I Wanna Pee

1
I Wanna PeeBut I Cant!!!Renal Failure
Dialysis In the ED

• A.F. Chad, MD, CCFP
• Resident Rounds July 25, 2002

2
Definitions ARF

• Deteriorating GFR over hours to days
• 50 decrease in GFR
• 50 decrease in CrCl
• 50 increase in Scr
• Need dialysis
• Non-oliguric vs oliguric vs anuric

3
Plumbing

• GFR
• Gradient Glomerulus Bowmans Capsule
• Glomerulus pressure depends on RBF
• RBF afferent efferent arterioles

4
When Kidney Pie Goes Wrong

• Acute
• Chronic
• Acute on Chronic
• Transplant

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When Kidney Pie Goes Wrong

• Pre-renal
• Intrinsic
• Post-renal
• Evil Kidney Gnomes

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Before Kidney Pie Goes Wrong

• Most common cause
• 40-80
• Decreased renal perfusion

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Before Kidney Pie Goes Wrong

• Hypovolemia
• Sequestration
• Cardiac
• Renal artery
• Small Vessel

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Inside Kidney Pie Goes Wrong

• 11-45
• 45 of kids
• ATN 2nd to ischemia
• 25 nephrotoxins

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Inside Kidney Pie Goes Wrong

• Tubular
• Interstitial
• Glomerulonephritis
• Vasculitides

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After Kidney Pie Goes Wrong

• 2-5
• 20-35 of Old Men
• Young Men - stones
• Young Women - CA
• Kids
• M postrior urethral valve
• F VCUR

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After Kidney Pie Goes Wrong

• Urethra and Bladder Outlet
• Ureter
• Intra Renal Failure

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When It All Goes Down the Loo

• GFR -gt gradient b/t glomerulus Bowman
• Pressure determined by aff eff a.a.
• Prerenal decreased RBF
• Intrinsic release of vasoconstrictors
• Postrenal increased tubular pressure

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When It All Goes Down the Loo

• Low RBF -gt cell death -gt slough -gtblock
• Nephrons Filtration hypertrophy
• Too many damaged -gt hypertrophy -gt sclerosis
  -gt Decreased GFR -gt CRF

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This is NOT good for you!!!

• Mortality 40-90
• No change since Dialysis (other causes now)
• OR for dying 4.9 for ARF
• Worse for anuric / oliguric
• 20-60 will need dialysis
• 25 of these long term

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What 2 Ask?

• FIFE
• Sx of Hypovolemia (NVD, CVD, Hemorrhage,
  insensible)
• Infxn, HypoTN, Meds, Xray, MSK, Allergy
• Prostatism, OR, Gyne, Stones
• Usuals (PMHx, All, ROS, FHx, SHx)

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What 2 look for?

• ABCs, VS (esp HR BP - orthostatic)
• Fluid status
• Derm (skin, eyes)
• CV Resp
• Abdo (MAGIC FINGER!!!)
• MSK

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What 2 Order? (Pizza? Chinese?)

• RM
• BUN, Creatinine,
• Lytes
• CBC
• Urine Lytes
• ABG
• other

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What 2 Calculate

• Cockroft-Gault Equation (He taught me does
  ice sculptures _at_ Xmas)
• CrCl(140-age)xWt / Scr
• (x 0.85 for F)
• N120mL/min
• Fractional Excretion of Na
• FeNa (UNa/PNa) X (UCr/PCr) X 100
• lt1 - Prerenal, gt1 ATN

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What 2 See?

• U/S
• IVP
• CT
• Nuc Med
• KUB
• Renal Biopsy

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Who Cares About This Crap! What Do I Do?!?!

• ABCD
• Stop Toxins
• Rx post renal - Catheter
• Volume status
• Correct Lytes, Acid-Base
• Drugs?
• Dialyse

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Diuretics?

• CRAP!
• 92 pts with ARF given diuretic or placebo
• NO change in recovery, need for HD, death
• Shilliday IR, Quinn KJ, Allison ME. Loop
  diuretics in the management of acute renal
  failure a prospective, double-blind,
  placebo-controlled, randomized study. Nephrol
  Dial Transplant 1997 Dec12(12)2592-6

22
Dopamine?

• Not helpful in RCT of CVD OR pts Lassnigg A,
  Donner E, Grubhofer G, Presterl E, Druml W,
  Hiesmayr M.Lack of renoprotective effects of
  dopamine and furosemide during cardiac surgery.
  J Am Soc Nephrol 2000 Jan11(1)97-104
• Not Helpful in Anaesthesia either
• Hladunewich M. Pathophysiology and management of
  renal insufficiency in the perioperative and
  critically ill patient. Anesthesiol Clin North
  America - 01-Dec-2000 18(4) 773-89

23
CCB?

• Not helpful 4 prevention radiocontrast tox
• Carraro M, Mancini W, Artero M, Stacul F,
  Grotto M, Cova M, Faccini L Dose effect of
  nitrendipine on urinary enzymes and
  microproteins following non-ionic radiocontrast
  administration. Nephrol Dial Transplant 1996
  Mar11(3)444-8

24
Mannitol HCO3?

• Good for Rhabdo within 6hrs
• Better OS, Rubenstein I Management of shock and
  acute renal failure in casualties suffering from
  the crush syndrome. Ren Fail 19647 1997.

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Pee for Them Hemodialysis

• Acidosis
• Lytes (esp K)
• Fluid (too much)
• Uremia (pericarditis, encephalopathy)
• Drugs
• Evil Humours

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Disposition Bring em in!!!
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Definitions CRF

• Progressive decline in GFR over months to years
• Irreversible
• Chronic insufficiency GFR30-70mL/min
• CRF GFRlt30mL/min
• ESRD GFRlt10mL/min

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CRF problems

• Lytes
• Pericardium
• IHD
• HypoTN
• Dysequilibrium
• Infection
• Vascular

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ESRD

• Kidneys dont work -gt Uremia
• 96 - USA- 300,000 Rx (75,000 new)
• DM (33), HTN (25), Glomerular (18), Evil
  Kidney Gnomes (0.371)
• Either get New Kidney(s) or Dialysis
• 30 5 year survival rate (with Rx!)
• CVD (50), Infxn (25), Withdrawal

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ESRD Beware the Gnomes!
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UREMIA This is Mucho Bad!!!

• CLINICAL Dx!!!

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UREMIA Neuro

• Uremic Encephalopathy
• Dialysis Dementia
• SDH
• Peripheral

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UREMIA CV

• HTN
• CHF
• Pericarditis

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UREMIA Heme

• Anemia
• Bleeding
• Immunocompromise

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UREMIA GI

• GIB
• Ascites
• NV
• Diverticular Dx

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UREMIA Bone

• Metastatic Calcification
• s
• Cysts
• CTS

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I Will Be Your Kidney Dialysis
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How Does HD Work?

• Pts blood into HD machine
• Filter instead of glomerulus
• Gradient determines fluid solute removal
• Lytes (Na, K, Cl, HCO3, Ca, Mg), Glucose
• Not proteins

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How Does PD Work?

• Uses peritoneum as filter
• Diasylate varied osmotic pressures
• Fluid left in for a while, then drained

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I Will Be Your Kidney Dialysis

• Chart review 50 CRF pts in Camden, NJ 68 went
  home post HD in ED ERSacchetti A .ED
  hemodialysis for treatment of renal failure
  emergencie.s Am J Emerg Med - 01- May-1999
  17(3) 305-7
• Chart review 288 HD pts presenting to ER in
  Albany, NY 68 admitted McErlean M et al.The
  Emergency Department Care of Hemodialysis
  Patients. Acad Emerg Med - 1999 6(5)538.

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Complications During HD

• Vascular
• Hypotension
• Dysequilibrium
• Air Embolism
• Lytes

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What 2 Ask HD?

• Cause ESRD?
• Dialysis schedgy (missed appt?)
• Baseline Weight, Labs
• Weight gain b/t HD
• Sx Uremia

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What 2 Look 4 HD?

• VS
• Vascular Access
• CV
• Neuro

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What 2 Ask PD?

• Cause ESRD?
• Recent PD complications
• Baseline weight, labs
• Sx Uremia

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What 2 Look 4 PD?

• VS
• Abdomen
• Peritoneal catheter

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I can PEE Again!!!! Transplant Specific Issues

• Rejection
• Infection
• ARF
• CVD
• Liver Dx
• The BIG C

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Pee 4 You What 2 Ask?

• FIFE
• Temp?
• Date of Transplant
• Graft Source?
• Rejection Hx
• Chronic Infxn
• Baseline (creatinine, wt, VS)
• PMHx, Meds, All, SHx

48
Special 4 Borrowed Kidneys ARF

• AFR in Transplanted 20 change in Scr
• Causes
• Surgical complications
• Rejection
• Immunosuppressive Nephrotoxicity

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Special 4 Borrowed Kidneys Infections ONE mos
post Surg

• UTI (E.Coli)
• IVs (S.aureus, S. viridans)
• Pneumonias (streptococcus)

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Special 4 Borrowed Kidneys Infections SIX mos
post Surg

• Viremia (CMV, EBV)
• Meningitis (Listeria)
• Sepsis (Aspegillosis)

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Special 4 Borrowed Kidneys Infections Later on

• Like you I (with min immunosupression)
• Chronic (EBV, CMV, Heps)
• Opportunistic (with max immunosupression)

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THE END

• QUESTIONS will be answered on a fee for service
  basis.