Insuficienta renala acuta

= Declin rapid al ratei filtrarii glomerulare

Retentia produsilor azotati + Tulburari a volumului extracelular, electrolitice, acido-bazice

Insuficienta renala acuta

Scaderea RFG > 75 %

Creatinina

>2-3X

< 0.3 ml/kg/ora 12 ore

Debit urinar

sau anurie > 12 ore

Insuficienta renala acuta

Scaderea RFG
Risc Leziune
> 25%

Creatinina
> 1.5 X

Debit urinar
< 0.5 ml/kg/ora 6 ore

> 50 %

>2X

< 0.5 ml/kg/ora 12 ore

Insuficienta

> 75%

>3X

< 0.3 ml/kg/ora 24 ore

Insuficienta renala acuta

Prevalenta 5% - 15% in ATI Mortalitate > 50%

Manifestari asimptomatica (screening ) 50% oligurie (< 400 ml/24 ore)

Clasificarea etiologica a IRA

- 55% prerenala (parenchim integru) 40 % renala (IRA intrinseca) 5% postrenala

1.IRA prerenala
Volumului intravascular cu hipoTA - TAs < 80 mmHG (Hg, pierderi digestive, renale, tegumentare) volumului efectiv intravascular (ICC, ciroza si sd. hepato-renal) Vasodilatatie sistemica/vasoconstrictie renala (sepsis)
AINS Stenoza artera renala Sindromul hepato-renal

IRA renala (intrinseca)

90% = Necroza tubulara acuta - ischemice - toxice

Glomerulonefrite Interstitiu - nefrite alergice (medicamente)

IRA renala (intrinseca)

Necroza tubulara acuta ischemica - hipovolemie - soc septic - interventii chirurgicale Persistenta retentiei azotate desi se normalizeaza factorii precipitanti

Fazele evolutive ale IRA ischemice

Faza initiala (scade RFG) Obstructia tubilor Ischemie medulara Stare (1-2 sapt) RFG- 5-10ml/min Oligurie Complicatii uremice Recuperare Creste RFG Poliurie

IRA renala (intrinseca) = Necroza tubulara acuta Nefrotoxica

Varstnici, IR cronica preexistenta, hipovolemie

Medicamente Substante de contrast

Crestere acuta a retentiei azotate ; 3-5 zile

Toxice Exogene Endogene mioglobina, Hb, mielom multiple, liza tumorilor

IRA postrenala
Prostata, calculi Vezica neurogena Obstructie uretrala bilaterala
Intraluminala Compresie extrinseca

IRA paraclinic
Creatinina serica, uree serica, acid uric Ionograma K, fosfatemie, Ca Echilibrul acido-bazic CK-MB Hemograma (eozinofilie)

Imagistica Biopsie renala

Eozinofilie (nefrite alergice)

Tablou clinic
IRA prerenala -status
semne de hipovolemie ICC, ciroza

IRA renala
Febra, artralgii, rash Durere in flanc Oligurie, edeme, HTA HTA maligna

IRA post-renala volum rezidual > 100 ml/ imagistica

Tablou clinic si paraclinic

Diureza Sediment
IRA prenala - benign (cilindrii hialini) IRA renala cilindrii granulosi , pigmentati; hematici IRA postrenala - sediment inactiv (posibil piurie, hematurie)

Proteinurie < 1g/zi; > 1g/zi (origine glomerulara)

IRA vs IRC
Analize anterioare Anemie, neuropatie, osteodistrofie renala Rinichi mici, cicatriciali

IRA prerenala renala - postrenala

diagnostic diferential
Densitatea urinii > 1018 Na urinar (mai putin util) < 20 mEg/l BUN/creatinina - 20:1 Excretia fractionata a NA < 1% Sediment urinar

Evaluarea stasului volumic depletie de volum; scaderea DC; sepsis

Imagistica , biopsie renala

IRA prerenala renala diagnostic diferential

Excretia fractionata a sodiului < 1%

Clearance Cr = Cr urinara X Volum / Cr plasmatica Clearance Na = Na urinar X Volum / Na plasmatic

Excretia Na % = Cl Na / Cl Cr
%Na excretat in urina = Na urinar X Cr plasmatica /Na plasmatic X Cr urinara

Diagnosticul IRA prerenala - renala

Uree/creatinina plasmatica Densitate urinara >1018 > 20 <1015 < 40 > 20 mmol/l < 1% > 1% cilindrii granulosi, pigmentati < 10 -15

Creatinina urinara/plasmatica > 40 Na urinar < 20 mmol/l

Excretia fractionata de NA Sediment urinar

cilindrii hialini

Diagnosticul diferential al insuficientei renale acute

IR acuta vs cronica
Istoric, ex clinic Creatinina anterior Rinichi mici (eco) exc DZ Anurie completa Vezica palpabila Ecografie renala Puls, PVJ, TA posturala, greutate/zi, balanta fluidelor Cresterea marcata raport uree/creatinina Concentratia urinara de Na (absenta diureticelor) Proba incarcarii cu lichide

Excluderea obstructiei

Evaluarea volemiei

Boli renale parenchimatoase prezente?

Istoric, ex. clinic Sediment urinar (hematii, cilindrii, eozinofile, proteinurie)

Exista ocluzia vasculara majora ?

Boala renala aterosclerotica Asimetrie renala Durere lombara Hematurie macroscopica Anurie completa

IRA - complicatii
Faza de stare creste volumul extracelular hipoNa si hipoosmolaritate hiperK cu 0.5 mEq/zi (rabdomioloza, hemoliza, liza tumorii)
Usoara < 6 mEq/l Acidoza metabolica Hiperfosfatemie + hipocalcemie

Anemie, leucocitoza, Tulburari de coagulare Infectie Cardiac Hg gastro-intestinale

Faza de recuperare hipovolemie, hipernatremie

IRA - tratament
IRA ischemica/nefrotoxica prevenire Azotemie prerenala
Volum intravascular; medicamente; evitarea hipovolemiei, medicamente nefrotoxice

- sange, plasma, solutii saline

IC, ciroza

Azotemie renala Azotemie postrenala Hipervolemie (furosemid, dopamina); Na, hiperK , Ca, acidoza, nutritie

IRA Dializa
Hemodializa sau dializa peritoneala Simptome/semne de sindrom uremic (uree > 100 mg/dl) Hipervolemie refractara HiperK Acidoza metabolica

Deces : 15 % obstetrica; 30% nefrotoxica; 60% traumatisme, chirurgie

IRA renala - tratament

ntrinsic ARF Treatment Advertising Disclaimer The goal of treatment for intrinsic ARF is to resolve the underlying cause and its complications. In nephrotoxic ARF, the toxins are eliminated. In ischemic ARF, adequate blood flow to the kidneys is restored. Acute glomerulonephritis and vasculitis are treated with glucocorticoids and plasmapheresis (plasma exchange). In allergic interstitial nephritis, the drug causing the condition is discontinued and glucocortoids are given.Malignant hypertension is treated with ACE inhibitors to control blood pressure. Treatment of ARF Complications Intravascular overload

Salt and water restriction Water restriction Dialysis Dietary potassium restriction Sodium bicarbonate Dialysis Dietary protein restriction Sodium bicarbonate Dietary phosphate restriction Calcium carbonate Calcium gluconate Discontinuation of magnesium-containing antacids (e.g., Maalox)

Hyponatremia (low sodium level in blood) Hyperkalemia (high level of potassium in the blood)

Metabolic acidosis

Hyperphosphatemia

Hypocalcemia

Hypermagnesemia