Quentin Oury (FY1)

 Several!! New Nice guidelines due 2014:  a rise in serum creatinine (of 26 μ mol/l or greater within 48 hours)  a 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days  a fall in urine output (to less than 0.5 ml/kg/hour for more than 6 hours in adults and more than 8 hours in children and young people)  a 25% or greater fall in eGFR in children and young people.  Put simply : Rise in serum creatinine over hours/days/weeks

 Age  CKD  HF  Diabetes  Surgery  Drugs- CANDA  Cognitive/neuro impairment

1) Pre-renal:  Hypovolaemia: sepsis, CCF, D+V, NSAID/ACEi, RAS 2) Renal:  ATN due to ischaemia/nephrotoxins (drugs/contrast/myeloma/rhabdo)  Gomerulonephritis, vasculitis 3) Post-renal:  Obstruction

 Think of causes:  Infection (UTI/sepsis)  Hypovolaemia (D+V, acute blood loss)  Drugs (any nephrotoxicx/new meds?)  Urine: output (&symptoms of UTI/prostate)  Weird and wonderful (nosebleeds, haemoptysis, backpain/weight loss)  PMHx: Diabetes, bladder/prostate Ca, FHx (PKD)

 General  Fluid status: BP, skin turgor, mucous membranes, JVP, oedema (peripheral/pulmonary), urine output  Abdominal (in exams)  Palpable bladder?

 Bedside:  Urine dipstick, urine input/output, daily weights/fluid monitoring  ABG/VBG  ECG  Bloods  FBC and regular tests inc cultures  “U+E’s” : CREATININE  Renal screen: myeloma, vasculitis, rhabdo  Imaging  CXR  USKUB  Special  Urine PCR  CT KUB  Renal biopsy

 Treat the cause!  Conservative:  Oral fluids, STOP CANDA, diet  Medical  IV fluids, treat life-threatening complications (next slide), catheter (if bladder/prostate obstruction), steroids for certain types of GN  Dialysis (if needed-see later)  Diuretics (if actually CKD crash-lander)  Surgical  Obstruction, bleeding

 Hyperkalaemia:  Life-threatening  ECG signs:  Low/flat P-waves,  Broad QRS  Tall-tented T waves  Mx:  1-Calcium gluconate (10/10) IV  2-Insulin+dex IV  3-Salbutamol  4-Calcium resonium

 Acidosis  Sodium bicarb IV  Dialysis  Pulmonary Oedema  Sit up  O2  Furosemide  Uraemia

1. Hyperkalaemia (refractory) 2. Severe acidosis (refractory) 3. Severe pulmonary oedema 4. Uraemic encephalopathy

 Causes: pre-, renal and post-  CANDA  Treatment: the cause  Manage: the complications (& be aware)