GENERAL APPROACH
Type of renal failure
- Acute (usually multi-factorial)
- Chronic (e.g. dialysis dependent) or
- Acute on Chronic (e.g. post-renal transplant)
Causes
- Pre-renal – hypovolemia, any cause of shock, sepsis, renovascular disease
- Intra-renal – nephrotoxins, urine for casts + protein, sepsis, rhabdomyolysis, nephritic/nephrotic syndromes
- Post-renal – catheter blocked, pelvic rim surgery, blocked ureters, intraabdominal pressure, hydronephrosis
INTRODUCTION
CUBICLE
- CRRT or IHD
- bags of dialysate fluid – lactate or bicarbonate buffer
- TMP
- settings
- anticoagulation strategy and filter life-spans
INFUSIONS
- inotropes/vasopressors to maintain organ perfusion
- N-acetylcystetine for imaging/ procedures with contrast
- sodium bicarbonate for metabolic acidosis
- systemic anticoagulation (for RRT or other indication)
VENTILATOR
- oxygen requirement (fluid overload with pulmonary oedema)
- PEEP
MONITOR
- CVP (number, waveform)
- renal perfusion pressure (MAP-CVP)
- ECG (signs of hyperkalaemia)
- arterial trace (pressure)
EQUIPMENT
- dialysis access — catheter (check previous insertion sites e.g. dressings), AV fistula, Tenckoff peritoneal dialysis catheter
- IDC or lack of (colour, volume, no bag suggests chronic renal failure)
- recent intra-abdominal pressures (manometer attached to IDC)
- IABP (low position may cause oliguria)
QUESTION SPECIFIC EXAMINATION
- hands -> head -> chest -> abdo -> feet -> back
-> cardiovascular
-> respiratory
-> abdominal (kidneys, organomegaly, distension)
-> compartments
-> end-organ perfusion
- neurological
-> paralysed
-> quick examination
-> unconscious
-> conscious
Questions
- urine output over last 8 hours?
- urine dipstick and microscopy?
- paired serum and urinary electrolytes?
- has IDC been flushed recently?
- recent exposure to nephrotoxic agents?
RELEVANT INVESTIGATIONS
- CXR (APO, check IABP isn’t too low)
- ABG (metabolic and electrolyte derangements)
- pregnancy test (eclampsia?)
- urea and creatinine
- compartment pressures? (if suspect limb or abdominal compartment syndrome)
OPENING STATEMENT
- = “Multi-factorial” and list headings of causes -> clinical signs associated with list
- “There is evidence of ESRF…”
DISCUSSION
Renal disorders
- CCC — Acute Kidney Injury and RIFLE Criteria and AKIN Classification
- CCC — Rhabdomyolysis
- CCC — Contrast-induced nephropathy
- CCC — Hepatorenal syndrome
- CCC — End-stage Renal Failure
- CCC — Renal transplant patient
- CCC — Renal disease biomarkers
RRT
- CCC — Indications, timing and patient selection for RRT
- CCC — RRT terminology and nomenclature
- CCC — CRRT Circuits
- CCC — IHD vs SLEDD vs CVVH
- CCC — Prevention of RRT circuit clotting
- CCC — Regional citrate anticoaguation
- CCC — Dose of RRT
- CCC — Summary of RRT Types
- CCC — RRT prescription
- CCC — Hemoperfusion
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