Intern Survival Series Lecture #9 Renal Insufficiency Shaping the - - PowerPoint PPT Presentation

Shaping the Future of Healthcare | www.thewrightcenter.org

Intern Survival Series Lecture #9

Renal Insufficiency

Shaping the Future of Healthcare | www.thewrightcenter.org

Goals and Objectives

• Be able to recognize the various types of renal

disease, and initiate an appropriate workup

• Be able to recognize signs and symptoms of

Hyperkalemia and address it with appropriate treatment modalities

Shaping the Future of Healthcare | www.thewrightcenter.org

A Brief Note

• This lecture series is not meant to be all inclusive
• r totally comprehensive to all of internal

medicine

• It is not meant to supersede clinical judgment
• It is not meant to replace daily reading or bedside

teaching

• It is meant to act as a starting point for which to

grow from as new primary care physicians

• It is a tool to help you survive the your new job

Shaping the Future of Healthcare | www.thewrightcenter.org

Most Frequent Primary Care, Inpatient Diagnosis

• 1)Pneumonia
• 2)Congestive Heart Failure
• 3)Osteoarthritis
• 4)Coronary Artery Disease
• 5)Septicemia
• 6)Cardiac Dysrhythmias
• 7)Chronic Obstructive Pulmonary Disease

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Fastest Growing Inpatient Diagnosis in Medicine

• 1)Acute Renal Failure
• 2)Anemia
• 3)Diabetes Mellitus
• 4)Malaise and Fatigue
• 5)Pulmonary Heart Disease

Shaping the Future of Healthcare | www.thewrightcenter.org

Most Common Secondary Diagnosis

• 1)Hypertension
• 2)Hyperlipidemia
• 3)Fluid and electrolyte disorders
• 4)Coronary Atherosclerosis
• 5)Diabetes Mellitus
• 6)Anemia
• 7)Cardiac Dysrhythmias
• 8)Esophageal Disorders

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Kidney Disease

• About 20 million Americans have kidney disease.
• The number of people diagnosed with kidney

disease has doubled each decade for the last two decades

• Diabetes and hypertension (high blood pressure)

are the number one and number two causes of kidney disease, respectively.

• Diabetes accounts for 35% of all new ESRD cases

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Renal Failure

• Acute Renal Failure

– Now referred to as acute kidney injury – abrupt and usually reversible decline in the GFR. – Develops in hours to days – Can develop into rapidly progressing renal failure

• Kidney disease that

progresses for weeks

• Chronic Renal Failure

– Now referred to as chronic kidney disease – A glomerular filtration rate less than 60 mL/min for three months or more – and/or evidence of kidney damage

• albuminuria
• urine sediment abnormalities
• findings on renal imaging or

renal biopsy

Shaping the Future of Healthcare | www.thewrightcenter.org

AKI Incidence

• The number of

hospitalizations that included an AKI diagnosis rose from 3,942 in 1996 to 23,052 in 2008.

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Common Causes of AKI

• Acute tubular necrosis (ATN)

– Most common cause in hospitalized patients

• Ischemia
• nephrotoxin exposure
• sepsis
• Volume Depletion
• Urinary Obstruction
• Rapidly Progressive Glomerulonephritis
• Acute Interstitial Nephritis

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Defining AKI

KDIGO criteria (Kidney Disease Improving Global Outcomes)

• An increase in serum creatinine of ≥0.3 mg/dL

(≥26.5 micromol/L) within 48 hours

• An increase in serum creatinine of ≥1.5 times

baseline, which is known or presumed to have

• ccurred within the prior 7 days; or
• Urine volume <0.5 mL/kg per hour for more

than 6 hours

Shaping the Future of Healthcare | www.thewrightcenter.org

Staging AKI

• Stage 1 AKI

– increase in the serum creatinine of 1.5 to 1.9 times baseline OR – serum creatinine increase of ≥0.3 mg/dL OR – urine output <0.5 mL/kg per hour for 6 to 12 hours.

Shaping the Future of Healthcare | www.thewrightcenter.org

Staging AKI

• Stage 2 AKI

– increase in the serum creatinine of 2.0 to 2.9 times baseline OR – urine output <0.5 mL/kg per hour for ≥12 hours.

Shaping the Future of Healthcare | www.thewrightcenter.org

Staging AKI

• Stage 3 AKI

– increase in the serum creatinine of 3x baseline OR – increase in serum creatinine to ≥4.0 OR – urine output of <0.3 mL/kg per hour for ≥24 hours, OR – anuria for ≥12 hours OR – the initiation of renal replacement therapy OR, – in patients <18 years, decrease in estimated GFR to <35 mL/min

Shaping the Future of Healthcare | www.thewrightcenter.org

AKI Workup

• UA
• Strict I/Os, daily weights
• Urine Electrolytes

– Urine Na, K, Cr

• Renal Imaging to assess for

– urinary tract obstruction – kidney stones – renal cyst or mass – renal vascular diseases

Shaping the Future of Healthcare | www.thewrightcenter.org

Fractional Excretion of Na

• The FENa is the most accurate screening test

to differentiate between prerenal disease and ATN.

• A value below 1 percent suggests prerenal

disease

• A value above 2 percent usually indicates ATN
• A value between 1 and 2 percent can be seen

with either disorde

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FENa

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FENa

• Be aware that there are limitations to FENa
• Some examples (but not all)

– The FENa may remain below 1 percent when ATN is superimposed upon a chronic prerenal disease – Diuretics can raise the FENa, even in patients with prerenal disease giving misleading numbers – A low FENa is not unique to prerenal disease, and can be seen in:

• Acute glomerulonephritis
• Vasculitis
• Contrast-induced nephropathy.

Shaping the Future of Healthcare | www.thewrightcenter.org

Shaping the Future of Healthcare | www.thewrightcenter.org

Complications of AKI

• Fluid overload
• Hyperkalemia or a rapidly increasing serum

potassium

• Signs of uremia, such as pericarditis, or an
• therwise unexplained decline in mental

status

• Severe metabolic acidosis (pH less than 7.1)

Shaping the Future of Healthcare | www.thewrightcenter.org

Hyperkalemia

• The urgency of treatment of hyperkalemia

varies with the cause and the presence or absence of the symptoms and signs associated with hyperkalemia.

– muscle weakness or paralysis – cardiac conduction abnormalities – cardiac arrhythmias

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Call from Tele

• Patient’s Rhythm strip is

showing some abnormalities…..

Shaping the Future of Healthcare | www.thewrightcenter.org

Shaping the Future of Healthcare | www.thewrightcenter.org

Shaping the Future of Healthcare | www.thewrightcenter.org

Hyperkalemia

Shaping the Future of Healthcare | www.thewrightcenter.org #1 Peak T waves #2 Increased PR intervals #3 Increased QRS #4 Loss of P waves #5 SINE Waves

Shaping the Future of Healthcare | www.thewrightcenter.org

Hyperkalemia Treatment

Rapid Acting Treatment Indications

• Patients with hyperkalemia and electrocardiographic changes
• Patients with a serum potassium greater than 6.5 to 7 meq/L

– Ok to wait if potassium is ≥7.0 meq/L in patients who have no clinical or electrocardiographic signs of hyperkalemia, use clinical judgment

• Ok to give rapid acting analogs in patients with a serum

potassium that is rapidly increasing, but again, use clinical judgment

Shaping the Future of Healthcare | www.thewrightcenter.org

Hyperkalemia

• Rapid Treatment

– Calcium Gluconate

• 1 ampoule, infused over two to three minutes, with

constant cardiac monitoring

• Stabilized the myocardium
• can be repeated after five minutes if the ECG changes

persist or recur

Shaping the Future of Healthcare | www.thewrightcenter.org

Hyperkalemia

• Rapid Treatment

– Insulin with dextrose

• 10units of regular insulin in 500ml D10W over 1hr

– Begins to work in 10-20mins, lasts 4-6 hours

• If Serum Glucose >250 ~ 10 Units only
• If Serum Glucose <250, but still on high side can give 10 unit

insulin bolus w 50ml of 50% dextrose

• asdf

Shaping the Future of Healthcare | www.thewrightcenter.org

Hyperkalemia

Rapid Treatment

– Albuterol Nebulizers – Bicarb

• Mostly ineffective, but in hypovolemic patients it is ok to give One liter of

½ NS with 75 Units of Bicarb

– Hemodialysis

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Hemodialysis Indications

• Acid base disorders

– i.e. Severe Metabolic Acidosis

• Electrolytes

– i.e. Hyperkalemia

• Intoxication

– i.e Lithium, Ethylene Glycol

• Overload

– Fluid Overload, not responding to diuretics

• Uremia

– Usually seen in patients with BUN>100

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Chronic Kidney Disease

• Defined as the presence of kidney

damage or decreased kidney function for three or more months

• irrespective of the cause
• Decreased kidney function is identified in

most cases by an eGFR less than 60 mL/min

Shaping the Future of Healthcare | www.thewrightcenter.org

CKD

• Kidney damage is identified in most cases by

the presence of:

– albuminuria – urinary sediment abnormalities – anatomic abnormalities discovered with imaging studies – pathologic abnormalities discovered with kidney biopsy – a history of kidney transplantation

Shaping the Future of Healthcare | www.thewrightcenter.org

CKD Staging

• The purpose of CKD staging is to guide

management, including risk for progression and complications of CKD

Shaping the Future of Healthcare | www.thewrightcenter.org

CKD Staging

Shaping the Future of Healthcare | www.thewrightcenter.org

Shaping the Future of Healthcare | www.thewrightcenter.org

• Questions?