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بسم الله الرحمن الرحيم 1 2 Acute Versus Chronic Renal Failure Manal Elshamaa, MD of pediatrics National Research Centre.

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Presentation on theme: "بسم الله الرحمن الرحيم 1 2 Acute Versus Chronic Renal Failure Manal Elshamaa, MD of pediatrics National Research Centre."— Presentation transcript:

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2 بسم الله الرحمن الرحيم 1

3 2 Acute Versus Chronic Renal Failure Manal Elshamaa, MD of pediatrics National Research Centre

4 Anatomy 2 Kidneys 2 Ureters Bladder Urethra

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6 Kidney Function Detoxify blood Increase calcium absorption – calcitriol Stimulate RBC production – erythropoietin Regulate blood pressure and electrolyte balance – renin

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9 Classifications Acute versus chronic Pre-renal, renal, post-renal Anuric, oliguric, polyuric

10 Acute Versus Chronic Acute – sudden onset – rapid reduction in urine output – Usually reversible – Tubular cell death and regeneration Chronic – Progressive – Not reversible – Nephron loss 75% of function can be lost before its noticeable

11 10 Acute Renal Failure Definition Acute Renal Failure Definition Renal function is diminished to the point where body fluid hemostasis can no longer be maintained.

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14 13 Prerenal Causes The most common cause of acute renal failure.  Hypovolemia  Hemorrhage  Gastroenteritis  Hypoproteinemia  Burns  Renal or adrenal disease with salt wasting  Hypotension  Septicemia  DIC  Hypothermia  Congestive heart failure  Hypoxia  RDS and pneumonia  Aortic calmping 

15 14 Prerenal Azotemia In severe cases hypovolemic shock. Oliguria is present in most individuals. Normal or increased urine output indicates either Aminogycoside or ATN nephrotoxicity

16 15 Prerenal ARF of Newborns and Infants Causes  Peri-natal hemorrhage - Twin-twin transfusion, complications of amniocentesis, birth trauma  Neonatal hemorrhage - Severe intra- ventricular hemorrhage, adrenal hemorrhage.  Perinatal asphyxia and hyaline membrane disease.  Other causes as NIC &renal vein thrombosis

17 16 Prerenal ARF of Children The most common cause of ARF Prerenal ARF:  The most common cause of hypovolemia in children is gastroenteritis.  Congenital and acquired heart diseases are important causes of ARF in this age group.

18 17 Intrinsic Renal Failure  Glomerulonephritis  Localized intravascular coagulation  Acute tubular necrosis  Acute interstitial nephritis  Tumors  Developmental abnormalities  Hereditary

19 18 Intrinsic Renal Failure  Glomerular diseases: The most common causes in older children Nephritic syndrome of hematuria and edema is synonymous with a glomerular etiology of ARF.

20 Intrinsic Renal Failure *Localized intravascular coagulation Acute dehydration HUS The most common causes of ARF in toddlers 19

21 20 Acute Tubular Necrosis  Tubular diseases: Acute tubular necrosis (Absence of arterial or glomerular lesions). There are major histologic changes that take place in ATN: (1) tubular necrosis with sloughing of the epithelial cells (2) occlusion of the tubular lumina by casts and by cellular debris (3)Back leak of filtrate

22 21 Major Causes of Acute Tubular Necrosis Renal Ischemia: * Severe pre-renal disease from any cause. Exposure to Nephrotoxins: * Amphotericin B Aminoglycosides * Heme Pigments * NSAID's (hemoglobinuria/myoglobinura) Require a period of dialysis before spontaneous resolution occurs.

23 22 Intrinsic Renal Failure  Interstitial diseases * Acute interstitial nephritis, drug reactions * infiltrative disease (lymphoma) * infectious agents.

24 23 Intrinsic ARF of Children  Hemolytic uremic syndrome (HUS) is the most common cause of ARF in children.  The disease is associated with a diarrheal prodrome caused by Escherichia coli Children usually present with microangiopathic anemia, thrombocytopenia, colitis, mental status changes, and renal failure.

25 24 Post-renal ARF Obstructive uropathy Uretropelvic junction Uretrocele Urethral valves Tumors Vesicouretral reflux Acquired Stones Blood clots

26 Symptoms of ARF Decrease urine output (70%) Edema, esp. lower extremity Mental changes Heart failure Nausea, vomiting Pruritus Anemia Tachypenic Cool, pale, moist skin

27 Diagnostic Evaluation: Urinalysis shows proteinuria, hematuria, casts. Serum creatinine and BUN levels are elevated; arterial blood gas levels, serum electrolytes may be abnormal. Renal untrasonography rules out treatable obstructive uropathy. 26

28 27 Laboratory Findings in the Differential Diagnosis of Acute Renal Failure:

29 28FeNa  Calculation of fractional excretion of sodium (FeNa)  FeNa = (urine Na/plasma Na)/(urine creatinine/plasma creatinine)  FeNa <1 % = prerenal ARF  FeNa >1% = ATN

30 Therapeutic and Pharmacologic Interventions: Surgical relief of obstruction. Correction and control of biochemical imbalances. Restoration and maintenance of blood pressure Low protein diet with supplemental amino acids and vitamins. Initiation of dialysis, or continuous renal replacement therapy for patients with progressive azotemia. 29

31 Continuous Hemofiltration (HF) It is useful in patients with ARF. Continuous AVHF Continuous VV HF Blood is pumped By a pump through fillter by patient heart 30

32 ARF: Life Threatening Conditions Hyperkalemia Volume overload Vascular access

33 Hyperkalemia Symptoms Weakness Lethargy Muscle cramps Paresthesias Dysrhythmias

34 Hyperkalemia & EKG K > Tall, peaked T’s Wide QRS Prolong PR Diminished P Prolonged QT

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36 Hyperkalemia Treatment Kayexalate Calcium gluconate (carbonate) Sodium Bicarbonate Insulin/glucose Lasix Albuterol Hemodialysis

37 Chronic Renal Failure 150–200 cases per million people = new cases each year Chronic renal failure and ESRD affect more than 2 out of 1,000 people in the U.S Mortality = 20%

38 Chronic Renal Failure Causes Glomerular diseases 40% (after 5 yrs old) Anatomic abnormalities 20% (under 5 yrs old) Hereditary renal diseases 15% (after 5 yrs old) Pylonephritis with reflux nephropathy 15% Miscellaneous10%: Vascular, HUS, JDM, wilms tumor.

39 CRF Symptoms Growth failure Weakness Fatigue Neuropathy CHF Anorexia Nausea Vomiting Seizure Constipation Peptic ulceration Diverticulosis Anemia Pruritus Jaundice Abnormal hemostasis

40 Problems Related to ESRD Metabolic – K/Ca Volume overload Anemia, platelet disorder, GI bleed Pericarditis Peripheral neuropathy, dialysis dementia Abnormal immune function

41 Dialysis ½ of patients with CRF eventually require dialysis Diffuse harmful waste out of body Control BP Keep safe level of chemicals in body 2 types – Hemodialysis – Peritoneal dialysis

42 Hemodialysis 3-4 times a week Takes 2-4 hours Machine filters blood and returns it to body

43 Types of Access Temporary site AV fistula – Surgeon constructs by combining an artery and a vein – 3 to 6 months to mature AV graft – Man-made tube inserted by a surgeon to connect artery and vein – 2 to 6 weeks to mature

44 Temporary Catheter

45 AV Fistula & Graft

46 What This Means For You No BP on same arm as fistula Protect arm from injury Control obvious hemorrhage – Bleeding will be arterial – Maintain direct pressure No IV on same arm as fistula A thrill will be felt – this is normal

47 Access Problems AV graft thrombosis AV fistula or graft bleeding AV graft infection Steal Phenomenon – Early post-op – Ischemic distally – Apply small amount of pressure to reverse symptoms

48 Peritoneal Dialysis Abdominal lining filters blood 3 types – Continuous ambulatory – Continuous cyclical – Intermittent

49 Dialysis Related Problems Lightheaded –give fluids Hypotension Dysrhythmias Disequilibration Syndrome – At end of early sessions – Confusion, tremor, seizure – Due to decrease concentration of blood versus brain leading to cerebral edema

50 Thank you 49


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