Renal Failure in the ED

1. Renal Failure in the ED CCFP(EM) Core Lecture Presentation University of Ottawa Dr. Debra J. Weatherhead, MD, CCFP (EM), FCFP April 25, 2013

2. Learning Objectives 1) Know the terminology associated with renal failure. 2) Know the causes and ED management of Acute Renal Failure (ARF). 3) Know the ED management of dialysis related emergencies.

3. Renal failure ..... Who?

4. Older Diabetic Hypertensive

5. A Case in Review • 8 yo F. Previously healthy. • Seen by FD #1 Wed for watery D. • F/U arranged for Fri afternoon. • Fri afternoon: drinking but still D. Since the am, blood in D. Dehydrated. Arrangements made for admission, rehydration & investigations.

6. Arrived at hosp @ 6pm. • Bloodwork done. • Stool cultures sent. • Rehydration started .

7. Sat am: FD # 2 doing rounds notes abN lytes , elevated WBC & sl decreased Plts. • Peds #1 consulted. • Dx SIADH.  Fluid restricted. • Febrile. Bloody D & anorexia persisting.

8. Sun am: FD # 3 morning rounds & Peds #1. Fluid restriction continued. • Sun pm FD #3 called re: increased abdo pain --> Demerol 60 mg IM ordered. • Mon 0100 hr FD #3 called re: increased abdo pain--> Demerol 60 mg IM ordered

9. Mon 0500 hr FD 3# called: much worse, increased abdo pain, tachycardiac, hallucinating, worsening dehydration …Demerol 60mg IM ordered.

10. 0720 hr Mon am: FD #1 signs into hospital computer --> immediately receives stat call to peds.

11. Looks ill. Looks toxic. Child is SICK !!! • Tachycardiac. Tachypneic. Febrile. • Severely dehydrated. Hallucinating. • Moaning in pain - lying rigidly. • Bed bumped -- child screams in pain.

12. rigid abdo • marked signs of peritonitis • multiple areas of petechaie & purpura

13. Markedly elevated WBC • Decreased Hgb • Markedly decreased Plts • Creat > 1300 BUN ~ 30 • Hyperkalemic

14. Diagnosis?

15. Stool cultures ………….. • …….. E . Coli 0157H7

16. Hemolytic Uremic Syndrome (HUS)

17. Anticipated lifetime anti - HTNs. • Amazingly, still N cognitive status but felt that she did lose ~ 5% of her previous cognitive functioning.

18. Terminology • Uremia = contamination of the blood with urine • Azotemia = accumulation of nitrogen in the blood • Urea = the major breakdown product of proteins • Creatinine = a breakdown product of the skeletal muscle protein creatine

19. The normal functions of the kidneys are: • glomerular filtration • tubular reabsorption • secretion

20. Acute Renal Failure (ARF) • The deterioration of renal function over hrs/days  accumulation toxins  loss of homeostasis.

21. Case 1 • 38 yo healthy male • onset watery diarrhea 1200hrs • “too sick” to try po fluids • diarrhea x at least 40 times • you see Px at MN

22. HR-160 80/50 • RR-not done 94% R/A • conscious, looks ashen • states “too weak to talk” • manage this patient….

23. Causes ofAcute Renal Failure (ARF) • Prerenal – decreased perfusion of N kidney - glomerular & tubular fn intact • Renal/Intrinsic – pathology of the kidney • - dz of glomerulus, interstitium, small vessels, tubules • assoc with release of renal vasoconstrictors • most common cause is ischemic ARF (ATN) = acute kidney injury • Postrenal – obstruction of urinary outflow

24. Community-acquired ARF • –most common cause is prerenal • - most common prerenal cause is volume depletion Hospital-acquired ARF - most common cause is renal/intrinsic

25. DDx of Prerenal ARF • Hypovolemia • Hypotension (frank and relative) • Renal artery & small vessel disease • emboli, thrombosis, microvasc thrombosis (DIC, HUS, vasculitis, sickle cell, preeclampsia), medications

26. DDx of Intrinsic ARF • tubular disease • ischemia, nephrotoxins (meds, IV contrast, heme pigments) • interstitial disease • interstitial nephritis (most commonly 2’ meds), infection, sarcoidosis, autoimmune (SLE) • glomerular disease • Goodpasture syndrome, Wegener, HSP • small vessel disease • microvasc thrombosis (DIC, HUS,TTP,vasculitis), malignant HTN, scleroderma

27. DDx of Postrenal ARF • Ureter – stone, stricture, tumor • Urethra & bladder outlet – BPH, Ca, phimosis, obstructed catheter, neurogenic bladder, clot, trauma • Peds – anatomic malformations

28. In postrenal ARF, if complete obstruction, significant permanent loss of renal function after 10-14 days. • Risk of permanent renal failure increases significantly if obstruction is complicated by UTI. • A postvoid bladder residual > 125 cc suggests obstruction ..... Keep catheter in until obstruction resolved.

29. Case #2 • 45 yo healthy male • Norwalk outbreak • 36 hrs V + D • to ED via EMS • CTAS 1  to resusc

30. EMS unable to get bp • O2sat not registering • sinus brady (30-32 bpm) • Px obtunded, incoherent, occasional moaning • Manage this patient ……

31. RIFLE Classification of ARF GFRUrine output Risk serum Cr x 1.5 0.5cc/kg/h x 6h Injury serum Cr x 2.0 0.5cc/kg/h x 12h Failure serum Cr x 3.0 0.3cc/kg/h x 24h or anuria x 12h Loss complete loss of kidney fn > 4 wks ESRD need renal replacement for> 3 mo

32. Imaging in ARF • U/S is imaging of choice • non-contrast CT also a consideration

33. Management of ARF • * • * • * • * • *

34. ARF with sepsis = almost 30% increase in mortality.

35. Stages of Chronic Renal Disease StageDescriptionGFR 1 kidney damage (protein in urine) >90 & normal GFR 2 kidney damage & mild decrease GFR 60-89 3 moderate decrease in GFR 30-59 4 severe decrease in GFR 15-29 5 kidney failure (dialysis/transplant) < 15

36. ESRD • Uremia • - contamination of the blood with urine • - the clinical syndrome resulting from ESRD

37. Pathophysiology of Uremia • Excretory failure – leads to build up of chemicals in blood • Biosynthetic failure – kidneys produce erythropoietin & 1alpha hydroxylase (needed for Vit D - resulting in anemia & renal bone disease • Regulatory failure – results in over secretion of hormones

38. Case # 3 • 64 yo male Hemodialysis • Intentionally missed last 2 dialysis treatments. • To ED via EMS – presyncopal, diaphoretic, gray, looks unwell • Manage this patient…..

39. Most Common Reasons for Emergent Dialysis • Hyperkalemia • Severe acid-base disturbances • Pulmonary edema resistant to other Mx

40. Dialysis • Hemodialysis • ~ 4 hrs per day every other day • Peritoneal Dialysis • Uses 4 exchanges daily (4 x 2 litres) with 10 litres off.

41. Case # 4 • 28 yo male Peritoneal dialysis • 2-3 days Hx feeling unwell. Today fevers, chills. • T- 38.9 HR – 114 RR- 16 142/76 98%r/a • Manage this patient……

42. Peritonitis • Most common complication of PD. • Fever, adbo pain, rebound tenderness • Cloudy effluent • Cell count > 100 leukocytes (>50% neutrophils) • Gram stain, + only 10-40% cases of culture + peritonitis • Expect gram positive & gram negative

43. Empiric AB coverage in dialysate • 1st gen cephalosporin 500mg/L 1st exchange then 200mg/L subsequent exchanges. • Vancomycin 500mg/L 1st exchange then 50mg/L subsequent exchanges. • Gentamycin 100mg/L 1st exchange then 4-8mg/L subsequent exchanges.

44. Case # 5 • 56 yo male • R flank pain, dysuria, polyuria, R testicular pain, microhematuria • diagnosis?

45. CT  9mm proximal ureteral stone • WBC – 7.5 • Creat – 100 • BUN – 5.6 • U/A – trace RBC, all else neg

46. Returns to ED 3 days later. • Fevers, chills, feels unwell. • WBC- 16.9 (with left shift) • Creat – 529 • BUN – 12.4

47. Manage this patient…..

48. Case # 6 • 5 yo healthy female. • WIC for fever and ST  Dx’ed strep throat  Amoxil • 5 days later  local community ED for V +++ • - told bp high but probably due to V • - advised continue Amoxil • 2 days later  WIC gross hematuria and persistent V

49. Manage this patient……

50. Case # 7 • 65 yo female HTN, DM (controlled) • Seen in ED by PGY 3 (non-cardiac CP) • Incidentally, creat – 130 • D/C’ed home