1. Mrs Gloria Nefritis

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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?

8. 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?

9. 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

10. Crystalloid vs Colloid
‘Colloids are big molecules. They stay in the circulation longer. They are better in resuscitation’
Evidence Base
ZERO

11. 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

12. Conclusion Colloids More expensive HES Dextrans
Coagulopathy
Dextrans
Anaphylactoid reactions
So what would you want?

13. 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

14. 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

15. 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

16. 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?

17. 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

18. 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

19. 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

20. Further Rx Further Fluid Challenge Furosemide (80mg) Err No……
Followed by Dopamine IVI
+/- Furosemide IVI

21. 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

22. Mrs Nefritis Ward Management Daily weights Scrupulous Fluid Balance
Dialysis/ filtration

23. Summary ED Guidance Treat Pulmonary Oedema Treat Hyper-K
Along standard lines
Treat Hyper-K
Liase with renal team