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Mrs Gloria Nefritis
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Mrs Gloria Nefritis 75-year-old Greek woman sent to the ED by GP
one-week history of lethargy, nausea, vomiting and diarrhoea GP checked some routine bloods two days ago urea of 25.0 mmol/l creatinine of 400 micromol/l
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What features in the Hx would make you think that this is an acute loss of renal function?
Anuria / Oliguria Oliguria <400ml/24hr Anuria <50ml/24hr True anuria is rare and usually indicates obstruction Anaemia Frequent in Chronic disease Can occur within days on onset of ARF Hypocalcaemia Chronic Loss of Vit D function Acute Loss of tubular function Kidney Size Bilat, small, thin cortex =Ch But not always Myeloma, amyloidosis, DM
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Other clues Diabetes Hypertension Recurrent UTI Renal Calculi
Vasculitis SLE RA Remember the results you see may be Acute (i.e new) Acute on Chronic Chronic The only sure way of knowing is access to old results
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Precipitant Drugs NSAIDs
Loss of autoregulation Via prostaglandin inhibition Acute Interstitial Nephritis (AIN) ACE I &II Hypotension Efferent arteriole VD Aminoglycosides / Tetracyclines / Amphotericin B Direct toxins ATN Penicillins / Cephalosporins / Cipro / Fruse / Allopurinol / Omeprazole AIN Radiocontrast agents Cyclosporin A Statins Rhabdomyolysis
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Back Pain & Renal Failure
Acute Renal inflammation causes swelling and capsular pain Rarely a prominent feature But can occur in Obstruction Acute Pyelonephritis AIN Acute Severe Glomerulonephritis Be aware of bony back pain Myeloma etc
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Mrs Nefritis 1/52 Diarrhoea 4/7 Vomiting 36/24 ‘Unwell’
Seems to be settling 4/7 Vomiting 36/24 ‘Unwell’ Lethargy Light-headed on standing Passing ‘less’ urine because ‘I haven’t been drinking much’ In a moment of hitherto unexpected brilliance you think of checking the ED results server for old blood results Her U&Es 3/12 were normal Likely cause of renal failure?
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Volume Depletion & Pre Renal Failure
End of the Bed Test General look, Skin Mouth JVP Post Hypotension Are you thirsty? What features would you look for to help you decide?
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O/E Looks Dry Cool peripheries Treatment? HR115 Systolic Which one?
Lying 145 Standing 115 JVP Not seen Treatment? Fluid Which one? N. Saline (See next slide) How Much? ml initially How Fast? Stat BUT reassess
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Crystalloid vs Colloid
‘Colloids are big molecules. They stay in the circulation longer. They are better in resuscitation’ Evidence Base ZERO
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Cochrane Reviews 2000 Xstalloids vs HAS, HES, Gelatin, Dextrans
No improvement in survival Meta-analysis - One colloid vs another All about the same 2001 HAS vs Xstalloid Hypovolaemic, hypoalbuminaemic, burns HAS 6% Increase in overall mortality
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Conclusion Colloids More expensive HES Dextrans
Coagulopathy Dextrans Anaphylactoid reactions So what would you want?
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Whilst Mrs Nefritis gets her fluid challenge
What other test do you really want to do? Urine Dipstick If at all possible Any patient with unexplained ARF needs a dipstick If Trace blood or more or 1+ protein or more Suggests presence of renal inflammatory disease GN, AIN, Vasculitis Requires microscopy
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Urine Microscopy Normal Occasional hyaline casts
Pre-Renal failure Occasional hyaline casts Pigmented Granular Casts ATN Secondary to nephrotoxins or ischaemia Red Cell Casts GN Possible vasculitis Rarely in AIN WCC or Eosinophil Casts AIN
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Other Tests USS Urine Electrolytes Immune Screen
Usually not of practical use Immune Screen ANCA Rapidly progressive GN Wegener’s ANA SLE GBM Goodpasture’s Complement Post infective GN USS Single best imaging test Size Obstruction 25% of ARF 5% obstructions are missed on USS
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4 hours and 3 litres later Warm NAD Chest clear
Mrs Nefritis Warm Chest clear maybe some fine basal creps JVP 6cm Passed a tiny volume of urine Urinalysis NAD Microscopy some waxy granular casts U&Es (on admission) Urea 37 Creat 620 K 5.1 Your diagnosis at this stage is?
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Options Pre- Renal failure ACN Is due to hypo-perfusion
When circulating volume restored renal function will be restored Resulting in a prompt return of urine output ACN Rare In setting of massive blood loss PPH,APH, pancreatitis Causes anuria without obstruction
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Or ? Acute GN AIN Always get haematuria Drugs commonest cause
Always get proteinuria Almost always get red cell casts AIN Drugs commonest cause 2-20/7 post exposure 80% fever >50% cutaneous rash or arthralgia Urine Blood protein & casts
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ATN Commonest Cause Usually Identifiable insult
Low BP, nephrotoxin Urinary Evidence of tubular damage Recovery over days to weeks So this is most likely here
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Further Rx Further Fluid Challenge Furosemide (80mg) Err No……
Followed by Dopamine IVI +/- Furosemide IVI
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Urgent Dialysis? Hyperkaleamia Acidaemia Uraemia Pulmonary Oedema
What features are going to make the Renal Team say ‘Dialysis Now’? Hyperkaleamia Depends on severity Any ECG finding > tented Ts Pulmonary Oedema Failure of medical therapy is an indication for dialysis May require huge Furosemide doses Better with a nitrate Acidaemia No set level Required if CVS compromise Uraemia Indicated if Encephalopathy Periarditis Bleeding
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Mrs Nefritis Ward Management Daily weights Scrupulous Fluid Balance
Dialysis/ filtration
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Summary ED Guidance Treat Pulmonary Oedema Treat Hyper-K
Along standard lines Treat Hyper-K Liase with renal team
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