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What would make you think of Wegener granulomatosis, as acute intrinsic renal failure?
Otitis, Sinusitis, Epistasxis, hemoptysis, or nasal septal ulcers (HONES)
Hemoptysis can be suggestive of what 3 causes of renal failure?
*Antiglomerular basement membrane disease
*Wegener granulomatosis
(GAW, you're bleeding and it's a kidney problem)
How do you evaluate fluid balance in context of renal failure?
*Orthostatic vital signs
*Assessment of skin turgor
*Examination of jugular veins
Fluid depletion can indicate what?
Prerenal condition
Fluid overload can indicate what? (2)
Severe intrinsic renal failure or a preenal edematous state, like CHF or cirrhosis
Abdominal bruits suggests?
renovascular disease
Pelvic or rectal examination could be useful why?
Find cause of urinary outflow obstruction, like enlargmed prostate or a pelvic mass
When might be you able to palpate the kidenys, and what would that indicate?
hydronephrosis or polycystic kidney disease (indicates chronic renal failure)
Physical findings of uremic syndrome?

*Pericarditis (cardiac RUB)
*Uremic frost (crystals of urea that collect on the skin)
 *Asterixis (flapping tremor)
*Uremic fetor= urine-like odor to the breath
DDx of ARF?
CHF, dehydration, intoxication
Dx ARF with what 2 things?
*Elevated BUN
*Elevated Creatinine
Monitor ARF how?
Serum electolytes (Na, K, Cl, Bicarb, Ca, Phosphate)
Other tests in ARF with urine?
*Urine sediment
 ---RBCs...alone of in casts suggests glomerulus or vascular lesions
---WBCs: seen in interstitial nephritis...granular casts= muddy brown casts: seen in acute tubular necrosis but aren't as specific as other casts)
*24 hr Urine Collection -- proteinuria...nephortic-range proteinuria= 3g/24 hr: GLOMRULAR lesion...lesser amnts: intersitial problem
*Fractual excretion of Na
--Calc this. 100*[(urine na/serum na)/ (urine cr/serum cr)] this for distinguishing prerenal <1: kidneys are trying to conserve na to preserve intravasc volume

How do you confrim prerenal failure due to a stimulus to preserve volume via water retention?
High urinary osmolarity (>500mOsm/kg H2O)
Do what if suspect suspect volume deficiency prerenal conditions? For what 2 purposes?
fluid challenge (for Dx and Tx)
If you suspect a glomerular process clinically, what type of disease do you want to look for? And how?
Look for immune-mediated disease! Measure antinuclear abs, ANCAs (in Wegener granumlomatosis), antiglomerular bm (anti-GBM) abs, complement levels, cryoglobluins
How do you dx and tx postrenal obstruction?
bladder catheterization (large postvoid residual volume --> catheter indicates bladder dysfunction or obstruction)
What kind of renal imaging can you do and what will it tell you?
*US...tells you kidney size and whether there's hydronephrosis (water inside the kidney)
*renal scan do look for unilateral renal artery stenosis...not very sensitive if bilateral disease though
What do you do if see hydronephrosis on US indicative of obstruction?
consult urolgoist and do helical CT or retrograde pyelography or cystoscopy to look for precise location of obstruction
When would you do a renal biopsy?
Not usually needed...done in conjunciton with urologist if dx is uncertain...or if want prognostic info
Basic tx of ARF involves correcting what 2 things?
fluid abormalities, electrolyte abnormalities, underlying case
Avoid which meds in ARF?
nephrotoxic (aminoglycosides, radiocontast dye) or reduce renal blood flow (NSAIDs)
Emergency condition in ARF? And how do you detect it?
*Hyperkalemia! (>6mmol/L or ECG abnormalities)
Tx prerenal axotemia how? (2)
restore intravascular volume and perfusion bp
How do you treat hypovolemia --> prerenal failure?
Depends on mech of fluid loss
**Hemorrhage: give saline and red cells!
*GI fluid loss: replace hypotonic fluid
Tx acute tubular necrosis how?
often caused by nephrotoxic agents, so remove that agent! 
Tx for Wegener's granulomatosis or glomulonephritis?
Immunosuppress with prednisone and cyclophosphamide to prevent irreversible renal damage! supportive methods until reversal of underlying problem achieved...if severe may need temporary dialysis
Tx for postrenal axotemia?
Determine magnitude! Relieve the obstruction of urinary flow. May need to consult. If obstruction is in URETHRA, can catheterize the bladder and if not possible, place a suprapubic tube. For a higher obstruction (vesicouretral junction in the ureter or renal pelvis): do a percutaneous nephrotomy or ureteral stent (urologist needed)
Long-term managment of pts who have had ARF involves what?
*Monitor for complicatios or renal failiure, maintenance of return of renal fucntion
*Adjust doses of drugs that are renally excreted (aboid systemic tox and renal tox!)
*Consider dialysis if recovery is late/ not happening
Which disease--> pts particularly at risk for not recovering sufficiently and needing long-term dialysis?
Start. 5 roles of kidneys?
*maintain water, volume, and electrolyte balance
*removal nitrogenous and other metabolic wastes
*metabolize vit d
*synthesis of erythropoietin
*bp regulation (via secretion of renin and prostaglandins
time frame for ARF?
hrs to days
3 main etiologies for ARF?
pre-renal (--> overal decrease in renal perfusion)
intrinsic renal (conditions affecting the renal vascular, glomerular, and tubular tissues)
postrenal (conditions that--> impairment of urine flow in kidneys)
Pre-renal conditions? (6)
*Hypovolemia (eg from blood loss, dehydration)
*Decreased CO (eg during acute myocardial infarction, cardiac arrest)
*Renovascular disease (eg dissection of renal artery, renal artery thrombosis)
*Systemic vasodilation (eg: from administration of systemic vasodilator agents)
*Renal vasoconstriction (eg: from admin of vasopressor agents)
*Impairment of renal autoregular of blood flow (eg caused by drugs such as ACE inhibitors or NSAIDs)
Intrinsic renal conditions? (5)
*Vassculitis or microangiopathy
*Acute tubular necrosis (can be caused by an ischemic insult or nephrotoxic drugs such as aminoglycoside antibiotics or radiographic contrast agents)
*Intersitial nephritis (often an allergic type reaction to various drugs such as beta-lactam antibiotics)
*tubular obstruction
Postrenal etiologies? (3)
Ureteral obstruction (eg: tumor, retroperitoneal hemorrhage, or nephroliathiasis)
Bladder neck obstruction (eg: tumor)
Urethral obstruction (seocndary to an enlarged prostate, bladder thrombus, renal calculus)
In ambulator pts, ARF is more often seen in pts with co-morbid conditions and a debilitated state. In admitted pts, associated with what settings?
-trauma (hemorrhage, muscle injury)
- admin of nephrotoxic drugs (aminoglycoside antibotics, contrast agents)
-bladder catherterization
-shock (low CO states adn use of vasoactive drugs)
At what % of normal GFR do you normally see symtpoms of ARF?
Symtpoms seen in ARF?
Oliguria or anuria
Intravascular volume overload (dyspnea, orthopnea, edema)
metabolic acidosis (dyspnea)
anemia (fatigue)
hyper K
uremic syndrome (BUN is over 60-100 mg/dL...anorexis, nausea/vomiting, pruritus, metal status changes, serositis/pericarditis, coagulopathy)
Hx elements that you should get for ARF?
recent surgery, trauma, infection
prior bladder function changes, such as nocturia, hesistancy, or reduced stream (postreanl failure)