Acute and chronic renal failure

Rob Flood FY1 LGI Laure Bret FY1 SJUH

Contents
Acute renal failure Chronic renal failure Exam tips Mock Slide show

ACUTE KIDNEY INJURY

AKI- Objectives
What is AKI? What causes AKI? How do I diagnose AKI? What Investigations should I order? How will I treat it?

AKI - Definition
An abrupt deterioration in parenchymal function Usually reversible over days/weeks Usually features oliguria (but not always)

AKI - Causes
1. Pre-renal
Hypovolaemia Hypotension Impaired Cardiac Pump Efficiency Vascular Disease

Basically: Less blood going in to kidneys

AKI - Causes
2. Renal (usually Acute Tubular Necrosis)
Haemorrhage Burns D&V, fluid loss from fistulae PancreatitisMI/CCF Endotoxic shock Snake bite Myoglobinaemia Haemoglobinaemia (Haemolysis e.g. malaria) Hepatorenal syndrome Radiological contrast agents Drugs:
-Aminoglycosides -NSAIDs -ACEI -Platinum -Diuretics

Abruptio placentae Pre-eclampsia and eclampsia

Basically: Damaged Kidneys

AKI - Causes
3. Post-Renal
Obstruction at any point between the renal calyces and urethral orifice

Basically: Blockage

AKI - Causes
In 99.99% of cases that you will see as an FY-1:

DRY PATIENT!!!

AKI - Diagnosis
Significant increase in Urea and Creatinine above baseline levels for your patient Low urine output (<0.5 ml/kg/hour) Urea: Product of Haemolysis
(Reference Range: 64-104 umol/L)

Creatinine: Product of muscle breakdown

(Reference Range: 2.5-7.8 mmol/L)

AKI Further Investigations

Urine Dip (?UTI, ?GN) Urine specific gravity/osmolality/Sodium (?prerenal vs. Intrinsic) Renal USS (?hydronephrosis, ?blockage) FBC (low Hb? High WCC?) ABG (metabolic acidosis/alkalosis, lactate, K+, Hb) LFT/clotting (?hepatorenal syndrome)

Is the cause not obvious from the clinical history or examination???

AKI Management for FY-1s

1. If dry, give fluid 2. Then look at drugs, see if there are any other glaringly obvious causes (i.e. ramipril, metformin, NSAIDs). 3. If still dry, give more fluid 4. Consider calling for a senior review (make sure all Obs/Ix are up to date) 5. If still dry, give even more fluid 6. Consider getting on to the Renal guys

Have I Given too much?

Sometimes its very hard to gauge how much fluid deficit someone is in Things to consider:
Raised/lowered JVP Evidence of Pulmonary Oedema Dry mucus membranes PMHx of CHD

Role of diuretics?

AKI Which Fluid?

Blood? Crystalloid?
Hartmanns, Saline 0.9%, or Dextrose 5%?

Colloid?
i.e. Albumin, Gelofusin?

Does it really matter?

Case 1
Mrs. VB is an 82 year-old lady admitted with abdominal pain, your registrar has a strong suspicion of a leaking AAA. She is catheterised but has only passed 10mls an hour since admission. You have no blood results as yet. Mrs, VB says she is really thirsty but on examination she has massive peripheral oedema, crackles on the lungs and a history of CHD.

Case 1
What do you do?
Give fluid What about the oedema?

What did I do?

I gave fluid I gave 40mg of furosemide as well

Case 2
Its Christmas Eve at around 11pm. PD is a 74 year-old man admitted last night with 24-hours of ischaemia to his right leg. The registrar on call did a R-L Fem-Fem Xover bypass to revascularise his ischaemic leg, with a 4-compartment, 2-incision fasciotomy. Sister calls you to see PD as he has not passed urine since 7pm. His MEWS is now 6 because he is anuric, tachycardic and hypotensive.

Case 2
Clinical examination:
HR 106, regular, BP 96/52 Chest clear, HS I+II+0 Abdomen Soft, non-tender Dry mucus membranes, feels thirsty On maintenance fluids only Large haematoma covering lower abdomen and scrotum Groin wound dehisced somewhat, oozing small amount of blood Fasciotomy wound oozing small amount of blood

Case 2
Post-op bloods:
Ur 13.2, Cr 136
(previously 7.2 and 82)

Hb 11.2
(previously 12.4)

PCV 0.32, WCC 6.98 LFTs normal ABG Lactate normal, Respiratory alkalosis, Hb dropping to 9.6, K+ 5.7

Case 2
What could be going on here?
Dry Patient? Reperfusion injury?

How would you treat it?

Fluid which type? What about the K+? What bout the MEWS score?

How did I treat it?

Case 3
Mr. AC is a 60 year-old man with a known history of morbid obesity, DM-II, CKI (baseline Cr is around 120-130) and depression. He is a long-standing patient on your dermatology ward at Chapel Allerton, and for the past few days has not looked quite right

Case 3
Its Wednesday afternoon, about 3:00 pm, you are chasing the bloods from the day. Mr. ACs urea and creatinine have shot up to 16.2 and 166 respectively, his last bloods were at his baseline, but being Chapel A, they were done 2 days ago.

You speak to Mr. AC, who says he is passing good volumes of urine, with no other symptoms

Case 3
Clinical examination findings are all normal Urine dipstick shows Protein and Blood only Urine output is about 30mls/hour You examine Mr. ACs Drug chart. He is on metformin, gliclazide, ramipril, atenolol, fluoxetine, insulin, aspirin, prednisolone and you had just started him on rifampicin on Monday due to his weird skin lesions on his legs

Case 3
What has happened here?
ATN secondary to nephrotoxics

What would you do?

Fluids? Correct cause!

What did I do?

Case 3
Its now Friday afternoon, about 4:00 pm, Mr. AC has not improved at all. His urine output is still the same, but his urea and creatinine are 19.6 and 204 respectively What do you do now?

Case 4
Mrs. FN is a 49 year-old lady who has just had a WLE and SNB the previous morning. Sister calls you to the ward at 3:00 am as she is now MEWS-ing at a 4 based on the fact that she is anuric since 11pm on her routine Obs. All other Obs are normal. You examine Mrs. FN and cannot find anything wrong. She is not catheterised.

Case 4
What has happened here?
Patient is anuric because she doesnt need to pee. NB: also huge cortisol response following surgery

What needs to be done?

CHRONIC RENAL FAILURE

Chronic Renal Failure

What is it? What causes it? Signs and Symptoms Treatment Relevance and management for the FY1

CRF- What
gradual and sustained decline in renal clearance (GFR); rise in serum creatinine Often co-exists with other diseases (Diabetes, CVD) Having End-stage renal disease: people with CRF but treated with dialysis or transplantation

Stages of CKD (NICE)

CRF- Why
Risk factors:
Diabetes Hypertension Cardiovascular disease Glomerulonephritis Pyelonephritis (chronic: VUR) PCKD Other: vasculitis, structural renal tract disease, renal calculi, BPH, drug-induced (NSAIDs)

CRF- Clinical Features

Often asymptomatic Impaired excretion
Sodium Oedema, Hypertension, fluid overload Potassium Hyperkalaemia, cardiac effects Acid load Acidosis, bone demineralisation, protein catabolism Phosphate Renal Bone Disease Drugs Drug toxicity e.g. gentamicin, metformin Nitrogenous waste Uraemia

Impaired endocrine function

Erythropoetin Anaemia Vitamin D Renal Bone Disease

CRF- Investigations
Bloods: Urea and creatinine Phosphate Calcium eGFR Urine: dipstick (haematuria) and proteinuria (24 hour collection) Renal USS (atrophic kidneys, obstruction) Other (CT, MRI, isotope scanning)

Management
Referral as appropriate Aim for prevention of progression and Cx
BP <140/90 (<130/80 if Diabetes) Proteinuria (Tx with ACE-I/ARBs) lipid lowering therapy as appropriate Anti-platelets Glycaemic control Lifestyle changes (diet, exercise, smoking)

Anaemia Renal bone disease

ARF and CRF for the Leeds Finals

OSCE scenario 1: Drug chart rewriting

Mr X. 69 year old man. Admitted with pneumonia. CURB 2 Previously fit and well. Ex-smoker Bloods on admission: Drugs on admission Lactulose 10ml BD Paracetamol 1g PO QDS Ramipril 5 mg OD Diclofenac 75mg PRN TDS Omeprazole 20mg OD Simvastatin 40 mg ON Metformin 1g BD Please re-write drug chart accordingly

WCC 15 Hb 13.4 Plat 450 Na+ 140

Creat 134 Ur 16 K+ 5.7 CRP 39

Drug Chart
Drugs on admission Lactulose 10 ml BD Paracetamol 1g PO QDS Ramipril 5 mg OD Diclofenac 75mg PRN TDS Omeprazole 20mg OD Simvastatin 40 mg ON Metformin 1g BD What do I do? OK OK STOP STOP OK OK STOP

Nephrotoxic drugs in ARF

Antibiotics: Gentamicin NSAIDs Metformin CT contrast Lithium ACE-I Chemotherapy drugs: methotrexate, ciclosporin

OSCE Scenario 2:

Management of hyperkalaemia
10mls 10% Ca gluconate iv over 1-2 min 50mls 50% glucose + 10u insulin
intracellular shift of K+

Salbutamol nebs (5mg)

Stop drugs causing K+

ACE I, ARBs

OSCE scenario 3
History taking station: GP practice: man with recurrent UTIs as a child now presenting with CKF to GP What investigations would you do?

OSCE scenario 4
Gastro exam with results to interpret at the end.of renal failure! Transplanted kidney

Conclusion

Conclusion
Dont neglect renal, but dont bother learning details about everything. Be able to interpret blood results Look confident in your OSCE even if you see your first ever transplanted kidney during your OSCE! Read-up about the small print stuff not covered in this lecture (glomerulonephritides) but dont spend to much time on it!

Final Tips
Revision course? Sign up to Ask Dr Clarke Website: its free. Lots of useful resources including the past 5 years OSCE Contact us if any questions: weve been there, we know how it feels like!

In five months time

GOOD LUCK

ANY QUESTIONS ?

Thank you laurebret@doctors.org.uk robertgflood@doctors.org.uk