3/28/2013 ESSENTIALS OF NEPHROLOGY: Family Medicine Board Review ACUTE AND CHRONIC KIDNEY DISEASE Geriatrics Psychiatry Shieva Khayam-Bashi, M.D. Cardiology Clinical Professor , Dept. of Family & Community Medicine Neurology UCSF/ SFGH FCM Residency Program Medical Director, Skilled Nursing Facility/4A SFGH Nephrology ! Email: skhayambashi@fcm.ucsf.edu or shieva@att.net 415-206-3518 Neurology Pediatrics Gynecology 1
3/28/2013 Well, Mr.Osborne, it may not be kidney stones, after all. Chronic Kidney Disease Acute Kidney Injury Complications of CKD 2
3/28/2013 45 minutes Acute Kidney Injury (AKI) Chronic Kidney Disease (CKD) OVERVIEW TODAY: Part 1: The Left Kidney ACUTE RENAL FAILURE- ACUTE KIDNEY INJURY: � History � Physical Exam The Right Kidney � Evaluation: Lab/Studies (come back next year!) � Treatment 3
3/28/2013 Part 2: CHRONIC KIDNEY DISEASE Screening for CKD: – Whom do you screen? – Why do you screen ? – How do you screen ? Diagnosing CKD: – How do you diagnose the cause of CKD? – How do you slow the progression of CKD? – How do you treat the effects of CKD? ARF/AKI - IN A NUTSHELL: 3 QUESTIONS TO EVALUATE: � Pre-renal ? are they DRY ? � Post-renal ? are they OBSTRUCTED ? � Renal ? is it the KIDNEYS ? 4
3/28/2013 PRE-RENAL PRE-RENAL Intrinsic renal Intrinsic renal 60-70% 30% X X POST-RENAL POST-RENAL X X 5-10% 5
3/28/2013 ACUTE RENAL FAILURE case- Mr. M. � 55 yo man, hx DM, HTN, DJD: � 3 day h/o N/V/poor po intake/Diarrhea � 1 day hx oliguria � anuria, confusion, pruritis Labs : � Meds : Benazepril, Hctz, Glipizide, Ibuprofen � PHYSICAL EXAMINATION: Na= 129 � Vital Signs: BP 95/50 , HR 125 , RR 28 , O2: 91% RA K= 6.0 � Gen: confused , tired CO2= 20 � HEENT: mucus membranes DRY BUN= 64 � Heart : tachycardic � Lungs: tachypneic , diffuse rales Creat= 3.6 (baseline =1.2 one month ago) � Abdomen: no mass, NT Glucose= 425 � Skin: excoriations, no rash/petechiae/purpura � Prostate: normal size 6
3/28/2013 � As a rule of thumb, serum sodium concentration decreases by 1.6 mEq/l for every 100 mg/dl increase in glucose concentration [due to water shifts from the intracellular to the extracellular compartment] : � ie: for every 100 glucose that is greater than 100, add 1.6 to the Na, to get corrected Na � corrected Na= Serum Na + 1.6 x (glucose- 100) 100 � eg: Corrected Na= 129 + 1.6 x (approx 400-100) 100 129 + (1.6 x3) = 129 + 4.8 = 134 INITIAL TREATMENT � IV STARTED – GIVEN NS BOLUSES FOR HYPOTENSION � FOLEY CATHETER INSERTED: NO URINE � not obstructed at bladder level � HYPERKALEMIA : EKG= WITHOUT ACUTE CHANGES, TREATED WITH INSULIN/GLUCOSE,CALCIUM, KAYEXALATE � HCTZ, ACEI, AND NSAIDS HELD 7
3/28/2013 HOSPITAL COURSE � OVER NEXT HOURS: BP INCREASED, � UA SENT FOR MICROSCOPY AND CX: UOP IMPROVED, MENTAL STATUS S.G.1.025 , NO RBC, NO WBC, CLEARED NO CELLULAR CASTS (HYALINE ONLY) � BUN, CREAT DECREASED OVER NEXT � RENAL U/S NEGATIVE FOR DAYS IN HOSPITAL, WITH IV FLUIDS HYDRONEPHROSIS (obstruction) � Dx: AKI : PRE-RENAL AZOTEMIA , � KUB NEGATIVE FOR CALCULI SECONDARY TO ACUTE VIRAL GASTROENTERITIS ACUTE RENAL FAILURE(ARF) or ACUTE KIDNEY INJURY (AKI) � Definition: no universal definition – generally noted by a rapid rise in Creat, BUN, +/- decreased UOP : -- if the baseline Creat is < 2.5 mg/dl : ARF can be defined by an increase in serum Creatinine of at least 0.5 mg/dl , for 2 weeks or less --Or, if the baseline Creat is > 2.5 mg/dl: ARF can be defined by an increase in serum Creatinine by more than 20%. 8
3/28/2013 ARF / AKI Mortality is due to Complications: � pulmonary edema 30-50% � can be nonoliguric or can be oliguric � cardiac (MI, arrhythmias) 30-40% (oliguria=less than 400 ml urine output/day � GI (GI bleed, pancreatitis) 30% in adults or less than ½ cc/kg/hr) � Infections 50-70% � Neurologic abnormalities 30-50% � Anuria usually has worse prognosis (except in dehydration) and is defined as less than � Electrolyte disorders (hyperkalemia, 100 ml/day of urine output in adults. metabolic acidosis, hyperuricemia, hyperphosphatemia) 50-75% Evaluating for Causes of AKI/ARF: � History � Physical Exam � Lab/Studies 9
3/28/2013 IN A NUTSHELL: Hx, PE, Labs are to determine : � Pre-renal ? are they DRY ? � Post-renal ? are they OBSTRUCTED ? � Renal ? is it the KIDNEYS ? History : History: Ask for clues to help determine CAUSE: � (dry vs. obstructed vs. kidneys?) 2. “Is There An Obstruction?”: 1. “Are You Dry?”: Abdominal pain / signs of bladder obstruction? � Decreased PO intake? Sudden anuria? � � Hematuria? Flank pain? Renal/bladder stones? Increased fluid Losses? (N/V/D/diuretic � � Weight loss / cancer symptoms? use) � (also may have no urinary symptoms at all) Other reasons for volume depletion? � � anaphylaxis,sepsis,MI/CHF,cirrhosis � 10
3/28/2013 History: 3. “Is it the Kidneys?”: MEDS: Nephrotoxic medicines? IV � contrast? aminoglycosides, amphotericin, cisplatin, PCNs, cephalosporins, sulfas, NSAIDs, rifampin? Family History Kidney Disease? � Previous urologic / renal history? � Autoimmune/ vasculitis history? � Viral diseases which can affect kidneys? � 11
3/28/2013 Also, ASK for SYMPTOMS which can be the effects of ARF: � Encephalopathy ? (confusion/somnolence) � Chest pain? ( pericarditis ) � CHF/Fluid overload symptoms? � Pulmonary or Peripheral Edema? � Significant Hypertension? � Bleeding? (platelet dysfunction) PHYSICAL EXAMINATION 12
3/28/2013 Physical Exam: � Volume status (orthostatic vital signs, tachycardia, dry mucous membranes) � Neuro: mental status, asterixis ( encephalopathy ) � Heart: tachycardia, pericardial rub � Lungs: signs of pulmonary edema ( increased RR, decreased O2 sat, rales ) � Abdomen: bladder distention , mass? � Skin : petechiae (HUS,TTP), palpable purpura (vasculitis) , edema � Pelvic/ Prostate exam ( R/O obstruction ) LABS / STUDIES LABS/STUDIES: � CBC, CHEM 7 : Na, K , Cl, CO2 , BUN, Cr , Glucose (STAT EKG if Hyperkalemic) � UA with microscopy ( casts , RBC, WBC, protein) � +/- Urine Culture � Renal ultrasound (R/O Obstruction) � Serum Na& Creat, Urine Na & Creat (to calculate FENa ) � Optional : KUB (for stones), CT Abdomen (for masses) (note: many stones are radiolucent and not seen on KUB) 13
3/28/2013 Hyperkalemia: EKG changes: normal Often a sequential progression Peaked T waves , Prolonged PR interval Absent P wave widened QRS Ventricular tachycardia / VFib Note : EKG can progress to VT/VF at ANY level of hyper-K ! Evaluation Calculate the FENa:(Fractional Excretion of Sodium) U Na / P Na X 100 U Cr / P Cr ( make sure the U and P values are in the same units ) FENa < 1 % usually suggests Pre-renal FENa > 1 % usually suggests ATN (renal) 14
3/28/2013 Fractional Excretion of Urea BUT interpreting FENa FE- Urea can be problematic ! � If pt has recently received diuretic, � FENa can also be low with several intrinsic renal can use FE-Urea instead of FE-Na: problems such as acute GN, early ATN, rhabdo, (less influenced by diuretic therapy) contrast nephropathy, sepsis! � FE-Urea= U Urea / P Urea X 100 FENa is elevated by diuretic use U Cr / P Cr � Pts with CKD can lose their ability to reabsorb sodium (chronically elevated FENa) & thus < 35 % favors pre-renal not have a decreased FENa when pre-renal. >35 % favors ATN Can make Laboratory DIAGNOSIS of ARF/AKI by : 1. UA with MICROSCOPY (looking at urine sediment : cells / casts) 2. URINE Na 3. FE-Na 15
3/28/2013 DIAGNOSIS URINE SEDIMENT Urine Na FENa <20 mEq/L <1% Prerenal Normal, or hyaline casts Intrarenal Tubular necrosis Granular, tubular epithelial >20 mEq/L >1% (ATN) cell casts, muddy brown casts Interstitial nephritis WBC,RBC, mild proteinuria, >20 mEq/L >1% (AIN) granular and epithelial cell casts, WBC casts, eosinophils ! ** Hematuria(RBC), proteinuria, >20 mEq/L <1% Glomerulonephritis (GN) RBC casts, granular casts Vascular disorders Normal or RBC, >20 mEq/L <1% mild proteinuria_______________________________ Postrenal Normal or RBCs, granular casts, WBC >20 mEq/L >1% ** NOTE: WBCs in urine, but negative leukocyte esterase reaction can be clue for eosinophiluria � Hylaine casts: pre-renal � Granular cast + tubular epithelial cell casts: ATN,AIN : 16
3/28/2013 Urinalysis with microscopy : � WBC cast: AIN , chronic GN : � Hyaline and fine granular casts often seen in pre- renal failure � RBC casts : GN: � Tubular epithelial cells or casts : ATN, AIN � WBC CASTS, Urine eosinophils � AIN � Oval fat bodies: nephrotic syndrome : � RBC, RBC CASTS proteinuria � suggests Glomerulonephritis � + blood on Dipstick but no RBCs on microscopic � consider Rhabdomyolysis , check serum CK level 17
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