1. Bad Beans Acute Renal Failure

2. 3 AM

• Mr. Henle hasnt peed all night long!

• How is UO measured? By shift or by hour? Foley or urinating on own? Has the patient been sleeping?

• What is the trend over last 2-3 hours vs. last 24 hours?

• • Oliguria = 400ml and discomfort is relieved, leave catheter in place.
  • If foley in place, flus with 20-30ml saline
  • Consider stones or mass obstruction
  • Daily weights, strict I/O
• 16. Management: Renal
  • Hyperkalemia:
  • • Continuous cardiac monitoring
  • • Kayexalate 15 to 30g in 50-100ml 20% sorbitol PO q 3-4 hours or in 200ml 20% sorbitol PR q 4 hours
  • • Dialysis for failed kidneys: can remove 30-60 mEq/hr
  • Contrast dye:
  • • Creatinine peaks within 72 hours with slow recovery over 7 to 14 days with appropriate therapy.
  • Aminoglycosides:
  • • higher risk: elderly, volume depletion, >5 days, large doses, preexisting liver disease, and preexisting renal insufficiency.
  • • Correct preexisting volume depletion and monitor drug levels
• 17. Management: Renal
  • Acidosis:
  • • Treat as determined by cause of acidosis
  • • Watch for co-existing hyperkalemia
  • • Control is aided by restriction of dietary protein
  • Consider dialysis:
  • • Fluid overload unresponsive to diuretics
  • • Hyperkalemia with K+ >6 to 8
  • • Metabolic acidosis pH 35mmol/L with mental status changes, pericarditis or seizure
• 18. Complications
  • Death (50%)
  • Sepsis infection (leading cause of mortality)
  • Once ARF stabilizes, fluid replacement should be equal to insensible losses (500 mL/day) plus urinary or other drainage losses to avoid hypervolemia
  • Hypertension exacerbated by fluid overload: Use antihypertensives that do not decrease renal blood flow (non-dihydropyridine calcium channel blockers, cardioselective beta-blockers, and central acting agents).
  • Anemia is common, caused by increased red blood cell (RBC) loss and decreased RBC production.
  • Platelet dysfunction may occur secondary to the uremia and present as gastrointestinal (GI) bleeding.
• 19. Special Cases
  • Elderly:
  • • Elderly more susceptible to ARF (3.5 X more common)
  • • Creatinine clearance dependent on age
  • • Evolution to acute tubular necrosis more common
  • Pregnancy:
  • • Infected uterus (e.g., Clostridium welchii clostridium perfringens)
  • • Toxemia and related obstetric complications.
  • • Pregnant patients only group with a sharp drop in ARF mortality (1.7%)
  • Pediatric: Congenital anomalies (e.g., nurethral valves, etc)