acute renal failure in pregnancy
DESCRIPTION
ACUTE RENAL FAILURE IN PREGNANCY. Dr. Mona Shroff, M.D.(O&G) Asst.Prof;SMIMER; SURAT EMOC Advanced Trainer (FOGSI,GOI,JHPIEGO EmOC project) Diploma in O & G Ultrasound (Ian Donald). This presentation covers. BASIC OUTLINE Investigations MANAGEMENT PRINCIPLES - PowerPoint PPT PresentationTRANSCRIPT
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
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.