Acute Renal Failure 2* to Rhabdomyolysis 2* to Motor Vehicular Accident

Acute Renal FailureAcute Renal Failure

Dept of Family and Community MedicineDept of Family and Community Medicine

Perpetual Succour Hospital Perpetual Succour Hospital

April 28, 2009April 28, 2009

General Objectives: General Objectives: To present a case of a 20 years old male To present a case of a 20 years old male

who develop ARF secondary to who develop ARF secondary to rhabdomyolysis secondary to MVArhabdomyolysis secondary to MVA

A case of C.C., 20 years oldA case of C.C., 20 years old male, single, Filipino, Roman Catholicmale, single, Filipino, Roman Catholic Maya, Daan Bantayan, CebuMaya, Daan Bantayan, Cebu Multiple physical injuries secondary to Multiple physical injuries secondary to

MVAMVA

No Medical problemNo Medical problem Non-smoker, occ’l alcoholic beverage Non-smoker, occ’l alcoholic beverage

drinkerdrinker No FDANo FDA No hospitalizationNo hospitalization

HPI:HPI: NOI: MVANOI: MVA POI: Maya, Daan Bantayan, CebuPOI: Maya, Daan Bantayan, Cebu TOI: 11PMTOI: 11PM DOI: March 7, 2009DOI: March 7, 2009

Six hours PTA, patient was driving his Six hours PTA, patient was driving his motorcycle with his cousinmotorcycle with his cousin

Accidentally loss control of the vehicle Accidentally loss control of the vehicle upon making a turn in a blind curve.upon making a turn in a blind curve.

Patient was thrown, hitting his chin and Patient was thrown, hitting his chin and left side of the body on the groundleft side of the body on the ground

Vomiting twice was notedVomiting twice was noted No loss of consciousness.No loss of consciousness.

Brought to Daan Bantayan District Brought to Daan Bantayan District Hospital, IVF was startedHospital, IVF was started

Suturing of lacerated wound chinSuturing of lacerated wound chin Referred to our institution for further Referred to our institution for further

management. management.

Conscious, coherent, afebrile, not in Conscious, coherent, afebrile, not in respiratory distressrespiratory distress

BP: 80/50 Hr:82BP: 80/50 Hr:82 RR:23 Temp:37 RR:23 Temp:37 Skin: warm, good turgor Skin: warm, good turgor HEENT: anicteric sclera, pink palpebral HEENT: anicteric sclera, pink palpebral

conjunctiva, conjunctiva, 4 cm lacerated wound at the 4 cm lacerated wound at the mentummentum

Neck: supple, no LADNeck: supple, no LAD C/L: ECE, Clear breath sounds, no ralesC/L: ECE, Clear breath sounds, no rales CVS: DHS, NRRR, no murmurCVS: DHS, NRRR, no murmur Abd: flabby, Normoactive, soft, Abd: flabby, Normoactive, soft,

tenderness at the RLQtenderness at the RLQ GUT: normal KPSGUT: normal KPS

Ext: Ext: multiple abrasionsmultiple abrasions noted at the noted at the ant ant and medial partand medial part, , hematomahematoma at the at the posterior part of the left thighposterior part of the left thigh

CNS: conscious, coherent, GCS 15CNS: conscious, coherent, GCS 15

Motor: all ext 5/5Motor: all ext 5/5 Sensory: intactSensory: intact

Impression: 4 cm lacerated wound, Impression: 4 cm lacerated wound, mentum and multiple abrasions left thigh mentum and multiple abrasions left thigh sec to MVAsec to MVA

On admission:On admission:

IVF change to PNSS, run 300 mL, then IVF change to PNSS, run 300 mL, then regulated at 50 gtts/minregulated at 50 gtts/min

CXR Bucky and Skull Series: negativeCXR Bucky and Skull Series: negative CBCCBC.. and BT: AB(-) and BT: AB(-)..: leukocytosis, : leukocytosis,

neutrophilic predominance neutrophilic predominance Urinalysis:* hematuriaUrinalysis:* hematuria CT Scan – Brain Plain: negativeCT Scan – Brain Plain: negative Repeat CBC 6 hrs afterRepeat CBC 6 hrs after..

TT 0.5 mL IM R DeltoidTT 0.5 mL IM R Deltoid TIG 250 IU IM L DeltoidTIG 250 IU IM L Deltoid Ranitidine 50 mg IV q 8hrsRanitidine 50 mg IV q 8hrs Oxacillin 500 mg IV q 6hrsOxacillin 500 mg IV q 6hrs Bactroban creamBactroban cream

3 hrs after admission:3 hrs after admission:

Tramadol 50 mg IV q12Tramadol 50 mg IV q12 UTZ of the liver and kidney: negative.UTZ of the liver and kidney: negative.

11stst Hospital Day: Hospital Day:

Distended abdomenDistended abdomen RLQ pain RLQ pain LOM left thigh LOM left thigh Meds:Meds: Etoricoxib (Arcoxia)Etoricoxib (Arcoxia) Epirisone (Myonal) was addedEpirisone (Myonal) was added

22ndnd Hospital Day: Hospital Day:

Abdominal distension and tendernessAbdominal distension and tenderness NPO temporarily except medsNPO temporarily except meds Hyoscine Bromide 10 mg 1 amp IV q Hyoscine Bromide 10 mg 1 amp IV q

8hrs PRN for severe pain8hrs PRN for severe pain

33rdrd Hospital Day: Hospital Day: Persistence of abdominal pain and Persistence of abdominal pain and

distension distension Referred to Surgery ServiceReferred to Surgery Service CBCCBC,, Potassium normal, Potassium normal,

Creatinine:10.50Creatinine:10.50 CT SCAN – Whole AbdomenCT SCAN – Whole Abdomen Referred to a NephrologistReferred to a Nephrologist

Additional meds:Additional meds: NaHCO3 ½ vial IV q 4hrs for 6 dosesNaHCO3 ½ vial IV q 4hrs for 6 doses Dopamine 200 mg/ 250 mL at 10 cc/hrDopamine 200 mg/ 250 mL at 10 cc/hr Urinalysis was requestedUrinalysis was requested Furosemide 40 mg IV q 8 hrs PRN for Furosemide 40 mg IV q 8 hrs PRN for

U/O <300/ shiftU/O <300/ shift To secure 2 units WBTo secure 2 units WB

Nephrologist Additional Meds:Nephrologist Additional Meds:

O2 inhalation at 2LPMO2 inhalation at 2LPM Mannitol 50 mg IV q 6 hrsMannitol 50 mg IV q 6 hrs Paracetamol 650 mg, 1 tab BID for 6 Paracetamol 650 mg, 1 tab BID for 6

doses doses NaHCO3 650 mg 2 tablets TIDNaHCO3 650 mg 2 tablets TID Carnitine Oral Sol’n 1000 mg, 1 bottle Carnitine Oral Sol’n 1000 mg, 1 bottle

TIDTID Allupurinol 300 mg tab ODAllupurinol 300 mg tab OD

Urine Output: 1,800 mL/ 24hrsUrine Output: 1,800 mL/ 24hrs Labs requestedLabs requested::

44thth Hospital Day: Hospital Day:

Abd: Distended, hypoactive bowel Abd: Distended, hypoactive bowel sounds, no tenderness notedsounds, no tenderness noted

Alluprinol 300 mg 1 tablet TIDAlluprinol 300 mg 1 tablet TID Calci-Aid 1 cap BID pcCalci-Aid 1 cap BID pc Furosemide 40 mg IV q 6 hrs Furosemide 40 mg IV q 6 hrs


*Repeat Creatinine: 14, BUN, K, BUA, *Repeat Creatinine: 14, BUN, K, BUA, Repeat CBCRepeat CBC

Ciprofloxacin 250 mg 1 tablet BIDCiprofloxacin 250 mg 1 tablet BID Ketosteril 2 tabs TIDKetosteril 2 tabs TID


LightheadednessLightheadedness Ciprofloxacin was discontinuedCiprofloxacin was discontinued Shifted to Cefuroxime 750 mg IV q 12 hrsShifted to Cefuroxime 750 mg IV q 12 hrs Repeat Total CPK: 450Repeat Total CPK: 450 FBC was inserted FBC was inserted

77thth Hospital Day : Hospital Day :

IJ Catheter was insertedIJ Catheter was inserted 1st Hemodialysis for 3 cycles done1st Hemodialysis for 3 cycles done CBC- anemiaCBC- anemia Cefuroxime 750 mg IV q12hrsCefuroxime 750 mg IV q12hrs Oxacillin 500 mg IV q 6hrsOxacillin 500 mg IV q 6hrs Allupurinol 300 mg tab BID dec to ODAllupurinol 300 mg tab BID dec to OD Furosemide 40 mg IV q 8hrsFurosemide 40 mg IV q 8hrs


*For Repeat Creatinine, Potassium and *For Repeat Creatinine, Potassium and Uric AcidUric Acid

1 unit PRBC was transfused1 unit PRBC was transfused


Dec breathsounds bibasal lungsDec breathsounds bibasal lungs 22ndnd Hemodialysis done Hemodialysis done Repeat Creatinine_, K and Total CPKRepeat Creatinine_, K and Total CPK Recormon 5000 units SQ was givenRecormon 5000 units SQ was given


Still with distended abdomen, hypoactive Still with distended abdomen, hypoactive bowel soundsbowel sounds

febrile episodesfebrile episodes For repeat creatinine the next dayFor repeat creatinine the next day For Repeat UrinalysisFor Repeat Urinalysis..

1111thth Hospital day: Hospital day:3/19/093/19/09

Febrile episodesFebrile episodes Blood culture and sensitivity-Blood culture and sensitivity-

*Burkholderia cepacia-S- Ceftazidime*Burkholderia cepacia-S- Ceftazidime Repeat CreatinineRepeat Creatinine and CBC*and CBC* Repeat CXRRepeat CXR--PAPA Cefuroxime was discontinuedCefuroxime was discontinued Shifted to Ceftazidime 500 mg q 48hrs IVShifted to Ceftazidime 500 mg q 48hrs IV

1212thth Hospital Day: 3/20/09 Hospital Day: 3/20/09

Blood-streaked sputumBlood-streaked sputum Abdominal distensionAbdominal distension Hyperactive bowel soundsHyperactive bowel sounds 33rdrd Hemodialysis done Hemodialysis done

1313thth Hospital Day Hospital Day

Patient improved, no dyspnea, afebrilePatient improved, no dyspnea, afebrile Bp 120/80Bp 120/80 HR: 78HR: 78 ECE, Bibasal RalesECE, Bibasal Rales Ceftazidime Ceftazidime


Patient was able to sleep wellPatient was able to sleep well Comfortable, no dyspneaComfortable, no dyspnea BP:120/70BP:120/70 HR:78HR:78 Intake: 1270ccIntake: 1270cc Output: 550Output: 550 ECE, Bibasal rales, wheezeECE, Bibasal rales, wheeze *CBC, Creatinine *CBC, Creatinine


Still with febrile episodesStill with febrile episodes No dyspneaNo dyspnea ECE, minimal bibasal rales, wheezeECE, minimal bibasal rales, wheeze O2 Inhalation dec to PRNO2 Inhalation dec to PRN

1616thth Hospital Day: 3/24/09 Hospital Day: 3/24/09

Still with minimal bibasal ralesStill with minimal bibasal rales Intake: 1600, Output: 1420Intake: 1600, Output: 1420 Creatinine: 9.48Creatinine: 9.48 Crea Clearance: 12.31Crea Clearance: 12.31 Ceftazidime Increased to 1gm IVTT q12Ceftazidime Increased to 1gm IVTT q12 Repeat CXR*Repeat CXR* Comngt with PulmonologistComngt with Pulmonologist

1717thth hospital Day hospital Day

Still with febrile episodesStill with febrile episodes With minimal ralesWith minimal rales Intake: 2720Intake: 2720 Output: 2050 – Output: 2050 –

85cc/hr85cc/hr


Still with febrile episodeStill with febrile episode Intake: 2,700 Output: 5,650 +2950Intake: 2,700 Output: 5,650 +2950 CBC, Na, Creatinine, Albumin*CBC, Na, Creatinine, Albumin* Erythropoeitin 5000 u sq once a weekErythropoeitin 5000 u sq once a week


Low Grade Fever was only notedLow Grade Fever was only noted Still with rales both lungsStill with rales both lungs Repeat CXR: decrease infiltrates to both Repeat CXR: decrease infiltrates to both

lung fieldslung fields Malarial Smear: negativeMalarial Smear: negative

2121stst Hospital Day Hospital Day

Patient was afebrilePatient was afebrile Repeat CBC: anemia* and CreatinineRepeat CBC: anemia* and Creatinine IJ cath was removedIJ cath was removed

2222ndnd Hospital Day Hospital Day

MGHMGH To continue:To continue: Iron supplements 1 cap ODIron supplements 1 cap OD Follow up: April 4, 2009 with CBC, Follow up: April 4, 2009 with CBC,

Creatinine and Calcium levelCreatinine and Calcium level

DISCUSSIONDISCUSSION

DiscussionDiscussion

Urinary System

Functions of the Kidneys:Functions of the Kidneys: Excretion of metabolic waste products & Excretion of metabolic waste products &

foreign chemicals foreign chemicals Regulation of water & electrolyte balances Regulation of water & electrolyte balances Regulation of acid-base balance Regulation of acid-base balance Regulation of arterial pressure Regulation of arterial pressure Secretion, metabolism, & excretion of Secretion, metabolism, & excretion of

hormones hormones Gluconeogenesis Gluconeogenesis

Renal Blood FlowRenal Blood Flow In an average 70-kilogram man, the In an average 70-kilogram man, the

combined blood flow through both combined blood flow through both kidneyskidneys

1,100 ml/min1,100 ml/min 22 per cent22 per cent of the cardiac output. of the cardiac output.

Acute Renal FailureAcute Renal Failure

rapid decline in (GFR) over hours to days rapid decline in (GFR) over hours to days Clinical features:Clinical features: Retention of nitrogenous waste products Retention of nitrogenous waste products Oliguria (<400 mL/d )Oliguria (<400 mL/d ) Electrolyte and acid-base abnormalities Electrolyte and acid-base abnormalities

usually asymptomaticusually asymptomatic DX: when a new increase in BUN and DX: when a new increase in BUN and

serum creatinine is notedserum creatinine is noted causes of ARF :causes of ARF : 1) 1) prerenalprerenal ARF ARF, or azotemia (~55%) , or azotemia (~55%) 2) 2) intrinsic ARFintrinsic ARF (~40%)(~40%) 3) 3) postrenalpostrenal ARF ARF(~5%). (~5%).

Prerenal ARF:Prerenal ARF:

Altered renal hemodynamics resulting in Altered renal hemodynamics resulting in hypoperfusion hypoperfusion

A. A. Low cardiac output stateLow cardiac output state:: B. Systemic vasodilationB. Systemic vasodilation:: C. Renal vasoconstrictionC. Renal vasoconstriction:: D. Impairment of renal autoregulatory D. Impairment of renal autoregulatory

responsesresponses:: E. Hepatorenal syndromeE. Hepatorenal syndrome..

Intrinsic causes of ARF:Intrinsic causes of ARF: (1) ischemic / nephrotoxic tubular injury(1) ischemic / nephrotoxic tubular injury (2) tubulointerstitial diseases(2) tubulointerstitial diseases (3) diseases of the renal microcirculation (3) diseases of the renal microcirculation

and glomeruliand glomeruli (4) diseases of larger renal vessels (4) diseases of larger renal vessels

Prerenal ARF & ischemic ATN are part of a Prerenal ARF & ischemic ATN are part of a spectrum of manifestations of renal spectrum of manifestations of renal hypoperfusionhypoperfusion

ATN vs. prerenal ARF: renal tubular epithelial ATN vs. prerenal ARF: renal tubular epithelial cells are injured in the prerenal ARFcells are injured in the prerenal ARF

ATN occur in: major cardiovascular surgery, ATN occur in: major cardiovascular surgery, severe trauma, hemorrhagesevere trauma, hemorrhage, sepsis and , sepsis and volume depletionvolume depletion

other risk factors for ARF: exposure to other risk factors for ARF: exposure to nephrotoxinsnephrotoxins / preexisting chronic kidney / preexisting chronic kidney disease disease

Recovery takes Recovery takes 1–2 weeks after 1–2 weeks after normalization of renal perfusionnormalization of renal perfusion

Four phases of ischemic ATN:Four phases of ischemic ATN: A physiologic hallmark of ATN: failure to A physiologic hallmark of ATN: failure to

maximally dilute or concentrate urine maximally dilute or concentrate urine (isosthenuria). (isosthenuria).

1.1. initiation phaseinitiation phase (lasting hours to days), (lasting hours to days), GFR declines GFR declines

2.2. extension phaseextension phase is char by continued is char by continued ischemic injury and inflammation. ischemic injury and inflammation.

3) maintenance phase3) maintenance phase (1–2 weeks), GFR (1–2 weeks), GFR stabilizes at its nadir (5–10 mL/min), stabilizes at its nadir (5–10 mL/min), urine output is lowest, and uremic urine output is lowest, and uremic complications may arisecomplications may arise

4) recovery phase4) recovery phase is char by tubular is char by tubular epithelial cell repair & regenerationepithelial cell repair & regeneration

gradual return of GFR toward premorbid gradual return of GFR toward premorbid levelslevels

Symptoms of Symptoms of prerenalprerenal ARF: thirst and ARF: thirst and orthostatic dizziness orthostatic dizziness

Physical signs of ARF: orthostatic Physical signs of ARF: orthostatic hypotension, tachycardia, reduced hypotension, tachycardia, reduced jugular venous pressure, decreased skin jugular venous pressure, decreased skin turgor and dry mucous membranes turgor and dry mucous membranes

Laboratory StudiesLaboratory Studies

BUN & creatinine: the ratio exceed 20:1 BUN & creatinine: the ratio exceed 20:1 CBC/peripheral smearCBC/peripheral smear: : presence of presence of

myoglobin/free hemoglobin, increased uric acid myoglobin/free hemoglobin, increased uric acid levellevel and and schistocytesschistocytes

UrinalysisUrinalysis: : Reddish brown or cola-colored urine Reddish brown or cola-colored urine suggests the presence of myoglobin or suggests the presence of myoglobin or hemoglobinhemoglobin

Urine electrolytes serve as indicators of Urine electrolytes serve as indicators of functioning renal tubules. functioning renal tubules.

FENa = (UNa/PNa) / (UCr/PCr) X 100FENa = (UNa/PNa) / (UCr/PCr) X 100 Prerenal azotemia: FENa is usually <1%. Prerenal azotemia: FENa is usually <1%. ATN: FENa is >1%ATN: FENa is >1%

o Exceptions: ATN caused by severe burns, Exceptions: ATN caused by severe burns, AGN and rhabdomyolysis. AGN and rhabdomyolysis.

Renal UTZRenal UTZ is useful for evaluating is useful for evaluating existing renal disease and obstruction of existing renal disease and obstruction of the urinary collecting systemthe urinary collecting system

Doppler scansDoppler scans are useful for detecting are useful for detecting the presence and nature of renal blood the presence and nature of renal blood flowflow

RBF is reduced in prerenal/intrarenal RBF is reduced in prerenal/intrarenal AKI, test findings are of little use in the AKI, test findings are of little use in the diagnosis of AKI. diagnosis of AKI.

Nuclear scanNuclear scan used to assess renal blood used to assess renal blood flow and tubular functions. flow and tubular functions.

Aortorenal angiographyAortorenal angiography is used in the is used in the diagnosis of renal vascular diagnosis of renal vascular diseases(renal artery stenosis, renal diseases(renal artery stenosis, renal atheroembolic disease, atherosclerosis atheroembolic disease, atherosclerosis with aortorenal occlusion)with aortorenal occlusion)

Renal biopsy:Renal biopsy: useful in the diagnosis of useful in the diagnosis of intrarenal causes of AKI intrarenal causes of AKI

Also when renal function does not return Also when renal function does not return for a prolonged period and prognosis is for a prolonged period and prognosis is required to develop long-term required to develop long-term managementmanagement

Treatment:Treatment:

Dietary modulation: Dietary modulation: become crucial in the management of become crucial in the management of

oliguric renal failure, wherein the kidneys oliguric renal failure, wherein the kidneys do not adequately excrete either toxins or do not adequately excrete either toxins or fluidsfluids

Although diuretics seem to have no Although diuretics seem to have no effect on the outcome, they appear useful effect on the outcome, they appear useful in fluid homeostasisin fluid homeostasis

Furosemide (Lasix)Furosemide (Lasix) Increases excretion of water by interfering with Increases excretion of water by interfering with

chloride-binding cotransport systemchloride-binding cotransport system inhibits sodium and chloride reabsorption in the inhibits sodium and chloride reabsorption in the

thick ascending loop of Henle and the distal thick ascending loop of Henle and the distal renal tubulerenal tubule

peak of action: 60 min and lasting 6-8 h.peak of action: 60 min and lasting 6-8 h.

Dopamine Dopamine Stim adrenergic & dopaminergic receptorsStim adrenergic & dopaminergic receptors Lower dosesLower doses: stimulate dopaminergic receptors : stimulate dopaminergic receptors

(renal and mesenteric vasodilation)(renal and mesenteric vasodilation) higher doseshigher doses: cardiac stimulation & renal : cardiac stimulation & renal

vasodilationvasodilation AdultAdult 1-5 mcg/kg/min IV1-5 mcg/kg/min IV

calcium channel blockerscalcium channel blockers: used to : used to enhance the function of transplanted enhance the function of transplanted kidneys.kidneys.

NifedipineNifedipine: relaxes smooth muscle and : relaxes smooth muscle and produces vasodilationproduces vasodilation

N-acetylcysteine: N-acetylcysteine: used for prevention of used for prevention of contrast toxicity & provide substrate for contrast toxicity & provide substrate for conjugation with toxic metabolitesconjugation with toxic metabolites

600 mg PO bid on day preceding and 600 mg PO bid on day preceding and day of procedureday of procedure

Outpatient CareOutpatient Care

renal recovery is not complete and renal recovery is not complete and kidneys remain vulnerable to nephrotoxic kidneys remain vulnerable to nephrotoxic effects of all therapeutic agentseffects of all therapeutic agents

agents with nephrotoxic potential are agents with nephrotoxic potential are best avoidedbest avoided

Indications for dialysis in patients with AKI: Indications for dialysis in patients with AKI: Volume expansion that cannot be managed Volume expansion that cannot be managed

with diuretics with diuretics Hyperkalemia refractory to medical therapy Hyperkalemia refractory to medical therapy Correction of severe acid-base disturbances Correction of severe acid-base disturbances

that are refractory to medical therapy that are refractory to medical therapy Severe azotemia (BUN >80-100) Severe azotemia (BUN >80-100) UremiaUremia

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Acute Renal Failure 2* to Rhabdomyolysis 2* to Motor Vehicular Accident

Health & Medicine

Transcript of Acute Renal Failure 2* to Rhabdomyolysis 2* to Motor Vehicular Accident