Renal Emergencies

Acute Renal Failure

Dialysis Complications
Renal Transplant Complications
Painless Hematuria
The Nephron - Physiology
Glomerulus
Proximal Tubule
Loop of Henle
Ascending limb
Descending limb
Distal Tubule
Collecting Duct
Renal physiology

The kidneys function as a filter

o Excrete end-products of metabolism
o Control concentration of electrolytes
25% of cardiac output goes to kidneys
GFR is the index of renal function
GFR declines by 1% per year
Kidney function tests

In general creatinine is the most consistent ED reflection of GFR

The amount produced is proportional to muscle mass and stable daily
BUN will increase but is affected by extrarenal factors
FeNa - urinary sodium resorption
Urinalysis - urine output is a poor indicator
Acute Renal Failure

Azotemia is a 50% reduction of GFR or a 50% increase in serum

creatinine
Is a correctable process - to a point
If you have no GFR the creatinine will increase by 1-2 mg/dl per 24 hours
If GFR is halved then creatinine will double
Types of ARF

Pre-Renal
Intrinsic (Renal)
Postobstructive (Post-Renal)
Pre-Renal Failure

Is the most common cause - 70% of cases

Due to decreased renal perfusion
Normal glomerular and tubular function
Can be a precursor to intrinsic failure
And people with intrinsic failure are more sensitive to pre-renal status
Pre-Renal Failure - Causes

Volume Loss
o Shock, vomiting, diarrhea, diuretics
Fluid Sequestration
o Cirrhosis, pancreatitis, burns, rhabdo
Decreased Cardiac Output
o MI, tamponade, valve dz
Renal Artery Disease
o Stenosis, thrombosis, emboli
Pre-renal Failure - Signs

History and physical consistent with hypovolemia

BUN/Creatinine ratio > 10:1
FeNa < 1%
Urinary sodium < 20
Intrinsic Renal Failure

Comprises about 10-30% of ARF

Subdivided into diseases of the tubules, interstitium, glomeruli and vessels
ATN due to ischemia is the most common cause
Nephrotoxins are the second most

Intrinsic Failure - Causes

Glomular
o Acute GN, post-streptococcal, Wegeners,
Interstitial
o AIN (drugs), infiltrative dz, infectious agents
Tubular
o Ischemic ATN, nephrotoxins, heme pigments
Vascular
o Malignant HTN, scleroderma, TTP, HUS
ARF - Glomerular causes

Acute glomerulonephritis refers to group of diseases which cause nephritis

Post-streptococcal, RPGN, lupus, HSP
Wegeners, Goodpastures
Hallmarks of nephritis are edema, hypertension, proteinuria and
hematuria
Look for casts on UA
Red-cell casts on UA are diagnosticS
ARF - Intrinsic causes

Most commonly drug exposure or infection

Drugs are PCN, diuretics, anticoagulants and NSAIDs
Infections can be bacterial, fungal, protozoan or rickettsial
Classically have rash, fever, eosinophilia
Definitive dx can only be made with renal biopsy
ARF - Tubular causes

ATN is generally a diagnosis of exclusion

Most common precipitant is ischemia
Other causes include
o Nephrotoxic drugs - aminoglycoside
o Contrast agents
o Heme pigments - rhabdomyolysis

Postobstructive Failure

Only accounts for 5% of all cases

Most common prostatic hypertrophy or bladder outlet obstruction
Full renal recovery is possible after 1-2 weeks of total obstruction
ED ultrasound can easily reveal a full distended bladder or a post-void
volume
Postobstructive Causes

Urethra and Bladder Outlet Obstruction

o Phimosis, meatal stenosis, prostate CA, bladder CA, blood clot,
BPH, neurogenic bladder
Ureter
o Reflux, calculi, AAA, Stricture,
Renal
o Calculi, crystals
Incidence of ARF

Acute Pancreatitis = 4-6%

Trauma = 3-9%
Rhabdomyolysis = 25-30%
Severe Burns = 20-60%
Radiocontrast agents = 2-30%
Aminoglycoside = 10-30%
Cardiac surgery = 5-40%
AAA repair = 50%
Diagnosis - Imaging

IVP

Anatomic and functional info,

Time, contrast material, radiation

Painless, rapid way to detect hydro

Poor visualization of ureter, obesity,

Anatomic and functional info, alternative dx,

parenchymal dz
Radiation, cost

Ultrasound
Helical CT

MRI

ARF - Diagnostic Sequence

H & P to reveal evidence of pre-renal causes - fluid resusitation if prerenal

Relieve urinary obstruction with foley catheter
Obtain diagnostic study for hydronephrosis and renal anatomy
ARF - Other Treatment

Lasix - Renal dosing?

Low dose dopamine?
Dialysis - indications not bases on serum

BUN/creatinine levels

ARF - Indications for dialysis

Acidosis
Hyperkalemia
Fluid overload - pulmonary edema
Uremic encephalopathy
Uremic pericarditis???
Drug intoxication
o Digoxin, lithium, aspirin, theophylline, alcohols
Dialysis - What is it?

Diffusion of fluids and solutes through a semi-permeable membrane

(replaces glomerulus)
Pressure gradient across membrane controls the amount of fluid removed
The amount of electrolyte filtered depends on pre-determined
concentration of the dialysate, the amount of ultrafiltration, and pore sizes
of the membrane
Historical questions

Why are you on dialysis?

How often? Where?
Missed dialysis?
Whos your nephrologist?
Do you make urine?
What is your dry weight?
Do you adhere to a renal diet?

Dialysis Fistula

Dialysis PermCath

Temporary Quentin Catheter

PermCath

Intradialysis Lab Values

BUN/creatinine - the higher the better

Hyperphosphatemia is a frequent complication
May need to calculate calcium/PO4 product
If Ca x PO4 is greater than 70, metastatic calcification can lead to
pseudogout and small vessel ischemia

Complications during HD

Hypotension - most common ED transfer

o Timing - early vs. late
o Underestimation of the patients dry weight
o Autonomic dysfunction
o Usual suspects
Disequilibrium - occurs at the end of run
o Nausea, vomiting and hypertension
Air embolism - passing blood thru circuit
o Chest pain, dyspnea, pulm hypertension
Sepsis

Line sepsis is the most common cause of infection in a patient with a

central cath
Typically have fever and chills after each dialysis run due to line
manipulation
Catheter requires removal and culture
Bladder sweat is typically sterile, despite abnormal UA results
Hyperkalemia

Vague symptoms: tingling, paresthesias, muscles weakness, fatigue,

abd/back pain
EKG should establish the cardiotoxicity
o If > 5.5 give Kayexalate
o If > 6.0 give Glucose 50gm and 10u regular insulin
o If > 6.5 or EKG changes give Calcium and admit to ICU (dig)
Fluid Overload

Can be due to
Ischemic heart disease
Missed dialysis or diet noncompliance
Inaccurate dry weight
Treatment
Nitroglycerin
Lasix - only if they still make urine
Morphine, oxygen and BiPAP

Hypertension/Blood

An elevated BP is frequently a sign of volume overload

Usually does not require medication
Avoid nitroprusside (cyanide toxicity)
Blood can be safely transfused to anemic patients as long as they are not
overloaded
Use of PermCaths

Can have nontunneled Quinton catherter

PermCath are tunnel catheters over clavicle in IJ for intermediate use
Must remove dwell volume from PermCath
Continuous infusion should be maintained through PermCath to maintain
patency
PermCath should be flushed with 1:1000 heparin solution in excess of
dwell volume
Use of Grafts and Fistulas

Occasionally appropriate for IV or phlebotomy

True emergencies: cardiac arrest and life-threatening
trauma
If used as maintenance should be firmly secured and physician should
accompany patient to ICU due to possibility of displacement
Must be on a pump with maintenance fluid
Concerns include infection, hemorrhage and thrombosis
HD long-term complications

Neurologic
encephaolpathy, dementia, neuropathy, autonomic
dysfunction
Cardiovascular
Hypertension, heart failure, pericarditis
Hematologic
Anemia, bleeding, neutrophil dysfunction
Gastrointestinal
Metabolic
Elevated phosphorus, calcium

Complications of vascular access

Stenosis - grafts higher rate than fistulas

Thrombosis - loss of bruit or thrill
Infection - will not have usual signs, pain
Hemorrhage - direct pressure, tourniquet
Aneurysm - rare, rarely rupture
Heart failure - high output if >20% thru
Peritoneal dialysis

Infection is common
Symptoms include cloudy dialysate, fever, and abdominal pain
Coag negative Staph account for >70%
Look at catheter site - if not infected look for other causes of peritonitis
Therapy is intraperitoneal cefazolin and gentamicin
Dialysis

Major lifestyle issues

Can take vacation

Renal Transplant

Is the most common solid organ transplant

During the 1st year most deaths are infectious
Renal failure in transplant patients is defined as 20% rise in baseline
creatinine (not 50%)
Renal Transplant - rejection

Rejection less common with living donors

Hyperacute - in operating room
Acute - first 3 months
Chronic - more than 1 year after transplant
Immunosuppression directed towards cell-mediated immunity
Azathioprine, Cyclosporine, Prednisone, Cellcept

Infectious complications

Viral infections - mostly herpes

CMV - fever, malaise, penumonia, chorioretinitis
EBV - mono or PTLD
HSV - oral ulcerations or disseminated dz
VZV - shingles or virulent chicken pox
Hepatitis B or C
Bacterial - UTI, GI tract
Fungal - Candidiasis, aspirgillus, cryptococcus
Parasitic - PCP, toxo
Infectious complications

CMV is responsible for >66% of febrile episodes in first 6 months posttransplant

Transmission of CMV occurs from a seropositive donor
Diagnosis with viral culture and antibody titers
Treatment with ganciclovir and foscarnet are effective treatments.

Hematuria

Up to 1 million RBCs pass into urine daily

The amount of blood does not correlate with the severity of disorder
Causes can be hematologic, renal and postrenal
Timing of bleeding can be helpful
15-20% of people exhibit hematuria after strenuous exercise
Hematuria

Most common causes include:

Kidney stones, bladder/kidney CA, urethritis, UTI,
BPH and GN
Other causes
Hematologic: coagulopathy, sickle cell, anticoagulants
Glomerular: GN, papillary necrosis
Renal: renal infarction, TB, pyelo, PCKD, AIN, tumor,
trauma
Lower Tract: Stones, tumor, cystitis, prostatitis,
urethritis, exercise, BPH

Other: beets, food coloring, red berries, drugs

Hematuria - work-up

Urinalysis
BUN/Creatinine
Coags only if anticoagulated
Cystoscopy is the initial study of choice
Imaging only if history suggests upper tract disease
Most patients can be discharged
Renal - Key Points

Think of ARF as pre-renal, renal or post-renal

Rule out pre-renal and post-renal in ED
Indications for emergent dialysis include
Acidosis, hyperkalemia, fluid overload,
encephalopathy
Drug overdose
Call Nephrology early for dialysis