction! I

= $houldunder0o a thorou0h evaluation a%ter even a

$in0le epi$ode o% he(aturia/ In 86 to 1=6 o% ca$e$ no cau$e can )e

deter(ined/


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APPROAC. TO PROTEINURIA


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APPROAC. TO PROTEINURIA Denition

A)nor(al proteinuria i$ a$ e&cretion

o% (ore than 18= (09> hr in adult$/ (ore than 1>= (09(9> hr in

children/


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APPROAC. TO PROTEINURIA Cla$$ication

7lo(erular proteinuria

The (ore co((on t#pe/ Re$ult$ %ro( increa$ed per(ea)ilit# o%

the 0lo(erular capillarie$ to pla$(aprotein$/

Protein lo$$e$ o% 1= 0 or (ore per da# arenot unco((on


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Tu)ular proteinuria Nor(al 0lo(eruli/ ;(aller protein$ that are nor(all# ltered at

the 0lo(erulu$ and then rea)$or)ed in thetu)ule appear in the urine )ecau$e o% tu)ularor inter$titial a)nor(alit#/

E/0/ urinar# tract o)$truction* $ic"le cell

di$ea$e* and other cau$e$ o% acute or chronicinter$titial nephriti$/

Dail# urinar# protein lo$$e$ rarel# e&ceed 0/


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Over+ow proteinuria

Urinar# lo$$ o% $(all protein$ that arepre$ent in the )lood in e&ce$$iveconcentration$ and appear in the0lo(erular ltrate in a(ount$ e&ceedin0the nor(al tu)ular rea)$orptive capacit#e/0/* the li0ht chain$ produced in(ultiple (#elo(a!/


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Tran$ient proteinuria

E&ertion/ ;tre$$/ Fever/ pre0nanc# e&cretion o% up to 3== (0

protein9da# can occur!/


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Ortho$tatic proteinuria :

Durin0 period$ when the patient i$upri0ht )ut not durin0 recu()enc#

U$uall# tran$ient and )eni0n/

E&cretion o% (ore than 0 protein9> hr i$

li"el# to )e cau$ed )# a 0lo(erular proce$$*wherea$ le$$ than 0 i$ t#pical o% tu)ular*over+ow* or ortho$tatic proteinuria


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APPROAC. TO PROTEINURIA Nephrotic $#ndro(e

.#poal)u(ine(ia Ede(a Nephrotic ran0e proteinuria : 7reater than 3/8

09> hr/ .#perlipide(ia/

Ri$" %or thro()oe()olic event$* includin0 D


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APPROAC. TO PROTEINURIA In #oun0 %e(ale patient$* the po$$i)ilit# o%

pre0nanc# $hould )e "ept in (ind* $incepre0nanc# can e&acer)ate previou$l#

inapparent renal di$ea$e in late pre0nanc#*proteinuria (a# )e the r$t $i0n o%preecla(p$ia/

Proteinuria , R2C$ and red'cell ca$t$ 7N/

Proteinuria , p#uria AIN/ Proteinuria , 0l#co$uria dia)etic

nephropath#/


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ACUTE RENA@ FAI@URE


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ACUTE RENA@ FAI@URE Acute renal %ailure ARF! i$ a 0eneric ter( u$ed

to de$cri)e a precipitou$ decline in "idne#%unction/

It$ hall(ar" i$ pro0re$$ive a?ote(ia/

The$e include (eta)olic deran0e(ent$ e/0/*(eta)olic acido$i$ and h#per"ale(ia!*di$tur)ance$ o% )od# +uid )alance particularl#

volu(e overload!* and a variet# o% eJect$ onal(o$t ever# or0an $#$te( 2o& 133'>!/


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ACUTE RENA@ FAI@URE

V a s c u la r(V a s c u litis )

G lo m e ru la rG N

In te rstitia lA IN

A T N

U rin a ly s isU rin e e le c tro ly te s

In trin s ic re n a l d is e a s e

R u le o u t o b s tru c tio n

C o rre c t p re re n a l a z o te m ia

H is to ry ,p y s ic a l e ! a m ,s e ru m c e m is trie s

A z o te m ia


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Prerenal A?ote(ia Characteri?ed )# :

1/ increa$ed urine $pecic 0ravit#

/ 2UN9Cr ratio 1=:1

3/ urine $odiu( concentration H= (EK9dl

>/ FENa H16/

The condition can 0enerall# )e corrected readil#)# : 1/ e&pandin0 ECF volu(e*

/ au0(entin0 cardiac output* or

3/ di$continuin0 va$odilatin0 antih#perten$ivedru0$/


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Prerenal A?ote(ia $evere prolon0ed prerenal a?ote(ia can eventuate in

ATN/ Patient$ who have C.F or cirrho$i$ %or( an i(portant

$u)$et o% tho$e with prerenal a?ote(ia/ The$eindividual$ are o%ten $alt' and water'overloaded* #ettheir eJective intraarterial volu(e i$ decrea$ed/Ad(ini$tration o% diuretic$ ha$ the potential to decrea$eintrava$cular volu(e %urther* with decrea$ed 0lo(erularltration and prerenal a?ote(ia the re$ult/ For $o(e

patient$ with advanced C.F or hepatic di$ea$e* a $tateo% chronic stable prerenal azotemia(a# )e the)e$t achieva)le co(pro(i$e )etween $#(pto(aticvolu(e overload and $evere renal h#poper%u$ion/


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Prerenal A?ote(ia 7lo(erular per%u$ion (a# al$o )e decrea$ed in

patient$ with nor(al intrava$cular volu(e and nor(alrenal )lood +ow who ta"eACEIor* (ore co((onl#*pro$ta0landin inhi)itor$ e/0/ NSAIDs!/ Renalva$odilator pro$ta0landin$ are critical in (aintainin00lo(erular per%u$ion in patient$ with condition$ $ucha$ C.F* chronic renal in$ucienc#* and cirrho$i$* inwhich elevated circulatin0 level$ o% renin andan0ioten$in II act to di(ini$h renal )lood +ow and

7FR/ Other ri$" %actor$ include advanced a0e* diureticu$e* renova$cular di$ea$e* and dia)ete$/ Renalin$ucienc# $econdar# to N;AID$* i$ 0enerall#rever$i)le a%ter ce$$ation o% the cau$ative a0ent/


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Po$trenal O)$tructive! ARF O)$truction i$ an rever$i)le cau$e ARF/ 4o$t co((onl# produced )# 2P. or )# %unctional )ladder

nec" o)$truction (edication $ide eJect$ or neuro0enic)ladder!/

Intrarenal o)$truction (a# re$ult %ro( intratu)ularprecipitation o% uric acid cr#$tal$ tu(or l#$i$!* o&alic acideth#lene 0l#col in0e$tion!* (#elo(a protein$*(ethotre&ate* or ac#clovir/

2ilateral ureteral o)$truction (a# )e cau$ed )#retroperitoneal )ro$i$*tu(or* $ur0ical (i$adventure*

$tone$* or )lood clot$/ A $udden deterioration o% renal %unction in D4* anal0e$ic

nephropath#* or $ic"le cell di$ea$e $u00e$t papillar#necro$i$/


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Intrin$ic Acute Renal Failure The$e entitie$ are re$pon$i)le %or onl# 86 to

1=6 o% ca$e$ o% ARF in adult inpatient$ theva$t (aLorit# are due to ATN/

There i$ a (uch 0reater incidence o%0lo(erular* inter$titial* and $(all ve$$eldi$ea$e in adult$ who develop ARF out$ide theho$pital/

In children the$e entitie$ account %or a)out onehal% o% ca$e$ o% ARF


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Intrin$ic Acute Renal Failure 7lo(erular Di$ea$e :

.e(aturia* proteinuria 8== (0 to 3 09da#* i$ notunco((on!* or red cell ca$t$ are ver# $u00e$tive

o% 7N in %act* red cell ca$t$ are e$$entiall#dia0no$tic o% active 0lo(erular di$ea$e )utrarel# $een with other t#pe$ o% renal di$ea$e/

Conver$el#* the a)$ence o% R2C ca$t$*proteinuria* and he(aturia e$$entiall# e&clude$

A7N a$ the cau$e o% ARF/ The $pecic dia0no$i$ o% A7N cau$ed )# pri(ar#

renal di$ea$e i$ o%ten ulti(atel# (ade )# renal)iop$#/


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Intrin$ic Acute Renal Failure Inter$titial Di$ea$e :

AIN i$ (o$t co((onl# precipitated )# dru0e&po$urepenicillin$* diuretic$* anticoa0ulant$* andN;AID$! or )# in%ection)acterial* %un0al* proto'?oan*

and ric"ett$ial in%ection$!/ cla$$icall# pre$ent$ with ra$h*%ever*eo$inophilia* and

eo$inophiluria/ P#uria* 0ro$$ or (icro$copic he(aturia* and (ild

proteinuria are o)$erved in $o(e ca$e$/ A denite dia0no$i$ can )e (ade onl# on renal )iop$#/

Treat(ent o% AIN i$ directed at re(ovin0 the pre$u(edcau$e Renal %unction 0enerall# return$ to )a$eline over$everal wee"$* althou0h chronic renal %ailure ha$ )eenreported to occur/


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Intrarenal


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Intrarenal


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Acute Tu)ular Necro$i$ Re%er$ to a 0enerall# rever$i)le deterioration o%

"idne# %unction a$$ociated with an# o% avariet# o% renal in$ult$/

Oli0uria (a# or (a# not )e a %eature/

The dia0no$i$ i$ (ade a%ter prerenal andpo$trenal cau$e$ o% ARF and di$order$ o%0lo(eruli* inter$titiu(* and intrarenal

va$culature have )een e&cluded/ The (o$t co((on precipitant o% ATN i$ renal

i$che(ia durin0 $ur0er# or a%ter trau(a/


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Acute Tu)ular Necro$i$ Cau$e$ o% acute tu)ular necro$i$ :

I$che(ia

1/ ;hoc"

/ ;ep$i$

3/ Third $pacin0 e/0/ 86 o% (aLor )urn$* heat$tro"e !

>/ All cau$e$ o% $evere prerenal a?ote(ia e/0/ ..N-!

Nephroto&in$

1/ Anti)iotic$ and N;AID$

/ Radio0raphic contra$t a0ent$

3/ Pi0(ent (#o0lo)in* he(o0lo)in!


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Cau$e$ o% Pi0(ent'Induced Acute Renal

Failure Rha)do(#ol#$i$ and

(#o0lo)inuria


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ATN a$$ociated with rha)do(#ol#$i$ O%ten oli0uric/

Characteri?ed )# rapid increa$e$ in: ;eru( creatinine incre(ent$ o% (09dl9da#!

2UN9CrH1=:1/ ;eru( pota$$iu(/ ;eru( pho$phoru$/ ;eru( uric acid (a# accu(ulate to level$ hi0h enou0h to

$u00e$t acute uric acid nephropath#/!/

;eru( CP- i$ a (uch (ore $en$itive te$t than urinedip$tic" a po$itive re$ult %or he(e in onl# 8=6!/

No )ioche(ical para(eter can )e u$ed to predict inwhich patient$ who have rha)do(#ol#$i$ ARF willdevelop/ e0/CP-* (#o0lo)inuria* h#per"ale(ia!


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A(ino0l#co$ide$ Nephroto&icit# i$ correlated with hi0her do$e$

and lon0er duration o% therap#* increa$ed a0e*i(paired renal %unction* deh#dration* and

e&po$ure to other nephroto&in$/ It ha$ )een $u00e$ted that once'a'da#

ad(ini$tration o% a $o(ewhat hi0her do$e i$a$$ociated with le$$ nephroto&icit#

Clinicall# $i0nicant renal d#$%unction u$uall#

occur$ onl# a%ter $everal da#$ and o%ten a%ter(ore than a wee" o% therap#/ .owever* renal%ailure can develop a$ lon0 a$ 1= da#$ a%ter adru0 ha$ )een di$continued/


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Radio0raphic contra$t a0ent$

A co((on cau$e o% ho$pital'acKuired renal

in$ucienc#/ Renal %ailure produced )# the$e a0ent$ (a# )e

dened a$ an increa$e in $eru( creatinine levelo% 8=6 over )a$eline* with a te(poral relation tocontra$t (ediu( ad(ini$tration and in thea)$ence o% other identia)le cau$e$/

The hi0he$t incidence i$ that a%ter arterio0raph#/ T#picall# an increa$e in the $eru( Cr i$ noted

within 3 d o% e&po$ure* with a return to nor(alwithin 1= to 1> d/


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Radio0raphic contra$t a0ent$

The (o$t i(portant ri$" %actor$ %or contra$t'induced ATN are :

1/ pree&i$tin0 renal in$ucienc# /8 (09dl or

1/8(09dl in dia)etic$!

/ (ultiple (#elo(a* particular with deh#dration

3/ a0e 0reater than M= #ear$

>/

volu(e depletion8/ hi0her do$e$ o% contra$t (aterial (l9"0!

M/ repeated do$e$ o% contra$t (aterial Hhr!


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APPROAC. TO T.E PATIENT IT.AQOTE4IA OR ACUTE RENA@

FAI@URE


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ARF


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7eneral 4ana0e(ent

Patient$ who have oli0uric ARF have a$i0nicantl# hi0her (ortalit# rate and a (uch0reater ri$" o% co(plication$ than tho$e who are

not oli0uric : Recover# %ro( oli0uric ATN occur$ a%ter an

avera0e o% 18'8 da#$* ver$u$ 8'1= da#$ %ornonoli0uric ATN/

;ince nonoli0uric patient$ are ea$ier to (ana0e*an atte(pt to increa$e urine +ow i$ warranted/;uch an atte(pt i$ $ucce$$%ul 3=6 to 8=6 o% the

ti(e/


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7eneral 4ana0e(ent

The o% %uro$e(ide i$ 2 to 6 mg/kgI< maximum 400mg!* )ut there i$ an increa$ed ri$" o% ototo&icit# at thehi0her do$e$* and i% the patient doe$ not re$pond withan increa$e in urine output* additional do$e$ are not

help%ul/ The reco((ended do$e o% (annitol i$ 12.5 to 25 g IV/ I%

urine output doe$ not increa$e* %urther do$e$ (a# cau$eh#pero$(olalit# and clinicall# $i0nicant intrava$cularvolu(e overload in patient$ with i(paired renal%unction/

Dopa(ine 1 to 3 (09"09(in! * with and without%uro$e(ide* i$ in an eJort to increa$e urine output* )utit$ ecac# ha$ not #et )een validated in pro$pective$tudie$/


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Pi0(ent'induced ATN

Avoidance o% he(ol#$i$ and (u$cle inLur#/ A00re$$ive volu(e repletion/ Al"alini?ation (#o0lo)in precipitate$ in an acid

urine )ut not in an al"aline urine!/ 4annitol in%u$ion to reduce the li"elihood o%

ARF and to control h#per"ale(ia!/ Furo$e(ide ha$ not con$i$tentl# $hown a

)enecial eJect/ Earl# dial#$i$ (a# )e reKuired to control rapidl#

developin0 h#per"ale(ia* h#perpho$phate(ia*

and h#perurice(ia/


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Contra$t'induced ATN

ReKuire onl# $upportive therap# )ut $hould )eho$pitali?ed and $een )# a nephrolo0i$t/


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Or0an ;#$te( EJect$

In%ection$ Ure(ia i(pair$ ho$t de%en$e$* particularl#

leu"oc#te %unction/ In%ection occur$ in 3=6to =6 o% patient$ with ARF and i$ a$i0nicant cau$e o% (or)idit# and (ortalit#/

Thu$* patient$ with %ever reKuire pro(ptinve$ti0ation and a00re$$ive treat(ent


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Or0an ;#$te( EJect$

Pericarditi$ Prevalence o% 16 to =6 in dial#?ed patient$

with E;RD/

4a# al$o occur in patient$ with ARF/ Che$t pain that i$ wor$e in a recu()ent po$ition

i$ the (o$t co((on $#(pto(/ Pericarditi$ or pericardial eJu$ion i$ 0enerall# an

indication %or the ur0ent initiation o% dial#$i$ in

ARF/ .e(od#na(icall# $i0nicant ta(ponade reKuire

$ur0ical draina0e o% the eJu$ion or* occa$ionall#*e(er0enc# pericardiocente$i$/


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Or0an ;#$te( EJect$

Neurolo0ic a)nor(alitie$ : 4a# )e precipitated )# electrol#te a)nor(alitie$*

(edication$* or ure(ia/

Co((on $#(pto($ in ure(ic patient$ includelethar0#* con%u$ion* a0itation* a$teri&i$* (#oclonu$*and $ei?ure$/

7I a)nor(alitie$ : Anore&ia* nau$ea* vo(itin0* 0a$triti$* and pancreatiti$

are al$o a$$ociated with ARF/ 7I he(orrha0e i$ $een in 1=6 to 3=6 o% patient$ it

re$ult$ %ro( a co()ination o% $tre$$ and i(pairedhe(o$ta$i$/ 7I he(orrha0e i$ the $econd leadin0cau$e o% death in ARF/


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Or0an ;#$te( EJect$

Nor(oc#tic nor(ochro(ic ane(ia : I(paired er#thropoie$i$* $hortened red )lood cell

$urvival* he(ol#$i$* he(odilution* and

0a$trointe$tinal )lood lo$$ all pla# a role/ 2leedin0 tendenc# :

ualitative de%ect in platelet %unction The prolon0ed )leedin0 ti(e can )e corrected

phar(acolo0icall# :1/ In%u$ion o% 1= U cr#oprecipitate nor(ali?e$ the )leedin0

ti(e in 1 to hour$* with a return to )a$eline in > hour$/

/ Ad(ini$tration o% de$(opre$$in acetate DDA hour$/

renal function evaluation and the approach to the patient with acute renal failure

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