ACUTE RENAL FAILURE IN ACUTE RENAL FAILURE IN PREGNANCYPREGNANCY

Dr. Mona Shroff, M.D.(O&G)Dr. Mona Shroff, M.D.(O&G) Asst.Prof;SMIMER; SURAT

EMOC Advanced Trainer EMOC Advanced Trainer (FOGSI,GOI,JHPIEGO EmOC (FOGSI,GOI,JHPIEGO EmOC

project)project) Diploma in O & G Ultrasound (Ian Diploma in O & G Ultrasound (Ian Donald)Donald)

This presentationThis presentation covers covers BASIC OUTLINEBASIC OUTLINE InvestigationsInvestigations MANAGEMENT PRINCIPLESMANAGEMENT PRINCIPLES Prerenal Vs ATN Vs ACNPrerenal Vs ATN Vs ACN ROLE OF ROLE OF NutritionNutrition Volume & metabolic controlVolume & metabolic control Diuretics : helpful or harmful ??Diuretics : helpful or harmful ?? Dopamine : helpful or harmful ??Dopamine : helpful or harmful ?? Dialysis : when & which ??Dialysis : when & which ?? Renal biopsy ??Renal biopsy ?? DeliveryDelivery Conditions specific to pregnancyConditions specific to pregnancy

DEFINITIONS OFDEFINITIONS OF ARFARF

The syndrome is characterised The syndrome is characterised by a sudden in parenchymal by a sudden in parenchymal function (UOP<400ml/d;30ml/hr) function (UOP<400ml/d;30ml/hr) which is usually but not always which is usually but not always reversiblereversible

This produces disturbance of This produces disturbance of water, electrolyte, acid base water, electrolyte, acid base balance and nitrogenous waste balance and nitrogenous waste productsproducts & blood pressure.& blood pressure.

Physiological changes in Physiological changes in normal gestationnormal gestation

Kidney weight and size Kidney weight and size increaseincrease

Dilation of renal calyces, Dilation of renal calyces, pelves, and ureterspelves, and ureters

Urinary stasis Urinary stasis Glomerular filtration, Glomerular filtration,

effective renal plasma flow, effective renal plasma flow, fractional clearance of fractional clearance of urate increase urate increase

Bicarbonate reabsorption Bicarbonate reabsorption threshold decreasesthreshold decreases

Clinical relevanceClinical relevanceConcentrations of serum creatinine, Concentrations of serum creatinine,

urea N, and uric acid of 0.9, 14, and 5.6 urea N, and uric acid of 0.9, 14, and 5.6 mg/dl, normal in nonpregnant subjects, mg/dl, normal in nonpregnant subjects, are are already suspiciously high in gravid already suspiciously high in gravid womenwomen..

Asymptomatic bacteriuria - frank Asymptomatic bacteriuria - frank pyelonephritis. pyelonephritis.

PP reduction in size should not be PP reduction in size should not be mistaken for parenchymal lossmistaken for parenchymal loss

Post renal failure difficult to diagnosePost renal failure difficult to diagnoseS.bicarb lower,PCO2 10 mmHg lowerS.bicarb lower,PCO2 10 mmHg lower

CausesCauses

Bimodal distribution -peaks in Bimodal distribution -peaks in the first trimester (related to the first trimester (related to unregulated and/or septic unregulated and/or septic abortion,hyperemesis) and the abortion,hyperemesis) and the late third trimester (related to late third trimester (related to obstetric complications obstetric complications APH,PPH,Preeclampsia, APH,PPH,Preeclampsia, Chorioamnionitis,AFE etc). Chorioamnionitis,AFE etc).

P R E R E N A LC A U S E S

IN TR A R E N A LC A U S E S

P O S TR E N A LC A U S E S

E TIO L O G Y O FA C U TE R E N A L F A IL U R E

ATNCORTICAL NECROSIS

THOMBOTIC MICROANGIOPATHIES

The The RIFLE classificationRIFLE classification (ADQI group) of (ADQI group) of ARF:ARF:

Risk (R)Risk (R) - Increase in serum creatinine - Increase in serum creatinine

level X 1.5 or decrease in GFR by 25%, or level X 1.5 or decrease in GFR by 25%, or UO <0.5 mL/kg/h for 6 hours UO <0.5 mL/kg/h for 6 hours

Injury (I)Injury (I) - Increase in serum creatinine - Increase in serum creatinine level X 2.0 or decrease in GFR by 50%, or level X 2.0 or decrease in GFR by 50%, or UO <0.5 mL/kg/h for 12 hours UO <0.5 mL/kg/h for 12 hours

Failure (F)Failure (F) - Increase in serum creatinine - Increase in serum creatinine level X 3.0, decrease in GFR by 75%, or level X 3.0, decrease in GFR by 75%, or serum creatinine level serum creatinine level >> 4 mg/dL; UO 4 mg/dL; UO <0.3 mL/kg/h for 24 hours, or anuria for <0.3 mL/kg/h for 24 hours, or anuria for 12 hours 12 hours

Loss (L)Loss (L) - Persistent ARF, complete loss - Persistent ARF, complete loss of kidney function >4 wk of kidney function >4 wk

End-stage kidney disease (E)End-stage kidney disease (E) - Loss of - Loss of kidney function >3 monthskidney function >3 months

PHASESPHASES

OLIGURIAOLIGURIA

POLYURIAPOLYURIA

RECOVERYRECOVERY

InvestigationsInvestigationsBLOODBLOOD

CBCCBC

Urea,creatinine,uric Urea,creatinine,uric acidacid

ElectrolytesElectrolytes

LFTLFT

S.proteinsS.proteins

Coagulation profileCoagulation profile

ABGABG

RBSRBS

OsmolalityOsmolality

URINEURINE

sp.gravitysp.gravity

osmolalityosmolality

electrolyteselectrolytes

proteinsproteins

pigment castspigment casts

c/sc/s

ECGECG

ManagementManagement

Restore or maintain fluid balanceRestore or maintain fluid balanceThe maintenance of electrolytes and The maintenance of electrolytes and

acid base balanceacid base balanceThe maintenance of nutritional The maintenance of nutritional

supportsupportPrevention of infectionPrevention of infectionAvoid renal toxins (including Avoid renal toxins (including

NSAIDS)NSAIDS) Instigate renal replacement Instigate renal replacement

therapiestherapies

Prerenal failurePrerenal failure Adequately replace blood & fluid Adequately replace blood & fluid

losses,maintain BP.losses,maintain BP. Control continuing blood lossControl continuing blood loss Mannitol (100ml, 25%) trial to d/d b/w Mannitol (100ml, 25%) trial to d/d b/w

reversible prerenal failure & established ATN reversible prerenal failure & established ATN (provided oliguria <48 hrs & U:P osmolality > (provided oliguria <48 hrs & U:P osmolality > 1.05)1.05)

If diuresis (>50ml/hr or doubling) established If diuresis (>50ml/hr or doubling) established within 3 hrs,maintain NS infusion acc to UOP within 3 hrs,maintain NS infusion acc to UOP & replace electrolytes acc to urinary loss & replace electrolytes acc to urinary loss estimations.estimations.

If unsuccessful –objective is to support the If unsuccessful –objective is to support the functionally anephric pt till kidneys recover.functionally anephric pt till kidneys recover.

Volume controlVolume control

IP/OP charting dailyIP/OP charting dailyState of hydration-wt,hct,proteinState of hydration-wt,hct,protein Input = Output/24hrs + Input = Output/24hrs +

500ml(nonfebrile) 500ml(nonfebrile)

+ 200 ml/ deg C of inc. in Tem+ 200 ml/ deg C of inc. in Tem

Balance : 0.3-0.5kg wt loss/d Balance : 0.3-0.5kg wt loss/d Avoid overhydration : Rx Avoid overhydration : Rx

diuretics,dialysis diuretics,dialysis CVP monitoring (b/w 10-15cm H2O) CVP monitoring (b/w 10-15cm H2O)

DiureticsDiuretics Diuretics commonly have been Diuretics commonly have been

given in an attempt to convert the oliguric given in an attempt to convert the oliguric state to a nonoliguric state. However, state to a nonoliguric state. However, diuretics have not been shown to be diuretics have not been shown to be beneficial, and they may worsen beneficial, and they may worsen outcomes.outcomes.

In the absence of compelling contradictory In the absence of compelling contradictory data from a randomized, blinded clinical data from a randomized, blinded clinical trial, the widespread use of diuretics in trial, the widespread use of diuretics in critically ill patients with acute renal critically ill patients with acute renal failure should be discouraged. failure should be discouraged.

Useful only in management of fluid-Useful only in management of fluid-overloaded patientsoverloaded patients

Cantarovich F, Rangoonwala B, Lorenz H, Verho M, Esnault VL. High-dose furosemide Cantarovich F, Rangoonwala B, Lorenz H, Verho M, Esnault VL. High-dose furosemide for established ARF: a prospective, randomized, double-blind, placebo-controlled, for established ARF: a prospective, randomized, double-blind, placebo-controlled, multicenter trial. Am J Kidney Dis 2004;44:402-9.multicenter trial. Am J Kidney Dis 2004;44:402-9. Kellum JA. Systematic review: The use of diuretics and dopamine in acute renal Kellum JA. Systematic review: The use of diuretics and dopamine in acute renal failure: a systematic review of the evidence. Critical Care1997;1(2):53–9.failure: a systematic review of the evidence. Critical Care1997;1(2):53–9.

DOPAMINEDOPAMINE

Dopamine traditionally has been used to Dopamine traditionally has been used to promote renal perfusion(1-5 promote renal perfusion(1-5 mcg/kg/min ) mcg/kg/min )

However, systematic reviews of However, systematic reviews of dopamine treatment in critically ill dopamine treatment in critically ill patients and in patients with sepsis do patients and in patients with sepsis do not support the use of dopamine to not support the use of dopamine to prevent renal insufficiency, morbidity, or prevent renal insufficiency, morbidity, or mortality. In the majority of ARF mortality. In the majority of ARF studies, dopamine was associated only studies, dopamine was associated only with an increase in urine output. with an increase in urine output. Kellum JA, Decker MJ. Use of dopamine in acute renal failure: a meta-analysis. Crit Care Med

2001;29:1526-31. Denton MD, Chertow GM, Brady HR. "Renal-dose" dopamine for the treatment of acute renal failure: scientific rationale, experimental studies and clinical trials. Kidney Int 1996;50:4-14.

NutritionNutrition INTAKEINTAKE

1500 cal (protein free)1500 cal (protein free)

Oral/parenteralOral/parenteral

If vol limitation-50%D via If vol limitation-50%D via central veincentral vein

Essential L-aminoacids: Essential L-aminoacids: K,Mg,P:Improve wound K,Mg,P:Improve wound healing, hasten healing, hasten recovery recovery

Protein intake of 0.6 g Protein intake of 0.6 g per kg per day per kg per day

Electrolyte & acid-base Electrolyte & acid-base correctioncorrection

Hyperkalemia, which can be life-Hyperkalemia, which can be life-threatening, should be treated bythreatening, should be treated by

decreasing the intake of potassium,decreasing the intake of potassium, delaying the absorption of potassium, delaying the absorption of potassium, exchanging potassium across the gut exchanging potassium across the gut

lumen using potassium-binding resins,lumen using potassium-binding resins, controlling intracellular shiftscontrolling intracellular shifts dialysis.dialysis.

Acidosis- sodabicarb ,dialysisAcidosis- sodabicarb ,dialysis

• Treat coagulopathy with FFP for Treat coagulopathy with FFP for a prolonged aPTT, a prolonged aPTT, cryoprecipitate for a fibrinogen cryoprecipitate for a fibrinogen level less than 100 mg/dL, and level less than 100 mg/dL, and transfuse platelets for platelet transfuse platelets for platelet counts less than 20,000/mm3counts less than 20,000/mm3

Timely identification of UTI, Timely identification of UTI, proper treatment & prevention proper treatment & prevention using prophylactic antibiotics using prophylactic antibiotics

Indications for Kidney Indications for Kidney Replacement TherapyReplacement Therapy

Acidosis unresponsive to medical therapyAcidosis unresponsive to medical therapy Acute, severe, refractory electrolyte Acute, severe, refractory electrolyte

changes (e.g., hyperkalemia)changes (e.g., hyperkalemia) EncephalopathyEncephalopathy Significant azotemia (blood urea nitrogen Significant azotemia (blood urea nitrogen

level >100 mg per dL [36 mmol per L])level >100 mg per dL [36 mmol per L]) Significant bleedingSignificant bleeding Uremic pericarditisUremic pericarditis Volume overloadVolume overload

Early “Prophylactic” Early “Prophylactic” DialysisDialysis

Allows more liberal Allows more liberal fluid, protein & fluid, protein & salt intake.salt intake.

Prevent Prevent hyperkalemic hyperkalemic emergencies.emergencies.

infectious Cx.infectious Cx. Improves comfort Improves comfort

& survival& survival

Hemodialysis Vs PeritonealHemodialysis Vs Peritoneal dialysis dialysis

Limited Limited usefulness if usefulness if hypotensionhypotension

C/I in actively C/I in actively bleeding pt.bleeding pt.

Controlled Controlled anticoagulation anticoagulation reqdreqd

Volume shifts-Volume shifts-carefulcareful

Faster correctionFaster correction

Can be used in Can be used in preg/PP pt.preg/PP pt.

Easily availableEasily available Simple,inexpensivSimple,inexpensiv

ee Lower Cx rateLower Cx rate Minimises rapid Minimises rapid

metabolic metabolic pertubations & pertubations & fluid shiftsfluid shifts

Insert cath high Insert cath high direct visiondirect vision

DeliveryDelivery Development of ARF in obs pt is Development of ARF in obs pt is

indication of delivery in majority cases.indication of delivery in majority cases. Deliver if UOP<20 ml/>2hrs despite Deliver if UOP<20 ml/>2hrs despite

adequate vol expansion & immediate adequate vol expansion & immediate delivery not expected delivery not expected

Redistribution of CO – better renal Redistribution of CO – better renal perfusion.perfusion.

Remove fetus from hostile environment.Remove fetus from hostile environment. Neonate urea –osmotis diuresis -Neonate urea –osmotis diuresis -

dehydrationdehydration

Renal biopsyRenal biopsy

Potentially v.risky in Potentially v.risky in pregnancypregnancy

Defer until postpartum even Defer until postpartum even if ACN( for prognostication).if ACN( for prognostication).

Rare indication sudden renal Rare indication sudden renal failure before 32 wks with failure before 32 wks with no obvious cause.no obvious cause.

PreeclampsiaPreeclampsia

A decrease in the GFR occurs A decrease in the GFR occurs secondary to intrarenal secondary to intrarenal vasospasm. This may manifest as vasospasm. This may manifest as a "prerenal" picture. Acute renal a "prerenal" picture. Acute renal failure (ARF) may develop, and failure (ARF) may develop, and acute tubular necrosis (ATN) may acute tubular necrosis (ATN) may ensue if this hypoperfusion ensue if this hypoperfusion persists.persists.

Pre-eclampsia: Pre-eclampsia: ManagementManagement

Renal problemsRenal problems Hyperuricaemia and proteinuria are NOT Hyperuricaemia and proteinuria are NOT

indications for delivery indications for delivery per seper se

Consider delivery for progressive renal Consider delivery for progressive renal

impairment (creatinine >0.09 mmol/L)impairment (creatinine >0.09 mmol/L)

Care with fluids (pulmonary oedema can Care with fluids (pulmonary oedema can

kill!)kill!)

Kidney Function is CriticalKidney Function is Critical

for Drug Eliminationfor Drug Elimination

Pre-eclampsiaPre-eclampsiaInvasive monitoringInvasive monitoring

CVP monitoring may NOT be helpful!CVP monitoring may NOT be helpful! poor correlation between CVP and PCWPpoor correlation between CVP and PCWP

PA catheters have risks!PA catheters have risks! rarerare indications: indications:

pulmonary oedema resistant to diureticspulmonary oedema resistant to diuretics

oliguric renal failure despite volume expansionoliguric renal failure despite volume expansion

Idiopathic postpartum renal Idiopathic postpartum renal failurefailure

Associated primarily with Associated primarily with microangiopathic processes microangiopathic processes

Postpartum hemolytic-uremic Postpartum hemolytic-uremic syndrome.syndrome.

These were often irreversible and These were often irreversible and were associated with substantial were associated with substantial mortality.mortality.

Now improved outcome with plasma Now improved outcome with plasma exchange,dialysis,prostacyclin exchange,dialysis,prostacyclin infusion, correcting coagulopathyinfusion, correcting coagulopathy

ACUTE FATTY LIVER OF ACUTE FATTY LIVER OF PREGNANCYPREGNANCY

Associated with acute renal failure Associated with acute renal failure in up to 60 percent of cases. in up to 60 percent of cases.

The diagnosis should be The diagnosis should be suspected in a woman with suspected in a woman with preeclampsia who has preeclampsia who has jaundice,hypoglycemia, jaundice,hypoglycemia, hypofibrinogenemia, and a hypofibrinogenemia, and a prolonged PTT in the absence of prolonged PTT in the absence of abruptio placentae. abruptio placentae.

KEY RECOMMENDATIONS KEY RECOMMENDATIONS FOR PRACTICEFOR PRACTICE

Identify & prevent at prerenal phase as Identify & prevent at prerenal phase as early as possibleearly as possible

Dopamine should not be used to preventDopamine should not be used to prevent acute renal failure. (Evidence level A) acute renal failure. (Evidence level A) Diuretics should not be used to treat Diuretics should not be used to treat

oliguria in patients with acute renal failure oliguria in patients with acute renal failure unless volume overload (Evidence level B)unless volume overload (Evidence level B)

Early prophylactic dialysis should be Early prophylactic dialysis should be strongly considered.strongly considered.

The maintenance of electrolytes,acid base The maintenance of electrolytes,acid base balance & nutritional support plays vital balance & nutritional support plays vital role.role.

THANK YOUTHANK YOU