1. Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC, CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN

2. Objectives Discuss the significance of the RIFLE classification for renal dysfunction. Differentiate between pre – renal, intra – renal and post – renal failure with regard to etiologies, diagnosis and treatment. Utilizing a case study, identify management strategies of a patient with renal dysfunction

3. Definition rapidly progressive potentially reversible cessation of renal function UO < 0.5 mL/kg/hr

5. Renal Failure Index (RFI) RFI = UNa x SCr/UCr Intrepretation RFI < 1 (prerenal failure) RFI > 1 (intrarenal failure)

6. Fraction Excreted Sodium (FENa) FE Na = U na X P Cr / P na X U cr x 100 Intrepretation FENa < 1 (prerenal failure) FENa > 1 (intrarenal failure)

7. Renal Failure Index (RFI) RFI = UNa x SCr/UCr Example  RFI < 1  UNa < 20 mEq/L  FENa < 1%  UCr/SCr > 30

8. Renal Failure Index (RFI) RFI = UNa x SCr/UCr Example  RFI > 1  UNa>40 mEq/L  FENa > 2-3%  UCr/SCr<20

9. Renal Biomarkers Urine interleukin – 18 (IL – 18) Urine or blood NGAL neutrophil gelatinase – associated lipocalin Increase 24 to 48 hours earlier than creatinine

10. Prerenal Etiology (PRE) most common type  volume  cardiac function use of vasopressors

11. Prerenal Etiology (PRE) Diagnostics BUN/Creatinine ratio RFI/FENa urinalysis

12. Postrenal (POST) obstructive process structural functional lower tract or bilaterally in upper tracts

13. Intrinsic Diagnostics BUN/Creatinine ratio RFI/FENa urinalysis

14. Intrinsic - kidney acute tubular necrosis (hypoxic or nephrotoxic) glomerular disorders (AGN), rhabdomyolysis, postinfectious

15. Intrinsic - kidney Vascular lesions – blood flow compromise (HUS) Interstitial nephritis (AIN) reactions to drugs or infections

16. Intrarenal Etiology Diagnostics BUN/Creatinine ratio RFI/FENa urinalysis

17. Treatment underlying cause prevention on injury high risk patient hydration limit exposure

18. Management Principles maintain fluid balance manage hyperkalemia glucose & insulin calcium gluconate sodium bicarbonate

19. Clinical Manifestations hyperkalemia hypocalcemia hypermagnesemia hyperphosphatemia uremia acid – base imbalance

20. Management Principles control hypertension in presence of encephalopathy bicarbonate for severe acidosis (pH < 7.2) manage anemia

21. Renal Replacement Therapies

22. Treatment Replacement Therapies acidosis HCO 3 < 10 mEq/L K + > 6.5 mEq/L need high protein diet deteriorating

23. Treatment: Types hemodialysis peritoneal dialysis continuous renal replacement therapy

24. Treatment fluid balance anticoagulation prevent clotting prevent blood loss ultrafiltration

25. Rhabdomyolysis  Causes  trauma  burns  compression syndrome  infection

26. Rhabdomyolysis  Causes  vascular occlusion  prolonged shock  electrolyte disorders  drugs (cocaine, alcohol)

27. Rhabdomyolysis  Clinical Manifestations  myalgias  muscle swelling & weakness  DIC  color of urine

28. Rhabdomyolysis  Lab Values  elevated muscle enzymes  hyperkalemia  hyperphosphatemia  hypocalcemia

29. Rhabdomyolysis  Treatment  volume replacement  treat electrolyte abnormalities  protect renal perfusion  alkalinization of urine  fasciotomy

30. Case Study 1  45 – year old female with history of peptic ulcer  10 – day history of intractable vomiting and abdominal pain  drinking small amounts of water @ frequent intervals  weaker, now complaining of dizziness

31. Case Study 1 Vital Signs (Supine)Vital Signs (Sitting) BP 96/50 HR 110 RR 20 Temp 99°F BP 72/38 HR 140

32. Case Study 1  Physical Exam:  tenting of the skin  sunken eyes  dry mucous membranes  flat jugular veins  epigastric tenderness

33. Case Study 1 Serum ElectrolytesABGs Na 134 K 2.6 Cl 70 CO 2 41 Glucose 80 Creatinine 4.5 BUN 112 pH 7.55 PaCO 2 50 PaO 2 90 SaO 2 95% HCO 3 40

34. Case Study 1 Urine ChemistriesUrinalysisSediment Na 15 K 40 Cl <10 Creatinine 200 Urea 2000 Osmolality 700 Color dk amber pH 5.0 SG 1.020 Ketones + Protien - Blood - WBC 0-1 RBC 0-1 Casts None

35. Case Study 2  20 – year old male with friends “doing drugs – cocaine”  Police break up party – male runs from police but collaspes – states legs became so weak that he fell  Admitted to ED – lower extremity weakness and severe pain in legs

36. Case Study 2 Serum ElectrolytesABGs Na 141 K 6.7 Cl 104 CO 2 7 Creatinine 4.5 BUN 20 Ca 5.0 Mg 2.0 PO 4 11.2 pH 7.11 PaCO 2 27 PaO 2 97 SaO 2 98% HCO 3 7

37. Case Study 2 Serum EnzymesHematology ValuesClotting Profile CK 4,780 LDH 812 Hct 30 WBC 18,400 PT 28 PTT >180 Platelets 80,000

38. Case Study 2 UrinalysisSedimentUrine Chemistries Color Reddish brown SG 1.008 pH 5.0 RBC 0-1 WBC 4-5 Casts granular & epithelial Urine Na 42 Urine Osm 280