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Acute nonoliguric renal failuAcute nonoliguric renal failurere
Ri Ri 黃正憲黃正憲2003/10/272003/10/27
Acute Renal FailureAcute Renal Failure Definitions:Definitions:
An increase in the An increase in the serum creatinine of serum creatinine of 0.5 0.5 mg/dl over baseline valuemg/dl over baseline value
An increase in the serum creatinine of more than An increase in the serum creatinine of more than 50% over base line value50% over base line value
A reduction in the calculated creatinine clearance A reduction in the calculated creatinine clearance of 50%of 50%
A decrease in the renal function that results in A decrease in the renal function that results in the need for dialysisthe need for dialysis
Category Category
1. urine output1. urine outputAnuric: <100 mL/dAnuric: <100 mL/dOliguric: 100-500 mL/dOliguric: 100-500 mL/dNonoliguric: >500 mL/d
2. the more common 2. the more common Pre-renalPre-renal IntrinsicIntrinsicPost-renalPost-renal
Acute Renal FailureAcute Renal Failure
Pre Renal CausesPre Renal Causes - Intravascular volume depletion from vomiting - Intravascular volume depletion from vomiting
diarrhea, diarrhea, poor fluid intake, fever, use of diureticspoor fluid intake, fever, use of diuretics - Decreased glomerular perfusion in the setting of - Decreased glomerular perfusion in the setting of renal artery atherosclerotic disease with decreased renal artery atherosclerotic disease with decreased systolic head of BP, use of ACE inhibitors or NSAIDSsystolic head of BP, use of ACE inhibitors or NSAIDS - Decreased effective arterial blood volume in CHF, - Decreased effective arterial blood volume in CHF,
liver dysfunction, septic shock, anesthesialiver dysfunction, septic shock, anesthesia
Acute Renal FailureAcute Renal Failure
Pre Renal CausesPre Renal Causes
Post Renal CausesPost Renal Causes - External compression to the outflow tract from tumors, - External compression to the outflow tract from tumors,
increased intra abdominal pressure, retroperitoneal fibrosisincreased intra abdominal pressure, retroperitoneal fibrosis
- Intrinsic blockage from tumor, calculi, blood clots, - Intrinsic blockage from tumor, calculi, blood clots,
papillary necrosispapillary necrosis
- Intratubular obstruction from crystals and myeloma chains- Intratubular obstruction from crystals and myeloma chains
- Blocked Foley catheter- Blocked Foley catheter
Acute Renal FailureAcute Renal Failure
Pre Renal CausesPre Renal Causes
Post Renal CausesPost Renal Causes
Intrinsic causesIntrinsic causes
Tubulo- Glomerular VascularTubulo- Glomerular Vascular InterstitialInterstitial
Acute Renal FailureAcute Renal Failure
Pre Renal CausesPre Renal Causes
Post Renal CausesPost Renal Causes
Intrinsic causesIntrinsic causes
Tubular Interstitial AcuteTubular Interstitial Acute necrosis nephritis necrosis nephritis glomerulonephritisglomerulonephritis (10% of cases) (5% of cases)(10% of cases) (5% of cases)
Ischemia ToxinsIschemia Toxins(50% of cases) (35% of cases)(50% of cases) (35% of cases)
Ischemic Acute Renal FailureIschemic Acute Renal Failure Intravascular volume depletion and hypotension Gastrointestinal, renal, dermal losses, hemorrhage, shock
Generalized or localized reduction in renal blood flow
IschemicIschemic Acute Renal FailureAcute Renal Failure
Decreased effective intravascular volume: CHF, cirrhosis, nephrosis, peritonitis
Medications: ACE inhibitors, NSAIDS, radiocontrast agents, Ampho B, Cyclosporin
Hepatorenal syndrome
Large vessel renal vascular disease: Renal artery thrombosis or embolism, operative arterial cross clamping, renal artery stenosis
Small vessel renal vascular disease:Atheroembolism, vasculitis, malignant hypertension, hypercalcemia, transplant rejection
SepsisSepsis
Toxin induced Acute Renal FailureToxin induced Acute Renal Failure
Reduction in renal perfusion thrReduction in renal perfusion through alteration of intra renal heough alteration of intra renal hemodynamicsmodynamics
Direct tubular injuryDirect tubular injury
Heme pigment induced ARFHeme pigment induced ARF
Intratubular obstructionIntratubular obstruction
Allergic Interstitial NephritisAllergic Interstitial Nephritis
Hemolytic Uremic SyndromeHemolytic Uremic Syndrome
NSAIDs, ACE inhibitors, CyclosporiNSAIDs, ACE inhibitors, Cyclosporin, Tacrolimus, IV contrast, Ampho Bn, Tacrolimus, IV contrast, Ampho B
Aminoglycosides, IV contrast, CycloAminoglycosides, IV contrast, Cyclosporin, Cisplatin, Ampho B, Heavy sporin, Cisplatin, Ampho B, Heavy metals, IV immunoglobulinsmetals, IV immunoglobulins
Rhabdomyolysis, Hemolysis, CocaiRhabdomyolysis, Hemolysis, Cocaine, Ethanol, Statinsne, Ethanol, Statins
Acyclovir, Sulfonamides, Ethylene glAcyclovir, Sulfonamides, Ethylene glycol, myoglobinycol, myoglobin
Penicillins, Cephalosporins, SulfonaPenicillins, Cephalosporins, Sulfonamides, Rifampin, Cipro, NSAIDs, Thimides, Rifampin, Cipro, NSAIDs, Thiazides, Cimetidine, Allopurinolazides, Cimetidine, Allopurinol
Cyclosporin, Cocaine, Mitomycin, QCyclosporin, Cocaine, Mitomycin, Quinineuinine
Categories of anuria, oliguria, and nonoliguria Categories of anuria, oliguria, and nonoliguria may may bebe useful in differential diagnosis of ARF. useful in differential diagnosis of ARF.
AnuriaAnuria - Urinary tract obstruction, renal artery ob - Urinary tract obstruction, renal artery obstruction, RPGN, bilateral diffuse renal cortical nstruction, RPGN, bilateral diffuse renal cortical necrosisecrosis
OliguriaOliguria - Prerenal failure, hepatorenal syndrome - Prerenal failure, hepatorenal syndrome Nonoliguria Nonoliguria – AIN, AGN, partial obstructive neph– AIN, AGN, partial obstructive neph
ropathy, nephrotoxic and ischemic ATN, radiocoropathy, nephrotoxic and ischemic ATN, radiocontrast-induced ARF, and rhabdomyolysisntrast-induced ARF, and rhabdomyolysis
Nonoliguric ARFNonoliguric ARF
Oliguria is a frequent but not invariable clinOliguria is a frequent but not invariable clinical feature (~50%). ical feature (~50%).
Harrison’s 15ed
Nonoliguric ARFNonoliguric ARF
ATN: aminoglycoside, ATN: aminoglycoside, streptomycinstreptomycin, polymyxin B,, polymyxin B, lithium, or cisplatin nephrotoxicity. lithium, or cisplatin nephrotoxicity.
Case report:Case report: Celecoxib-induced Celecoxib-induced nonoliguric acute renal failure
Annals of Pharmacotherapy. 36(1):52-4, 2002 Jan.Annals of Pharmacotherapy. 36(1):52-4, 2002 Jan.
Lupus nephritisLupus nephritis American Journal of the Medical Sciences. 321(6):381-7, 2001 Jun.American Journal of the Medical Sciences. 321(6):381-7, 2001 Jun.
Isoniazid-induced Isoniazid-induced crescentic glomerulonephritis Omeprazole-induced Omeprazole-induced acute interstitial nephritis..
…………..
Nonoliguric ARFNonoliguric ARF
Glomerular alterations in experimental oliguric and nonoliguric acute renal failure.
tubular damage was more pronounced in olig was more pronounced in oliguric kidneys…. There was uric kidneys…. There was no significant difference in these glomerular changes between oli in these glomerular changes between oliguric and nonoliguric kidneys. guric and nonoliguric kidneys.
The findings suggest that less reduction in the The findings suggest that less reduction in the whole-kidney GFR in nonoliguric ARF kidneys whole-kidney GFR in nonoliguric ARF kidneys is ascribed largely to is ascribed largely to less pronounced tubular damage rather than to less severe glomerular morphologic alterations.
Renal Failure. 15(2):215-24, 1993.
Nonoliguric ARFNonoliguric ARF
Acute renal failure: clinical outcome and causAcute renal failure: clinical outcome and causes of death.es of death.
Higher mortalityHigher mortality was observed in was observed in oliguric patieoliguric patientsnts (62.9%) than nonoliguric (34.5%) (p < 0.0 (62.9%) than nonoliguric (34.5%) (p < 0.05) and in 5) and in ischemic renal failureischemic renal failure (56.7%) when (56.7%) when compared to nephrotoxic renal failure (14.7%) compared to nephrotoxic renal failure (14.7%) (p < 0.05).(p < 0.05).
Renal Failure. 19(2):253-7, 1997 Mar
Nonoliguric ARFNonoliguric ARF
Acute renal failure in a teaching hospital.
…Compared with nonoliguric patients, oliguric patients had higher mortality (56.3% vs 18.9%, p < 0.01), and needed dialysis more frequently (43.8% vs 12.9%, p < 0.01)
Singapore Medical Journal. 36(3):278-81, 1995 Jun.
Conclusion Conclusion
Nonoliguric acute renal failure Although the causes of nonoliguric renal failure vAlthough the causes of nonoliguric renal failure v
aried, aried, nephrotoxic failure occurred more frequent occurred more frequently in nonoliguric than in oliguric subjects (P <0.0ly in nonoliguric than in oliguric subjects (P <0.01). 1).
As compared to oliguric patients, those without oAs compared to oliguric patients, those without oliguria had significantly lower urinary sodium conliguria had significantly lower urinary sodium concentrations (P<0.05) and FENa (P < 0.02), had scentrations (P<0.05) and FENa (P < 0.02), had shorter hospital stay (P < 0.01), had fewer septic horter hospital stay (P < 0.01), had fewer septic episodes, neurologic abnormalities, gastrointestiepisodes, neurologic abnormalities, gastrointestinal bleeding and acidemia, required dialysis less nal bleeding and acidemia, required dialysis less frequently (P < 0.001) and had lower mortality rafrequently (P < 0.001) and had lower mortality rate (P < 0.05). te (P < 0.05).
NEJM. 296(20):1134-38,1977 May
Management of acute renal Management of acute renal failure failure
Management of volume homeostasisManagement of volume homeostasisManagement of electrolyte homeostasisManagement of electrolyte homeostasisManagement of acid- base homeostasisManagement of acid- base homeostasisManagement of uremia Management of uremia Nutritional management in acute renal Nutritional management in acute renal
failure failure Dialysis in acute renal failure Dialysis in acute renal failure
Management of volume Management of volume homeostasishomeostasis
Record I/O Record I/O Physical examination Physical examination Fluid = urine output + 300-500Fluid = urine output + 300-500Sodium intake<2 g/daySodium intake<2 g/dayDiureticsDiureticsLow dose dopamin ( 0.3 ug/kg/min)Low dose dopamin ( 0.3 ug/kg/min)CVP or pulmonary capillary wedge pressurCVP or pulmonary capillary wedge pressur
e e
Management of electrolyte homManagement of electrolyte homeostais eostais
Hypernatremia and hyponatremiaHypernatremia and hyponatremiaHyperkalemiaHyperkalemiaHypocalcemia Hypocalcemia Hypomagnesemia Hypomagnesemia Hyperphosphatemia Hyperphosphatemia
Management of acid- base Management of acid- base homeostasishomeostasis
Dietary protein restriction 0.8-1.0g/kg of bDietary protein restriction 0.8-1.0g/kg of body weight 30 kcal /kg/day ( except hyperody weight 30 kcal /kg/day ( except hypercatabolism )catabolism )
Look for cause of acidosis Look for cause of acidosis Sodium bicarbonate Sodium bicarbonate Dialysis Dialysis
Management of uremiaManagement of uremia
Fatigue, lethargy, mental dullness, norexia Fatigue, lethargy, mental dullness, norexia and nausea and nausea
More serious– myoclonus, confusion, deliriMore serious– myoclonus, confusion, delirium or coma, seizure and pericarditis um or coma, seizure and pericarditis
Diet protein controlDiet protein controlCheck GI bleeding Check GI bleeding Hemodialysis Hemodialysis
Nutritional management in Nutritional management in acute renal failure acute renal failure
Minimal recommand protein intake0.6-0.8gMinimal recommand protein intake0.6-0.8g/kg/day/kg/day
Carbohydrate and lipid should maximal witCarbohydrate and lipid should maximal with a target of providing 30-65kcal /kg/dayh a target of providing 30-65kcal /kg/day
Limit fluid volume potassium , magnesium, Limit fluid volume potassium , magnesium, and phosphorus should avoid.and phosphorus should avoid.
Indications for dialysisIndications for dialysis
Absolute indicationsAbsolute indications
uremic symptomsuremic symptoms
uremic pericarditisuremic pericarditis Relative indicationsRelative indications
volume overlosdvolume overlosd
hyperkalemiahyperkalemia
metabolic acidosismetabolic acidosis
Other electrolyte abnormalitiesOther electrolyte abnormalities
Drug management in acute Drug management in acute renal failure renal failure
Stop nephrotoxic drugsStop nephrotoxic drugsAdjust medication doseAdjust medication doseCheck drug level Check drug level
Thanks for your attentionThanks for your attention