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Oliguria and Acute Renal Failure
Terms in this set (15)
History of the Present Illness
Oliguria (<20 mL/h, 400-500 mL urine/day); anuria (<100 mL urine/day); hemorrhage, heart failure, sepsis, infection, vomiting, nasogastric suction; diarrhea, fever, chills; measured fluid input and output by Foley catheter; prostate enlargement, kidney stones, anticholinergics.
Nephrotoxic drugs (aminoglycosides, amphotericin, NSAID's), dysuria, flank pain. Abdominal pain, hematuria, passing of tissue fragments, foamy urine (proteinuria). Administration of renally excreted medications.
Recent upper respiratory infection (post streptococcal glomerulonephritis), recent chemotherapy (tumor lysis syndrome).
Physical Examination General Appearance
Signs of dehydration, septic appearance. Note whether the patient looks "ill" or well.
BP (orthostatic vitals; an increase in heart rate by >15 mmHg and a fall in systolic pressure >15 mmHg, indicates significant volume depletion); pulse (tachycardia); temperature (fever), respiratory rate (tachypnea).
Decreased skin turgor over sternum (hypovolemia); skin temperature and color; delayed capillary refill; jaundice (hepatorenal syndrome).
Oral mucous membrane moisture, ocular moisture, flat neck veins (volume depletion), venous distention (heart failure).
Crackles (heart failure).
S3 (volume overload).
Hepatomegaly, abdominojugular reflex (heart failure); costovertebral angle tenderness; distended bladder, nephromegaly (obstruction).
Pelvic masses, cystocele, urethrocele.
Prostate hypertrophy; absent sphincter reflex, decreased sensation (atonic bladder due to vertebral disk herniation).
Peripheral edema (heart failure).
Sodium, potassium, BUN, creatinine, uric acid. Urine and serum osmolality, UA, urine creatinine. Ultrasound of bladder and kidneys.
Fractional excretion of sodium (FE Na) =
Na(mMol/L) x SCr(mmol/L) / SNa(mMol/L) UCr(mMol/L) x 100
Renal Failure Index
UNa/ x 100
Differential Diagnosis of Acute Renal Failure
A. Prerenal insult is the most common cause of acute renal failure, accounting for 70%.
B. It is usually caused by reduced renal perfusion pressure secondary to extracellular fluid volume loss (diarrhea, diuresis, GI hemorrhage), or secondary to extracellular fluid sequestration (pancreatitis, sepsis), in-adequate cardiac output, renal vasoconstriction (sepsis, liver disease), or inadequate fluid intake or replacement.
A. Insult to the renal parenchyma (tubular necrosis) causes 20% of acute renal failure.
B. Prolonged hypoperfusion is the most common cause of tubular necrosis.
C. Nephrotoxins (radiographic contrast, aminoglycosides) are the second most common cause of tubular necrosis.
D. Pigmenturia induced renal injury can be caused by intravascular hemolysis or rhabdomyolysis.
E. Acute glomerulonephritis or acute inflammation of renal interstitium (acute interstitial nephritis) (usually from allergic reactions to beta-lactam antibiotics, sulfonamides, rifampin, NSAIDs, cimetidine, phenytoin, allopurinol, thiazides, furosemide, analgesics) are occasional causes of intrarenal kidney failure.
A. Postrenal damage results from obstruction of urine flow, and it is the least common cause of acute renal failure, accounting for 10%.
B. Postrenal insult may be caused by extrarenal obstructive uropathy (prostate cancer, benign prostatic hypertrophy, renal calculi obstruction) or by intrarenal obstruction (amyloidosis, uric acid crystals, multiple myeloma, or acyclovir).
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