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 2 nd 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 99% Abd pain 80-95% Rebound tenderness60% Abd discomfort, N, V, D 7-36% Chills 12-23% Fever 33% Other 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>100x10 6/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. Epidermides30-40% S. Aureus15-20% Streptococci10-15% Other2-5% Gram Negatives Pseudomonas5-10% Enterobacter5-20% Other2-5% Fungi (mainly Candida)10-30% Other organisms2-5% Culture Negative

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 ) Cephazolin1.5G IP Cephradine 250 mg QID PO Gentamycin0.6mg/kg Rounded nearest 10mg (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% Excessive ultra filtration Underestimation of dry weight Pre-dialysis volume deficiency Rx Stop HD, Trendelenberg Asses volume status N/S ml 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 Acute SOB, chest tightness  BP, CVS Arrest LOC Rx 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 - patency, infx CVS JVP/ BP CHF Peri  tamponade Murmers CNS PR ?Melena

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 Insulin units/hr ml/hr < >11315

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