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RIFLE Study: Application to Practice Cammy House-Fancher, ACNP University of Florida

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Text of RIFLE Study: Application to Practice Cammy House-Fancher, ACNP University of Florida

  • Slide 1
  • RIFLE Study: Application to Practice Cammy House-Fancher, ACNP University of Florida
  • Slide 2
  • RENAL BLOOD FLOW Kidneys receive 20-25% of CO Autoregulation: maintains constant in GFR MAP 80-180 mmHg prevents changes in GFR Afferent arterioles ability to dilate or constrict Filtration ceases MAP
  • LossPersistent ARF=Complete loss of Kidney Function>4 weeks ESKD End Stage Renal Failure (>3 months)
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  • Critical Care Environment AKI is marker of Mortality
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  • ACUTE RENAL FAILURE: ARF Definition: any sudden severe impairment or cessation of kidney function: characterized by accumulation of nitrogenous wastes and fluid and electrolyte imbalances: Prerenal : disrupted blood flow to the kidney
  • STAGES OF ARF Oliguric-Anuric: when urine output is > Mortality: 50-60% Other: metabolic acidosis, water gain w/ dilutional hyponatremia, hyperkalemia, hyperphosphatemia, hypocalcemia, hypermagnesemia, azotemia
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  • STAGES OF ARF Diuretic: urine output is >400cc/24h until lab values stabilize Duration: 1-2 weeks Urine output: may > 3L/24h (1500-2000 normal) BUN/creatinine: Mortality: 25% Other: metabolic acidosis, Na may be normal or low, high K continues
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  • STAGES OF ARF Recovery: period of time between when the lab values stabilize until they are normal Duration: 3-12 months BUN/creatinine: back to 100% normal Mortality: 10-15% Other: uremia, acid-base imbalances, and electrolyte imbalances gradually resolve
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  • TREATMENT Support renal perfusion and improve GFR Volume Inotropes, vasopressors (dopamine)?????? NO! Administer diuretic challenge Maintain fluid, lyte, and acid-base balanced Na, K, phosphorus, magnesium Diminish accumulation of nitrogenous wastes Protein restriction, dialysis
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  • TREATMENT Prevent further damage to kidney Eliminate nephrotoxic agents Monitor peak and trough levels of drugs Nutrition Prevent infection Monitor and treat anemia (Epogen)
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  • MANAGEMENT: COMPLICATIONS Renal failure increases mortality overall Renal: chronic RF in 25-30% of ARF CV: dysrhythmias, HTN, pericarditis, pulmonary edema, HF Neurologic: coma, seizures Metabolic: lyte imbalance GI: PUD, hemorrhage, anorexia, N/V, abd distention, pancreatitis, ileus
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  • MANAGEMENT: COMPLICATIONS Hematologic: anemia, uremic coagulopathies, >WBC, plts dysfunction Infection: pneumonias, Immunosuppressed Pulmonary: pulmonary edema, hyperventilation, acid- base imbalance Nutrition
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  • RENAL REPLACEMENT THERAPIES Dialysis Semipermeable membrane Blood/dialysate Principles: Types: Peritoneal Hemodialysis Continuous Renal Replacement Therapy
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  • Reasons for CVVHD Electrolyte disorder Hypoxemia Met acidosis Symptomatic uremia Bleeding: plts (DDAVP) Pericarditis Intolerance to HD Clear Myoglobin Rhabdomyolysis Obese Pt undergoing surgery ICP w liver failure
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  • Evidence Unknown at present time which form of dialysis is best for renal recovery There is an increase in CRRT esp. in the pt with sepsis and liver/GI disease NO change in mortality Is more costly
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  • Look for AKI Can we prevent AKI?
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  • Preventing AKI Limit dehydration, hypotension, exposure to nephrotoxins Maintaining renal perfusion pressure: not just pressure remember abdominal compartment syndrome
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  • Strategies to Prevent AKI IV isotonic hydration Maintenance of adequate MAP (>65) Minimizing nephrotoxin exposure
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  • Strategies to Prevent Contrast Nephropathy N-acetylcysteine Hydration with sodium bicarb Strategies that are under investigation ANP, fenoldopam with septic pts, theophylline, and hemofiltration
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  • Acute Renal Failure Chronic renal failure occurs in about 25% of patients with acute renal failure Careful renal protection must continue
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  • Real Deal Think Renal Protection Thank You
  • Slide 32
  • CRF CRF is a slowly progressive disease that causes gradual loss of kidney function. It can range from mild dysfunction to severe renal failure Over number of years Asymptomatic Progression may be so slow: symptoms occur when RF is 1/10th of normal
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  • Incidence 2 out of 1000 people in US DM and HTN are the two most common causes and account for most cases Other Causes Heart Failure, Hypotension, Glomerulonephritis, kidney stones, obstructive uropathy, Polycystic disease
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  • CRF Categorized as diminished renal reserve, renal insufficiency, or renal failure. Decreased renal function interferes with the kidneys ability to maintain fluid and electrolyte homeostasis. Changes precede predictability
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  • CRF First: ability to concentrate urine declines early Followed by decreases in ability to excrete phosphate, acid and Potassium RF advanced: (GFR < 10mL/min/1.73m 2 ) Ability to dilute UA is lost--volume
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  • CRF As RF progresses Abn of Ca, phosphate, PTH, vit D metabolism, renal osteodystrophy occur Decreased renal excretion of Calcitrol leads to hypocalcemia 2 hyperparathyroidism is common SO---monitoring PTH is recommended
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  • Symptoms Fatigue: anemia Frequent hiccups General ill feeling Generalized itching (pruritus) Headache Nausea and vomiting Unintentional weight loss
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  • Late Symptoms Hyper vomiting, uremic frost Confusion, change is behavior and LOC Decreased sensation in the hands, feet Easy bruising or bleeding Increased or decreased urine output Muscle twitching or cramps Seizures
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  • Diagnosis UA Creatinine Creatinine clearance Potassium--Electrolyte Disturbances Metabolic Acidosis CT scan, Abd MRI, ultrasound Renal Biopsy
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  • Classification Stage 1: normal GFR (>90mL/min/1.73m 2 ) Plus persistent albuminuria Stage 2: GFR 60 to 89 Stage 3: GFR 30 to 59 Stage 4: GFR 15 to 39 Stage 5: GFR < 15
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  • ESRD A. 90% nephrons damaged B. Renal function has deteriorated that chronic and persistent abnormalities exit C. Patient requires artificial support to sustain life D. Uremic syndrome
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  • Treatment Goal: control symptoms, reduce complications, and slow the progression of the disease (tx underlying problem) Fluid restriction, diet control, BP monitoring and control, DM control, Vit D supplements, electrolyte control Doses of all drugs adjusted Dialysis ??
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  • Treatment Underlying disorders and contributory factors must be controlled. Hyperglycemia BP--110 to 130/