Mr Brown hasnt passed urine since last shift

1
Mr Brown hasnt passed urine since last shift

• Suda Swaminathan
• Department of Nephrology
• Royal Perth Hospital

2
65 yr male Day 1, 0300 hrs

• Admitted 2100 yesterday with chest pain,
  pulmonary oedema, BP 180/100 and NSTEMI (trop 10)
• Settled with O2, frusemide and morphine
• Initial diuresis then oliguria
• PMH
• Hypertension 10yrs Rx ramipril, usually 140/80
• Osteoarthritis L hip Rx meloxicam
• Ex-smoker 20/d, age 20-60

3
Any extra history?

• Oliguria
• No current discomfort or dysuria
• No prior prostatism, calculi or family history of
  CKD
• Previous serum creatinine 95 umol/L 2 months ago
• CVS
• ?L calf claudication 2 yrs
• No previous angina or exertional dyspnoea

4
Key questions for you

• Urgency
• MET call (K, APO)?
• Acute retention?
• Volume status
• wet or dry?
• warm or cold?

• Cause
• Pre-renal?
• Renal?
• Glom, Tubl, Int, Vasc
• Post-renal?
• ARF or Acute-on-CKD?

5
Day 1, 0315 hrs

• BP 110, P 120 AF
• Ht 170cm, 68Kg
• Cool, JVP 3cm
• S4 gallop
• Bibasal creps
• Poor pulses
• Gde II fundi

• Bladder scan 20 mls
• Creat 120
• K 5.1, HCO3 19
• MSU bland
• Diagnosis?

6
Pre-renal acute renal failure

• Relative hypotension 2 to AF/LVF
• Rx DC cardioversion
• How severe is his ARF?
• Exacerbated by concurrent ACEI NSAID
• ACEI prevent efferent arterioles constricting
• NSAID prevent afferent arterioles dilating
• Underlying PVD
• Does he have underlying CKD (eg mild
  nephrosclerosis?)
• If so, how severe is his CKD (ie baseline GFR?)

7
New terminology ARF ? AKIAcute kidney injury

• Stage GFR Urine output
• (mls/kg/hr)
• Risk Creat x 1.5 lt 0.5 x 6hrs
• Injury Creat x 2 lt 0.5 x 12 hrs
• Failure Creat x 3 lt 0.3 x 24 hrs
• (or gt 400) (or 0 x 12 hrs)
• Loss Dialysis gt 4 wks
• ESKD Dialysis gt 12 wks

8
CKD grading by GFR

• gt 140 Hyperfiltration
• 90-120 Normal
• lt 90 Mild CKD
• lt 60 Moderate CKD
• lt 30 Severe CKD
• 5-15 End-stage CKD

9
eGFR MDRD vs C G

• MDRD
• Based on age, sex, creatinine
• Automated, /- Afr US
• No adjustment for size or ATSI
• No answer gt60 mls/min
• No normal range

• Cockroft Gault (MT)
• Based on age, sex, creatinine weight
• (140-age) x lean wt
• stable creatinine
• x 1.23 for males
• N (140 age) mls/min

10
Mr Brown baseline eGFR

• 65 yo, Ht 170cm, 68 Kg, creatinine 95
• eGFR (140 65) x 68 x 1.23
• 95
• 66 mls/min
• Normal GFR for age (140 65) 75

11
Day 1, 0600

• Successful cardioversion
• Warm, BP 130/90, P 80, JVP 0 _at_ 10o
• 0.5L saline
• Warm, BP 150/90, P 80, JVP 0 _at_ 40o
• Urine output returns 1 hour later

12
Day 2

• Well, BP 140/70, P 80 SR
• Creatinine 100
• Extensive anterior reversible perfusion defect on
  dipyridamole-thallium scan

13
Day 3

• 0900 hrs Coronary angio, 50mls contrast
• Severe triple vessel disease, suitable for CABG
• 1800 Creatinine 130
• ?diagnosis
• ?action

14
Radiocontrast media toxicityacute tubular
necrosis

• Avoidance
• Non-contrast imaging
• Minimisation
• Pre-hydration IV saline, or NaHCO3
• N-acetyl cysteine
• Low-volume, isosmolar contrast
• Treatment
• Nil

15
Day 6

• CABG x 5
• Surgical ICU
• BP 140 warm fingers
• Blotchy lower limb skin perfusion
• Purpuric spots on toes
• WBC 11.0, Eosinophils 1.1
• Diagnosis?

16
Athero-emboliacute renal vascular injury

• Cholesterol plaque
• Multiple micro-infarcts
• Skin, calves, gut, kidneys, brain
• Irreversible

17
Day 9

• On CV surgical ward
• 0800 hrs Creatinine stable at 180
• CVC line in situ
• 1400 hrs fever, rigor
• Urine output lt 20mls/hr next 3 hrs

18
Staph sepsis

• Pre-renal acute-on-CKD, risk of acute tubular
  necrosis if prolonged
• Remove CVC, culture blood tip
• Broad-spectrum Abs
• IV saline
• Improved and afebrile by next day

19
Day 15

• Fever returning last 2 days
• Maculo-papular truncal rash
• Eosinophil count increased again
• Creatinine 180 ? 230
• Diagnosis?

20
Acute interstitial nephritis

• Day 7-10 of penicillin
• Withdraw antibiotic wait
• Steroids may reduce fever rash, ??shorten
  duration of dialysis

21
Day 25 Discharge

• Moderate LVF
• Creatinine 250
• Cardiology RMO adds spironolactone to his
  ramipril, metoprolol, aspirin and atorvastatin

22
Re-admitted 5 days later

• Leg weakness, no reflexes
• K 7.2, HCO3 18, creatinine 280
• ECG tall peaked T waves, flat P waves
• What do you do?

23
Acute management of K

• IV Calcium CO3 stabilise cell membranes
• Cause spironolactone ACEI
• Stop input check diet
• Re-distribute salbutamol, HCO3, insulin/gluc
• Remove from body
• diuresis (if non-oliguric),
• diarrhoea (sorbitol, PR resonium),
• dialysis

24
Take-home messages

• CV risk renal risk
• Elderly patients have elderly kidneys
• Prevention is better than cure
• Withdraw NSAIDs on admission
• Hydrate when fasting
• N-acetyl cysteine pre-contrast
• Watch drugs (retention, nephrotoxicity)
• Hyperkalemia is a medical emergency