Ricky Bell Renal/ICM Registrar

Transcription

1 Ricky Bell Renal/ICM Registrar

2 Objectives When to call renal How to manage the patient with AKI How the manage the patient with CKD (HD/PD) Special AKI situations

3 What do the guidelines say?

4 My referral summary Refer when cause of AKI isn t obvious (medication, dehydration, sepsis, obstruction most commonly) Refer when AKI thought to be intrinsic cause Blood/Protein in urine dip or positive immunology Refer when AKI isn t getting better especially with oliguria Refer when nearing need for RRT

5 Renal services at LGH Oncall registrar doing 24 hour non- resident oncall Start 8.45am 9am following day Expected to be in until 11am following day After 10pm, junior managing 55 bed renal ward including HDU. Can be F1-CT2

6 Leicester Renal Services Based at LGH 4 wards Transplant, 2 general neph, HDU Total 41 Beds, and 14 Side rooms High Dependency Unit 8 beds Can provide CVVH, noradrenaline, invasive arterial monitoring

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8 The HD/PD patient overnight -

9 Managing the HD/PD patient overnight Treat their presentation Don t panic if their creatinine is >1000 or urea 30+ or bicarb 15 Treat a high K+ medically Unable to excrete. Especially K+, H2O and acids Avoid giving fluids We can usually arrange transfer and dialysis Inform us with any PD/HD patient admission

10 But Local transfer guidelines

11 AKI 80% Pre- renal 10% obstruction Urine dip is biggest clue to intrinsic cause. Blood or protein should raise suspicion Cough + AKI Look at the urine dip Rash + AKI look at the urine dip Diarrhoea and AKI Look at the urine dip What s the urine output? Helps predict course ANA, ANCA, anti- GBM, myeloma screen

12 Dialysis indications A Acidosis E Electrolyte abnormalities (Potassium) I Ingestion (Methanol, Ethylene glycol, Salicylates ) O Overload U Ureamic pericarditis, ureamic encephalopathy Unresponsive to standard therapy.

13 Hepatorenal syndrome Can occur in acute or chronic liver disease of any cause Usually due to portal hypertension and cirrhosis Very poor prognosis Decline in renal perfusion

14 Hepatorenal syndrome Typical presentation Background of acute or chronic liver disease Increasing Creatinine Normal urine dip Minimal proteinuria Low urine sodium <10 oliguria

15 Hepatorenal syndrome treatment Treat the underlying liver disease Terlipressin + albumin HD is an option if reversibility present. Is underlying disease reversible or expected to recover? Is the patient suitable for liver transplant? Overall poor prognosis

16 Cardiorenal syndrome Cardiac failure leads to low cardiac output and decreased renal perfusion. Typically a patient with deteriorating cardiac function or presenting with signs of cardiac failure

17 Cardiorenal syndrome management Cardiac output optimisation. Diuresis Lungs are more important than kidneys Ignore the renal function

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20 Ultrafiltration for Heart failure Fluid removal via ultrafiltration. CARRESS-HF similar fluid loss in pharmacologic therapy vs UF but with worse renal function.

21 Bicarbonate Sodium bicarb 1.26% (150mmol/l of Na+ and HCO3-) Treat it s use as a replacement for 0.9% NaCl when patient has a metabolic acidosis from bicarb loss. May be of benefit in AKI but no RCTs in AKI Anecdotally works in diarrhoea (GI bicarb loss) Evidence that it doesn t improve outcome for DKA, Lactic acidosis, Septic shock, cardiac arrest. Can improve low bicarb levels and lower K+ Avoids Chloride Don t give if unable to ventilate CO2 load and don t give immediately after calcium (precipitates in veins)

22 Who benefits from dialysis Has significant consequences Depression, Psychological distress Pain, Impaired sleep, Itch Pill burden, fluid and diet restrictions Loss of independence, HD 3 x/week Associated with poor outcomes in patients with other comorbidities especially older, diabetic or functionally impaired.

23 Mean life expectancy with age at dialysis initiation

24 Mortality on dialysis vs General population Annual mortality (%) Dialysis 1 General population Age (years) Male Female Black White

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26 My key points Please call early we do 24 hour oncall shifts Ideally between 8am 10pm Can it wait until morning? AKI Is the cause obvious? what s in the urine dip? What s the urine output? Dialysis is it worth it? Bicarb Probably not using it enough Cardiorenal - diurese Hepatorenal treat cause Multi organ failure ITU A high creatinine never killed anyone.

27 Questions?