I Wanna Pee…But I Can’t!!!Renal Failure & Dialysis

In the ED

A.F. Chad, MD, CCFPResident Rounds: July 25, 2002

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

Plumbing

• GFR• Gradient: Glomerulus

& Bowman’s Capsule• Glomerulus pressure

depends on RBF• RBF: afferent &

efferent arterioles

When Kidney Pie Goes Wrong

• Acute• Chronic• Acute on Chronic• Transplant

When Kidney Pie Goes Wrong

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

Before Kidney Pie Goes Wrong

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

Before Kidney Pie Goes Wrong

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

Inside Kidney Pie Goes Wrong

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

Inside Kidney Pie Goes Wrong

• Tubular• Interstitial• Glomerulonephritis• Vasculitides

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

After Kidney Pie Goes Wrong

• Urethra and Bladder Outlet• Ureter• Intra Renal Failure

When It All Goes Down the Loo

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

When It All Goes Down the Loo

• Low RBF -> cell death -> slough ->block• Nephrons: ++ Filtration & hypertrophy • Too many damaged -> ++ hypertrophy ->

sclerosis -> Decreased GFR -> CRF

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

What 2 Ask?

• FIFE• Sx of Hypovolemia

(N&V&D, CVD, Hemorrhage, insensible)

• Infxn, HypoTN, Meds, Xray, MSK, Allergy• Prostatism, OR, Gyne, Stones• Usuals (PMHx, All, ROS, FHx, SHx)

What 2 look for?

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

What 2 Order? (Pizza? Chinese?)

• R&M• BUN, Creatinine,• Lytes• CBC• Urine Lytes• ABG• other

What 2 Calculate

• Cockroft-Gault Equation (He taught me & does ice sculptures @ Xmas)

– CrCl=[(140-age)xWt] / Scr– (x 0.85 for F)– N~120mL/min

• Fractional Excretion of Na– FeNa = (UNa/PNa) X (UCr/PCr) X 100– <1% - Prerenal, >1% ATN

What 2 See?

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

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

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

Diuretics?

CRAP!92 pts with ARF given diuretic or placeboNO 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 Dec;12(12):2592-6

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 Jan;11(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

CCB?

• Not helpful 4 prevention radiocontrast toxCarraro 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 Mar;11(3):444-8

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 19:647 1997.

Pee for Them: Hemodialysis

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

Disposition: Bring ‘em in!!!

Definitions: CRF

• Progressive decline in GFR over months to years

• Irreversible• Chronic insufficiency: GFR=30-70mL/min• CRF: GFR<30mL/min• ESRD: GFR<10mL/min

CRF: problems

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

ESRD

• Kidneys don’t work -> 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

ESRD: Beware the Gnomes!

UREMIA: This is Mucho Bad!!!

• CLINICAL Dx!!!

UREMIA: Neuro

• Uremic Encephalopathy• Dialysis Dementia• SDH• Peripheral

UREMIA: CV

• HTN• CHF• Pericarditis

UREMIA: Heme

• Anemia• Bleeding• Immunocompromise

UREMIA: GI

• GIB• Ascites• N&V• Diverticular Dx

UREMIA: Bone

• Metastatic Calcification• #’s• Cysts• CTS

I Will Be Your Kidney: Dialysis

How Does HD Work?

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

How Does PD Work?

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

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.

Complications During HD

• Vascular• Hypotension• Dysequilibrium• Air Embolism• Lytes

What 2 Ask HD?

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

What 2 Look 4 HD?

• VS• Vascular Access• CV• Neuro

What 2 Ask PD?

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

What 2 Look 4 PD?

• VS• Abdomen• Peritoneal catheter

I can PEE …Again!!!! Transplant Specific Issues

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

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

Special 4 Borrowed Kidneys: ARF

• AFR in Transplanted: 20% change in Scr• Causes:

– Surgical complications– Rejection– Immunosuppressive Nephrotoxicity

Special 4 Borrowed Kidneys: Infections ONE mos post Surg

• UTI (E.Coli)• IV’s (S.aureus, S. viridans)• Pneumonias (streptococcus)

Special 4 Borrowed Kidneys: Infections SIX mos post Surg

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

Special 4 Borrowed Kidneys: Infections Later on

• Like you & I (with min immunosupression)• Chronic (EBV, CMV, Hep’s)• Opportunistic (with max

immunosupression)

THE END

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