61
RENAL FAILURE RENAL FAILURE

Renal Failure

Embed Size (px)

Citation preview

Page 1: Renal Failure

RENAL FAILURERENAL FAILURE

Page 2: Renal Failure

BY BY

PROF. E. D. YEABOAHPROF. E. D. YEABOAH

(MA BCHIR MD (CANTAB) FRCS (MA BCHIR MD (CANTAB) FRCS FWACS FICS FMCS FGA)FWACS FICS FMCS FGA)

UNIVERSITY OF GHANA UNIVERSITY OF GHANA MEDICAL SCHOOLMEDICAL SCHOOL

Page 3: Renal Failure

OBJECTIVESOBJECTIVES

1.1. AETIOOLOGYAETIOOLOGY..PATHOGENESISPATHOGENESIS. . MANAGEMENTMANAGEMENT

2.2. RENAL FUNCTIONSRENAL FUNCTIONS – ASSESSMENT – ASSESSMENT 3.3. ACUTE RENAL FAILUREACUTE RENAL FAILURE (ARF (ARF))

– DEFINITION DEFINITION – AETIOLOGY PATHOGENESISAETIOLOGY PATHOGENESIS– DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS – MANAGEMENTMANAGEMENT– COMPLICATIONSCOMPLICATIONS

Page 4: Renal Failure

4.4. CHRONIC RENAL FAILURE (CRF)CHRONIC RENAL FAILURE (CRF) ■ ■ DEFINITIONDEFINITION ■ ■ AETIOLOGIES PATHOGENESISAETIOLOGIES PATHOGENESIS ■ ■ CLINICAL APPROACHCLINICAL APPROACH ■■ DIAGNOSIS & DDDIAGNOSIS & DD ■ ■ COMPLICATIONSCOMPLICATIONS

MANAGEMENTMANAGEMENT ■■CONSERVATIVECONSERVATIVE ■ ■ DIALYSIS CAPD, HD, HFDIALYSIS CAPD, HD, HF ■ ■ RENAL TRANSPLANTATIONRENAL TRANSPLANTATION

Page 5: Renal Failure

RENAL FUNCTIONSRENAL FUNCTIONS

A.A. MAINTENANCE OF HOMEOSTASISMAINTENANCE OF HOMEOSTASIS ■■ FLUID AND ELECTROLYTE BALANCEFLUID AND ELECTROLYTE BALANCE ■ ■ EXTRACELLULAR VOLUMEEXTRACELLULAR VOLUME ■ ■ ACID BASE BALANCE ACID BASE BALANCE ■ ■ BPBP

B.B. HORMONESHORMONES ■■ PRODUCTIONPRODUCTION - RENIN - RENIN ■■ PROSTAGLANDINSPROSTAGLANDINS ■■ KALLIKREINKALLIKREIN ■■ VIT DVIT D ■■ ERYTHROPROIETINERYTHROPROIETIN ■■ HORMONE DETOXICATION /EXCRETIONHORMONE DETOXICATION /EXCRETION

Page 6: Renal Failure

A.A. EXCRETION NITOGENOUS AND WASTE EXCRETION NITOGENOUS AND WASTE PRODUCTS OF METABOLISMPRODUCTS OF METABOLISM

B.B. RENAL FUNCTION TESTSRENAL FUNCTION TESTS 1.1. CLINICAL RECOGNITIONCLINICAL RECOGNITION HISTORYHISTORY

– DEHYDRATION–DIARRHOEA VOMITING BURNS DEHYDRATION–DIARRHOEA VOMITING BURNS – DRUGSDRUGS– BURNS BURNS – PAIN – RENAL/URETERIC COLICPAIN – RENAL/URETERIC COLIC

DISORDERSDISORDERS– MALARIA,TYPHOID,ABORTION, MALARIA,TYPHOID,ABORTION, – BILHARZIASIS BILHARZIASIS – NEPHRITIDES, DM, SICKLE CELL CRISISNEPHRITIDES, DM, SICKLE CELL CRISIS– MULTIPLE INJURIES, CCF, CANCER, ALLERGY, MULTIPLE INJURIES, CCF, CANCER, ALLERGY,

THROMBOEMBOLISM MI, BITES-SNAKE, BEES THROMBOEMBOLISM MI, BITES-SNAKE, BEES INSECTSINSECTS

Page 7: Renal Failure

OPERATIONS OPERATIONS – MAJOR CARDIOVASCULAR PELVIC MAJOR CARDIOVASCULAR PELVIC – GYNAECOLOGICAL INSTRUMENTATIONGYNAECOLOGICAL INSTRUMENTATION

URINARY TRACT SYMPTOMS URINARY TRACT SYMPTOMS – PAIN – RENAL/ URETERIC COLICPAIN – RENAL/ URETERIC COLIC– LUTS (Lower Urinary Tract Symptoms)LUTS (Lower Urinary Tract Symptoms)– LUTO (Lower Urinary Tract Obstructive Symptoms)LUTO (Lower Urinary Tract Obstructive Symptoms)

EARLY LUTOEARLY LUTO – NOCTURIANOCTURIA POOR URINE POOR URINE flowflow– Bothersome “bladder” or “prostate” Bothersome “bladder” or “prostate”

LATE (LUTOLATE (LUTO) ) – Intermittency, Hesitancy, Incomplete bladder emptying Intermittency, Hesitancy, Incomplete bladder emptying

(residual urine), straining, POOR STREAM(residual urine), straining, POOR STREAM

Page 8: Renal Failure

IRRITATIVE SYMPTOMSIRRITATIVE SYMPTOMS NOCTURIA FREQUENCY URGENCY NOCTURIA FREQUENCY URGENCY..

IPSS 7 SYMPTOMS (EARLY) 4 OBSTRUCTIVEIPSS 7 SYMPTOMS (EARLY) 4 OBSTRUCTIVE Incomplete Emptying Incomplete Emptying Intermittency. Weak Stream. StrainingIntermittency. Weak Stream. Straining

3 3 IRRITATIVE IRRITATIVE Frequency Urgency NocturiaFrequency Urgency Nocturia SCORESSCORES 0-35 0-35

– MILD 0-7 MODERATE 8-18 SEVERE 19-35MILD 0-7 MODERATE 8-18 SEVERE 19-35

LATE SYMPTOMSLATE SYMPTOMS ACUTE RETENTION OF URINE (ARU) ACUTE RETENTION OF URINE (ARU) CHRONIC RETENTION OF URINE (CRU)CHRONIC RETENTION OF URINE (CRU) PROLONGED MICTURITONPROLONGED MICTURITON URINARY INCONTINENCEURINARY INCONTINENCE HAEMATURIA, UTI, CALCULI, DIVERTICULI, BILHAZIASISHAEMATURIA, UTI, CALCULI, DIVERTICULI, BILHAZIASIS

Page 9: Renal Failure

RECURRENT UTIRECURRENT UTI esp. Males prostatitis esp. Males prostatitis Cystitis, Epididymoorchitis, Pyelonephritis, Cystitis, Epididymoorchitis, Pyelonephritis,

Bacteraemia Septicaemia.Bacteraemia Septicaemia.

OTHER URINARY SYMPTOMS OTHER URINARY SYMPTOMS ANURIA OLIGURIA POLYURIAANURIA OLIGURIA POLYURIA DD ANURIADD ANURIA ARU, SEVERE ATN/CORTICAL ARU, SEVERE ATN/CORTICAL

NECROSIS, URETERIC OBSTRUCTION, OCCLUSION NECROSIS, URETERIC OBSTRUCTION, OCCLUSION RENAL ARTERIES (THROMBOSIS.EMBOLI)RENAL ARTERIES (THROMBOSIS.EMBOLI)

RUPTURED BLADDER/URETHRA RUPTURED BLADDER/URETHRA

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION URAEMIA URAEMIA DEHYDRATION ABDOMINAL WOUND. CCF ATRIAL DEHYDRATION ABDOMINAL WOUND. CCF ATRIAL

FIBRILLATION (AF) FIBRILLATION (AF) ANARSARCA PERITONITIS PANCREATITIS ACUTE ANARSARCA PERITONITIS PANCREATITIS ACUTE

ABDOMENABDOMEN

Page 10: Renal Failure

ABDOMINAL DISTENSIONABDOMINAL DISTENSION – ASCITES – ASCITES INTESTINAL obstructionINTESTINAL obstruction

ABDOMINAL MASSESABDOMINAL MASSES – Kidneys Bladder – Kidneys Bladder TumourTumour

ABDOMINAL VASCULAR DISORDERS BRUIT ABDOMINAL VASCULAR DISORDERS BRUIT ANEURYSM. ATRIAL FIBRILLATION ANEURYSM. ATRIAL FIBRILLATION

EXTERNAL GENITALIA EXTERNAL GENITALIA ParaphimosisParaphimosis Phimosis Mental Stricture, Stigmata Urethral Phimosis Mental Stricture, Stigmata Urethral

Stricture – Urethral discharge, periurethral Stricture – Urethral discharge, periurethral swelling, fistulae. Extravation of urine.swelling, fistulae. Extravation of urine.

Female – Genital multilation caruncle.Female – Genital multilation caruncle.

Page 11: Renal Failure

CLINICAL EVALUATION AND INVESTIGATIONSCLINICAL EVALUATION AND INVESTIGATIONS

1.1. URINE URINE (a)(a) Hourly output INPUT OUTPUT CHARTHourly output INPUT OUTPUT CHART (b)(b) Anuria oliguria Polyuria (Diuresis)Anuria oliguria Polyuria (Diuresis) (c)(c) Inspection infected urine Haematuria Inspection infected urine Haematuria

Crystals Crystals (d)(d) CHEMISTRYCHEMISTRY OSMOLARITY Proteins Sugar OSMOLARITY Proteins Sugar

pH SG Urea Sodium electrolytes. Creatinine pH SG Urea Sodium electrolytes. Creatinine Bonce Jones proteinBonce Jones protein

(e)(e) MICROSCOPY MICROSCOPY Casts RBC WBC BacteriaCasts RBC WBC Bacteria FUNGIFUNGI Crystals S. Ova , Acid fast Bacilli Crystals S. Ova , Acid fast Bacilli

Malignant cellsMalignant cells (f) (f) CRYSTALSCRYSTALS – – pH AcidpH Acid Uric acid Uric acid PH alkaliPH alkali phosphates phosphates Uric acid oxalate Cystine PhosphatesUric acid oxalate Cystine Phosphates

Page 12: Renal Failure

((g) g) URINE CHEMISTRYURINE CHEMISTRY

PARAMETERPARAMETER PRERENAL PRERENAL ATN RENALATN RENAL POST POST RENALRENAL

Na ConcrnNa Concrn Low <30 mmol/L Low <30 mmol/L >30mmol>30mmol >30mmol>30mmol UreaUrea High 260-500mmol/lHigh 260-500mmol/l Low <175Low <175

>260-500>260-500 CreatinineCreatinine High High LowLow

HighHigh

Page 13: Renal Failure

(2) (2) BLOOD BLOOD Hb PCV Sickling Eletrophoresis G6-PD Hb PCV Sickling Eletrophoresis G6-PD

Status, WBC cultureStatus, WBC culture Leucocytosis – sepsis leukaemia Leucocytosis – sepsis leukaemia

Lymphoma eosinophilia allergy InterstitialLymphoma eosinophilia allergy Interstitial Disease. ThrombocytopeniaDisease. Thrombocytopenia

ABRNORMAL RBC Haemolytic uraemic SyndromeABRNORMAL RBC Haemolytic uraemic Syndrome Low platelets Thrombocytopenia, Low platelets Thrombocytopenia,

Haemolytic Uraemic syndromeHaemolytic Uraemic syndrome WIDAL – TyphoidWIDAL – Typhoid

Page 14: Renal Failure

(3) (3) BLOOD CHEMISTRYBLOOD CHEMISTRY 1.1. Urea & ElectrolytesUrea & Electrolytes 2.2. CREATININE LEVELCREATININE LEVEL (a)(a) Creatinine Clearance Creatinine Clearance (b) Serial measurement of creatinine levels(b) Serial measurement of creatinine levels (c) (c) Factors affecting creatinineFactors affecting creatinine – – Elevated Large body mass, Ageing. Trauma Elevated Large body mass, Ageing. Trauma

muscles, Collagen diseases.muscles, Collagen diseases.

DRUGSDRUGS Cimetidine, Cimetidine, Septrin ,Gentamicin ,CephalosporinsSeptrin ,Gentamicin ,Cephalosporins

Page 15: Renal Failure

1.1. UREAUREA (a) Rises RF, Blood in GIT, reabsorption of (a) Rises RF, Blood in GIT, reabsorption of

urineurine (GIT) Dehydration(GIT) Dehydration (b)(b) Urea Low – Liver disease Urea Low – Liver disease (iv) Derangements blood Chemistry & others in (iv) Derangements blood Chemistry & others in

RFRF (a) (a) RISESRISES (b) (b) FALLSFALLS CreatinineCreatinine ■Bicarbonate – ACIDOSIS■Bicarbonate – ACIDOSIS BUNBUN ■Free Ca++■Free Ca++ K+POK+PO44= Mg++= Mg++ ■RBC cell Mass■RBC cell Mass ■■PlateletsPlatelets ■■GFRGFR (4) (4) GFRGFR (1) Creatinine Clearance (1) Creatinine Clearance (ii) Radionucleotide scan(ii) Radionucleotide scan

Page 16: Renal Failure

(5) (5) IMAGINGIMAGING (i)(i) Plain Xray Abdomen Fractures Metastases – Plain Xray Abdomen Fractures Metastases –

Osteoblastic/osteolyticOsteoblastic/osteolytic Calculi Calcification Bladder Ureter kidneys AORTA Calculi Calcification Bladder Ureter kidneys AORTA

Pancreas Pancreas MASSESMASSES Kidney others Aorta. Kidney others Aorta. (ii)(ii) CHESTCHEST calcification. TB Cardiomegaly Metastses in ribs. calcification. TB Cardiomegaly Metastses in ribs. (iii)(iii) ULTRASOUND ABDOMENULTRASOUND ABDOMEN (a)(a) Bladder – Full/empty post void residual - Urine CalculiBladder – Full/empty post void residual - Urine Calculi (b)(b) KidneysKidneys. Small+small cortex CRF. Small+small cortex CRF ■■LargeLarge Dilated calyces Normal/thin cortex – Hydronephrosis. Dilated calyces Normal/thin cortex – Hydronephrosis. ■■Absent abnormal positions etc.Absent abnormal positions etc. ■■Calculi TumorsCalculi Tumors COLOUR DUPLEXCOLOUR DUPLEX USG Renal vessels Blood flow USG Renal vessels Blood flow (iv)(iv) Radionucleotide renal scanRadionucleotide renal scan (v)(v) IVU with care in RF Non ionic contrast preferred.IVU with care in RF Non ionic contrast preferred. (vi)(vi) RENAL ANGIOGRAM/VENOGRAM RENAL ANGIOGRAM/VENOGRAM Digital Subtraction angiogramDigital Subtraction angiogram

Page 17: Renal Failure

(6) (6) RENAL BIOPSYRENAL BIOPSY FNA Trucut FNA Trucut USG/CT GuidedUSG/CT Guided (7)(7) CT Scan/MR ICT Scan/MR I (8)(8) ENDOSCOPYENDOSCOPY Cystoscopy and Cystoscopy and retrograde Uretero pyelogramretrograde Uretero pyelogram

Page 18: Renal Failure

ACUTE RENAL FAILUREACUTE RENAL FAILURE Acute/sudden onset of renal dysfunction with Acute/sudden onset of renal dysfunction with

urine output less than 400mls/24h or less than urine output less than 400mls/24h or less than 20mls/min resulting in accumulation of end 20mls/min resulting in accumulation of end products of metabolism such as urea, products of metabolism such as urea, crentinine Hcrentinine H++ phosphates and a complex life- phosphates and a complex life-threatening illness.threatening illness.

(1)(1) PRE-RENAL (EXTRARENALPRE-RENAL (EXTRARENAL) Ureamia ) Ureamia without structural damage due to reversible without structural damage due to reversible renal hypoperfusion.renal hypoperfusion.

(2)(2) RENAL-ATN (Vasomotor nephropathy) RENAL-ATN (Vasomotor nephropathy) and other parenchymal renal diseases.and other parenchymal renal diseases.

(3) Acute obstructive renal failure(3) Acute obstructive renal failure

Page 19: Renal Failure

DIAGNOSISDIAGNOSIS

AWARENESS OF FACTORS THAT AWARENESS OF FACTORS THAT LEAD TO ARF – history of its signs.LEAD TO ARF – history of its signs.

■■PRERENALPRERENAL – RENAL POST RENAL – RENAL POST RENAL HISTORYHISTORY – Dehydration – Dehydration

Haemorrhage Bites shock Haemorrhage Bites shock haemolysis diarrhoea vomiting.haemolysis diarrhoea vomiting.

Anuria oliguria Polyuria operations.Anuria oliguria Polyuria operations. DRUG Hb SS/SC G6 PD DefDRUG Hb SS/SC G6 PD Def

Page 20: Renal Failure

CLINICAL EXAMINATIONCLINICAL EXAMINATION Thorough, Dehydration CCF shock Rashes . Thorough, Dehydration CCF shock Rashes .

UraemiaUraemia ■■PrerenaPrerenal Adequate urine flow after correction of l Adequate urine flow after correction of

dehydration & diuretics or replacement of blood.dehydration & diuretics or replacement of blood. ■■OBSTRUCTIVE ABDOMINAL USG Dilated calyces OBSTRUCTIVE ABDOMINAL USG Dilated calyces

HydronephrosisHydronephrosis ■■SPECIAL TESTSSPECIAL TESTS ■■URINEURINE ■ ■ BLOOD – filmBLOOD – film ■ ■ CulturesCultures Urine Blood Sputum Urine Blood Sputum ■ ■ IMAGING. PLAIN XRAY ABDOMINAL USG. IMAGING. PLAIN XRAY ABDOMINAL USG.

CYTOSCOPY RETROGRADE CYTOSCOPY RETROGRADE URETEROPYEROGRAM. IVU CT MRI URETEROPYEROGRAM. IVU CT MRI RADIONUCLEOTIDERADIONUCLEOTIDE

Page 21: Renal Failure

CLASSIFICATION OF CAUSES CLASSIFICATION OF CAUSES OF ACURE RENAL FAILUREOF ACURE RENAL FAILURE

Page 22: Renal Failure

MANAGEMENTMANAGEMENT

►►PRERENAL PRERENAL Correct hypovolaemia Correct hypovolaemia ►►Diuretics Frusemide 80mg in 70kg adultDiuretics Frusemide 80mg in 70kg adult Mannitol 10-50g (50-100ml 20%)Mannitol 10-50g (50-100ml 20%) ►►PREVENTION PREVENTION IntraoperativeBP, CVP, Urine output IntraoperativeBP, CVP, Urine output

prevent hypotension and prevent hypotension and dehyradation Dopanine dehyradation Dopanine infusion 1-5mg/kg/min renal Vasodilator reverses loguriainfusion 1-5mg/kg/min renal Vasodilator reverses loguria

►►Treat underlying causeTreat underlying cause GOO, Burns Intestinal obstrucon GOO, Burns Intestinal obstrucon peritonoitis etc.peritonoitis etc.

ACUTE TUBULAR NECROSIS (ATN)/RENALACUTE TUBULAR NECROSIS (ATN)/RENAL RENAL FAILURERENAL FAILURE ► ►Rehydration and diruretics no effect.Rehydration and diruretics no effect. ► ►Conservative Fluid restriction 500-100mls plus losses. Conservative Fluid restriction 500-100mls plus losses.

Low protein diet 20- 40g low electrolytes Daily weighing Low protein diet 20- 40g low electrolytes Daily weighing patient to loose 0.5kg/day. patient to loose 0.5kg/day.

Page 23: Renal Failure

DIALYSISDIALYSIS – Peritoneal charger – Peritoneal charger ►►Haemodialysis (venuses cannulation/Haemodialysis (venuses cannulation/ shunts external expensiveshunts external expensive ►►Haemofiltration less expensiveHaemofiltration less expensive

– INDICATIONS FOR DIALYSISINDICATIONS FOR DIALYSIS ►►Blood Urea >30mmol/L (180mg %)Blood Urea >30mmol/L (180mg %) ►►Rapid rises KRapid rises K++ over 5.5 mmol over 5.5 mmol ►►Severe acidosisSevere acidosis ►►Pulmonary oedema anarsacaPulmonary oedema anarsaca ►►Uraemic symptoms – Drowsiness, anaemia confusion Uraemic symptoms – Drowsiness, anaemia confusion

fits-( late presentation)fits-( late presentation)

Page 24: Renal Failure

EMERGENCY EMERGENCY Rx HyperkalaemiaRx Hyperkalaemia

IV 10% Ca gluconate 50G Dextrose/100mls +20 IV 10% Ca gluconate 50G Dextrose/100mls +20 unit soluble insulin unit soluble insulin

ii. Slow IV sodium bicarbonate 25-50mls 8.4%ii. Slow IV sodium bicarbonate 25-50mls 8.4%

TREAT Surgical emergencyTREAT Surgical emergency operation etc operation etc

ATN usually recover after 6 weeks Mortality ATN usually recover after 6 weeks Mortality depends on causedepends on cause

Medical good prognosisMedical good prognosis (over 70% of cases) (over 70% of cases) Survival 80%Survival 80%

Gynaecological/Obstetric (10-23% cases) Gynaecological/Obstetric (10-23% cases) Survival 10-20%Survival 10-20%

SURGICAL CAUSES Postoperative/post SURGICAL CAUSES Postoperative/post traumatic (10-20% cases) survival usually traumatic (10-20% cases) survival usually under 40%under 40%

Page 25: Renal Failure

ACUTE OBSTRUCTIVE UROPATHYACUTE OBSTRUCTIVE UROPATHY

A.A. Uraemia Treat as follows Uraemia Treat as follows

(i)(i) Bladder outlet obstruction/AcuteBladder outlet obstruction/Acute

Retention of Urine –catheterisation Suprapubic stab Retention of Urine –catheterisation Suprapubic stab cystostomycystostomy

ii. Ureteric Obstruction – (a) Cystosiopy double J stent ii. Ureteric Obstruction – (a) Cystosiopy double J stent insertion, ureteric catheterization)insertion, ureteric catheterization)

(B) PERCUTANEOUS NEPHROSTOMY (PCN) or occasionally (B) PERCUTANEOUS NEPHROSTOMY (PCN) or occasionally open nephrostomigopen nephrostomig

© © URETERIC CALCULI PCN – ESWLURETERIC CALCULI PCN – ESWL, Endoscopic lithotripsy , Endoscopic lithotripsy or Open procedures – ureterolithotomy, or Open procedures – ureterolithotomy, ureteropyelolithotomyureteropyelolithotomy

Page 26: Renal Failure

(D) (D) EXPLORATION AND SURGERYEXPLORATION AND SURGERY (i) Lower Ureteric obstruction – (i) Lower Ureteric obstruction –

Ureteroneocystostomy with or Ureteroneocystostomy with or without BOARI Flap and Psoas without BOARI Flap and Psoas hitch hitch

ii. Ureterioleal substitution –ii. Ureterioleal substitution –ureteroileocystoplastyureteroileocystoplasty

Page 27: Renal Failure

ANAESTHESIA AND RENAL FAILUREANAESTHESIA AND RENAL FAILURE

(1)(1) PreventionPrevention Proper monitoring and Proper monitoring and infusions to prevent renal hypoperfusion – BP, CVP, infusions to prevent renal hypoperfusion – BP, CVP, Arterial BP, Urine output by bladder catheterisationArterial BP, Urine output by bladder catheterisation

(2)(2) ANESTHESIA IN URAEMIC PATIENTSANESTHESIA IN URAEMIC PATIENTS (i)(i) Hyoerkalaemia and AcidosisHyoerkalaemia and Acidosis – Correct by Insulin – Correct by Insulin

/glucose/calcium gluconate/ iv sodium bicarbonate/glucose/calcium gluconate/ iv sodium bicarbonate

(ii). INHALATIONAL anaesthesia may lend to cardiac (ii). INHALATIONAL anaesthesia may lend to cardiac arrest- use - nerve block, local infiltration regional or arrest- use - nerve block, local infiltration regional or spinal anaesthesia.spinal anaesthesia.

(iii) Blood transfusion – Fresh blood preferred avoid citrate (iii) Blood transfusion – Fresh blood preferred avoid citrate intoxication by 5ml 10% ca gluconate per unit of bloodintoxication by 5ml 10% ca gluconate per unit of blood

Page 28: Renal Failure

(3) (3) DRUGS THERAPYDRUGS THERAPY ►►Impaired drug excretions lead to accumulation and Impaired drug excretions lead to accumulation and

toxicity.toxicity. ►►Remove drugs by HD, HF or PDRemove drugs by HD, HF or PD ►►Know pharmacokinetics before prescribing a particular Know pharmacokinetics before prescribing a particular

drug to drug to ureamic ureamic patientspatients (4)(4) DRUGSDRUGS (a) (a) AVOIDAVOID (i) Aminoglycosides (Gentamyin) Streptomycin(i) Aminoglycosides (Gentamyin) Streptomycin

– ii. Analgesic Aspirin Paracetamolii. Analgesic Aspirin Paracetamol

– iii. iii. NarcoticsNarcotics Morphine pethidrine – poisoning Morphine pethidrine – poisoning

iv. Others Digoxin Inmunosuppressants. Heparin iv. Others Digoxin Inmunosuppressants. Heparin Warfarin.Warfarin.

(b) (b) Use with cautionUse with caution

Chloramphenol, Ethombutal.Chloramphenol, Ethombutal. Tetracyclines CephalosporinsTetracyclines Cephalosporins

Page 29: Renal Failure

CHRONIC RENAL FAILURECHRONIC RENAL FAILURE

OBJECTIVESOBJECTIVES

DEFINITION DEFINITION

AETIOLOGY PATHOGENESISAETIOLOGY PATHOGENESIS

CLINICAL APPROACHCLINICAL APPROACH

DIAGNOSIS DDDIAGNOSIS DD COMPLICATIONSCOMPLICATIONS

MANAGEMENTMANAGEMENT

CONSERVATIVECONSERVATIVE

DIALYSIS – CAPD/HDDIALYSIS – CAPD/HD TRANSPLANTATIONTRANSPLANTATION

Page 30: Renal Failure

CHRONIC RENAL FAILURECHRONIC RENAL FAILURE

Results from progressive destruction of Results from progressive destruction of nephrons which leads to fluid and electrolyte nephrons which leads to fluid and electrolyte disturbances with progressive azotaemia and disturbances with progressive azotaemia and systemic effects on major systems of the body, systemic effects on major systems of the body, circulatory, respiratory , gastrointestinal, circulatory, respiratory , gastrointestinal, haemopoeitic, neurons, musculoskeletal haemopoeitic, neurons, musculoskeletal systems etc.systems etc.

It is progressive and consists of 5 stages.It is progressive and consists of 5 stages.

(1)(1) Reduced renal reserveReduced renal reserve

(2)(2) Renal insufficiencyRenal insufficiency (3)(3) Renal failureRenal failure (4)(4) Ureamic syndromeUreamic syndrome END STAGE RENAL DISEASE (ERSD)END STAGE RENAL DISEASE (ERSD)

Page 31: Renal Failure

1. 1. REDUCED RENAL RESERVEREDUCED RENAL RESERVE Loss of Loss of nephrons without rise in BUN, creatinine nor nephrons without rise in BUN, creatinine nor disturbance of homeostasis.disturbance of homeostasis.

2.2. RENAL INSUFFICIENCYRENAL INSUFFICIENCY mild elevation of mild elevation of BUN and creatinine and very mild symptoms eg. BUN and creatinine and very mild symptoms eg. Nocturia and easy fatigability. About 50% of Nocturia and easy fatigability. About 50% of renal functions is lost before retention of renal functions is lost before retention of nitroyenous end products occur.nitroyenous end products occur.

3.3. RENAL FAILURERENAL FAILURE Due to progressive loss Due to progressive loss of renal mass 90% with abnormalities of renal of renal mass 90% with abnormalities of renal excetion function, and fluid, electrolyte and acid excetion function, and fluid, electrolyte and acid base disturbance. base disturbance.

4.4.UREMIC SYNDROME . UREMIC SYNDROME . Loss of renal function Loss of renal function with multiple dysfunction of major organ with multiple dysfunction of major organ systems and abnormalities of renal excretory systems and abnormalities of renal excretory function fluid electrolyte and acid base function fluid electrolyte and acid base disturbancedisturbance

Page 32: Renal Failure

5.5. END STAGE RENAL FAILURE (ESRD) END STAGE RENAL FAILURE (ESRD) Renal Renal dysfunction cannot sustain body function usually GFR dysfunction cannot sustain body function usually GFR under 10ml/min. Renal replacement therapy – dialysis under 10ml/min. Renal replacement therapy – dialysis or transplant required to sustain life.or transplant required to sustain life.

PATHOPHYSIOLOGY PATHOPHYSIOLOGY Normal individuals have Normal individuals have nephrons in EXCESS OF THAT NECESSARY TO MAINTAIN nephrons in EXCESS OF THAT NECESSARY TO MAINTAIN NORMAL GFR. PROGRESSIVE LOSS OF RENAL MASS NORMAL GFR. PROGRESSIVE LOSS OF RENAL MASS LEADS TO LEADS TO

(1) (1) REDUCED RENAL RESERVEREDUCED RENAL RESERVE WITH NO CHANGES IN WITH NO CHANGES IN BUN CREATININE AND HOMEOSTASIS – FURTHER LOSS BUN CREATININE AND HOMEOSTASIS – FURTHER LOSS OF NEPHRONS PROGRESSES TO OF NEPHRONS PROGRESSES TO

(2) (2) RENAL INSUFFICIENCYRENAL INSUFFICIENCY WITH RISE IN BUN WITH RISE IN BUN CREATININE WHICH PROGRESSES TO CREATININE WHICH PROGRESSES TO

(3) (3) RENAL FAILURE RENAL FAILURE – DISTURBANCES OF BUN – DISTURBANCES OF BUN CREATININE ACID BASE AND ILL HEALTH WHICH LEADS CREATININE ACID BASE AND ILL HEALTH WHICH LEADS TOTO

Page 33: Renal Failure

(4) UREMIC SYNDROME SYMPTOM (4) UREMIC SYNDROME SYMPTOM COMPLEX. THIS IS DUE TOCOMPLEX. THIS IS DUE TO

ABNORMALITIES OF BUN, CREATININE ABNORMALITIES OF BUN, CREATININE MULTIPLE DISTURBANCES WHICH CAN MULTIPLE DISTURBANCES WHICH CAN PROGRESS WITH LOSS OF NEPHRONS TO PROGRESS WITH LOSS OF NEPHRONS TO

(5) ESRD GFR 5-10 ML/MIN. The (5) ESRD GFR 5-10 ML/MIN. The progression from stages 1 – 5 may be progression from stages 1 – 5 may be slowedslowed

RATE OF PROGRESSION FROM STAGE 1 – RATE OF PROGRESSION FROM STAGE 1 – 5 CAN BE SLOWED OR HALTED BY 5 CAN BE SLOWED OR HALTED BY SURGICAL CORRECTION OF URINARY SURGICAL CORRECTION OF URINARY OBSTRUCTION, INFECTION HPT ETCOBSTRUCTION, INFECTION HPT ETC

Page 34: Renal Failure

CLINICAL PRESENTATIONCLINICAL PRESENTATION

ASYMTOMATIC – REDUCED RESERVEASYMTOMATIC – REDUCED RESERVE

RENAL INSUFFICIENCY – OVER 50% RENAL FUNCTION RENAL INSUFFICIENCY – OVER 50% RENAL FUNCTION IS LOST BY THIS STAGE AND MILD SYMPTOMS EXIST IS LOST BY THIS STAGE AND MILD SYMPTOMS EXIST CONDITION DETECTED BY ROUTINE MEDICAL CONDITION DETECTED BY ROUTINE MEDICAL EXAMINATION SUCH AS HPT PROTENURIA ANAEMIA EXAMINATION SUCH AS HPT PROTENURIA ANAEMIA ELEVATED BUN GR CREATININEELEVATED BUN GR CREATININE

PROTEINURIA MICROSCOPIC HAEMATURIAPROTEINURIA MICROSCOPIC HAEMATURIA RENAL FAILURE/UREMIC SYNDROME 90% RENAL TISSUE RENAL FAILURE/UREMIC SYNDROME 90% RENAL TISSUE

IS LOST AND SYMTOMATIC TIREDNESS, METALLIC TASTE IS LOST AND SYMTOMATIC TIREDNESS, METALLIC TASTE IN MOUTH, ANAEMIA, OEDEMA OF ANKLE AND FACE, IN MOUTH, ANAEMIA, OEDEMA OF ANKLE AND FACE, SKIN RASHES, BONE PAINS POLYARTHRITIS POLYURIA, SKIN RASHES, BONE PAINS POLYARTHRITIS POLYURIA, POLYDIPSIA, DYSPEPSIA, DEAFNESS HAEMOPTYSIS POLYDIPSIA, DYSPEPSIA, DEAFNESS HAEMOPTYSIS HAEMATEMESIS, MELAENA HPT DROWSINESS EPILEPSY HAEMATEMESIS, MELAENA HPT DROWSINESS EPILEPSY COMACOMA

Page 35: Renal Failure

PRESENTING SYMPTONS DEPEND ON PRESENTING SYMPTONS DEPEND ON CAUSE, CAUSE,

LUTS/LUTO SYMPTOMS in those with LUTS/LUTO SYMPTOMS in those with bladder outlet obstruction – Incomplete bladder outlet obstruction – Incomplete emptying straining poor stream urgency emptying straining poor stream urgency frequency urinary retention (ARU/CRU) frequency urinary retention (ARU/CRU) Recurrent UTI Recurrent UTI

PAST HISTORY – HPT, DIABETES PAST HISTORY – HPT, DIABETES MELLITUS, RECURRENT UTI VESICAL MELLITUS, RECURRENT UTI VESICAL SCHISTOSOMIASIS, TB, UROLITHIASIS SCHISTOSOMIASIS, TB, UROLITHIASIS STU, FMH KIDNEY DISEASE EXPOSURE STU, FMH KIDNEY DISEASE EXPOSURE TO INDUSTRIAL HAZARDS e.g. mercuric TO INDUSTRIAL HAZARDS e.g. mercuric cpds, surgical operations.cpds, surgical operations.

Page 36: Renal Failure

CAUSES OF CHRONIC RENAL FAILURECAUSES OF CHRONIC RENAL FAILURE

1.1. MEDICAL CAUSES 94 - 98%MEDICAL CAUSES 94 - 98%

i. Nephrosclerosis, hypertensioni. Nephrosclerosis, hypertension

ii. Chronic pyelonephritisii. Chronic pyelonephritis

iii. Chronic glomerulonephritisiii. Chronic glomerulonephritis

iv. Cotical necrosisiv. Cotical necrosis

v. Interstitial v. Interstitial

vi. Renal artery thrombosis/stenosisvi. Renal artery thrombosis/stenosis

vii. Diabetes mellitusvii. Diabetes mellitus

vii. Goutvii. Gout ix. Amyloidosisix. Amyloidosis

Page 37: Renal Failure

i.i. HyperparathyroidismHyperparathyroidism– ii.ii. Idiopathic hypaercaliuriaIdiopathic hypaercaliuria

iii.iii. Analgesic nephropathyAnalgesic nephropathy iv.iv. nephropathynephropathy v.v. MyelomatosisMyelomatosis vi.vi. Collagen disordersCollagen disorders

– vii.vii. Polyarteritis nodosa Polyarteritis nodosa – viii.viii. Systemic lupus erytomatosisSystemic lupus erytomatosis– ix.ix. Systemic sclerosisSystemic sclerosis– x.x. Hereditary disordersHereditary disorders– xi.xi. Polycystic/Cystic kidneysPolycystic/Cystic kidneys– xii.xii. Alports syndrome, tubular disordersAlports syndrome, tubular disorders– xiii.xiii. MiscellanouesMiscellanoues

– Poison, irridiation etcPoison, irridiation etc

Page 38: Renal Failure

URINARY TRACT OBSTRUCTIONURINARY TRACT OBSTRUCTION (2-6%) (2-6%)

A.A. LOWER URINARY TRACT LOWER URINARY TRACT OBSTRUCTIONOBSTRUCTION

– Meatal stenosisMeatal stenosis– PhimosisPhimosis– Postrerior urethral valvesPostrerior urethral valves– Urethral strictureUrethral stricture– Urethral calculusUrethral calculus– Benign prostatic hyperplasiaBenign prostatic hyperplasia– Carcinoma of prostateCarcinoma of prostate– Vesical calculiVesical calculi– Neurogenic bladderNeurogenic bladder– Carcinoma of bladder neckCarcinoma of bladder neck

Carcinoma of cervix Carcinoma of cervix

Page 39: Renal Failure

(B) (B) UPPER URINARY TRACT UPPER URINARY TRACT OBSTRUCTIONOBSTRUCTION

Ureteric obstruction by:Ureteric obstruction by:Vesical and ureteric Vesical and ureteric

schistosomiasisschistosomiasis

TuberculosisTuberculosis

Ureteric CalculiUreteric Calculi

HydronephrosisHydronephrosis

Vesico-ureteric refluxVesico-ureteric reflux

MagauretersMagaureters

Retroperitoneal fibrosis Retroperitoneal fibrosis

Page 40: Renal Failure

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION ANAEMIA HPTN ANAEMIA HPTN PERIPHERAL NEUROPATHY/RENAL PERIPHERAL NEUROPATHY/RENAL OSTEODYSTROPHYOSTEODYSTROPHY

Smell and stigmata of uraemia. Smell and stigmata of uraemia. Abdominal masses – enlarged kidneys, Abdominal masses – enlarged kidneys, ARU/CRU, ASCITESARU/CRU, ASCITES

EXTERNAL GENITALIAEXTERNAL GENITALIA PHIMOSIS, PHIMOSIS, MEATAL STENOSISMEATAL STENOSIS

Urinary incontinence periurethralal Urinary incontinence periurethralal swelling fistulae.swelling fistulae.

DRE DRE BPH Prostrate cancer pelvic, BPH Prostrate cancer pelvic, neoplasia V/E Canceer cervix etc.neoplasia V/E Canceer cervix etc.

Page 41: Renal Failure

INVESTIGATIONSINVESTIGATIONS

►►Complete urinalysisComplete urinalysis ►►BLOOD BUN CREATININE ELECTROLYTES CALCIUM BLOOD BUN CREATININE ELECTROLYTES CALCIUM

/PHOSPHATE, CREATININE CLEARANCE EXCLUDE /PHOSPHATE, CREATININE CLEARANCE EXCLUDE HYPERPARATHYRODISM HYPERPARATHYRODISM

►►IMAGING PLAN XRAY IMAGING PLAN XRAY - PSA ABDOMEN/CHEST kidney - PSA ABDOMEN/CHEST kidney size, size,

Caleifications bladder ( vesical schistosomiasis)Caleifications bladder ( vesical schistosomiasis) Calculi metastasesCalculi metastases ABDOMINAL & PELVIC USG -Kidney hydronephrosis ABDOMINAL & PELVIC USG -Kidney hydronephrosis

ureter bladder ureter bladder Postvoid residunal urine Caleuli Postvoid residunal urine Caleuli IVU IVU Non ionic – hydronephrosis, non –functation Non ionic – hydronephrosis, non –functation

OthersOthers. urethrorcystogram VCURG (reflux) . urethrorcystogram VCURG (reflux)

Page 42: Renal Failure

ENDOSCOPY Urethrocystoscopy, ENDOSCOPY Urethrocystoscopy, cystoscopy and retrograde cystoscopy and retrograde ureteropyelogramureteropyelogram

Radio nucleotide renogramRadio nucleotide renogram CT Scan MRICT Scan MRI

RENAL ANGIO GRAPHY DIGITAL RENAL ANGIO GRAPHY DIGITAL SUBSTRACTION ANGIOGRAPHYSUBSTRACTION ANGIOGRAPHY

Page 43: Renal Failure

MANAGEMENTMANAGEMENT

CONSERVATIVE ELECTROLYE BALANCE CONSERVATIVE ELECTROLYE BALANCE LOW PROTEIN Diet – 20-40G LOW PROTEIN Diet – 20-40G

(0.5k/kg/day)(0.5k/kg/day) Weight ERYTHROPOIETIN/BLOOD Weight ERYTHROPOIETIN/BLOOD

TRANSFUSION FOR ANAEMIATRANSFUSION FOR ANAEMIA ARU/CRU – clen intermittent self ARU/CRU – clen intermittent self

catheterisationcatheterisation Urethral catheterization Urethral catheterization ►►SUPRA PUBIC CYSTOTTOMY STAB /OPENSUPRA PUBIC CYSTOTTOMY STAB /OPEN NEPHROSTOMY PCN/openNEPHROSTOMY PCN/open URETERIC STENTING – Double JURETERIC STENTING – Double J

Page 44: Renal Failure

TREATTREAT RECURRENT UTI RECURRENT UTI Surgery for underlying urinary obstruction Surgery for underlying urinary obstruction

PUV, US, BPH, CANCER PUV, US, BPH, CANCER PROSTATE/CERVIX/PELVIS PROSTATE/CERVIX/PELVIS

PHIMOSIS, PARAPHIMOSIS MEATAL STENOSISPHIMOSIS, PARAPHIMOSIS MEATAL STENOSIS ►►DIALYSISDIALYSIS (70-75%) (70-75%) INDICATIONS – Failed conservative treatmetntINDICATIONS – Failed conservative treatmetnt GFR 5-10mls/minGFR 5-10mls/min EncephalopathyEncephalopathy Anarsarca Fluid overloadAnarsarca Fluid overload NeuropathyNeuropathy PericarditisPericarditis

CCF/Pulmonary odema CCF/Pulmonary odema Bleeding Diathesis HyperkalaemiaBleeding Diathesis Hyperkalaemia Uncontroilled HPTNUncontroilled HPTN Metabolic acidosisMetabolic acidosis

Page 45: Renal Failure

►►TYPES OF DIALYSISTYPES OF DIALYSIS – 70-75% – 70-75%

REGULAR INTERMITTENT HAEMODIAYSIS OR REGULAR INTERMITTENT HAEMODIAYSIS OR HAEMOFILTRATION (60%) Require Vascular access by HAEMOFILTRATION (60%) Require Vascular access by venous cannulation Internal Jugular or femoal vein or A-venous cannulation Internal Jugular or femoal vein or A-V fistula (Brescia)V fistula (Brescia)

(External Quinton Scribner Shunt (ankle/wrist groin) PD (External Quinton Scribner Shunt (ankle/wrist groin) PD (CAPD) – 10-15%(CAPD) – 10-15%

CHRONIC AMBULATORY PD (CAPDCHRONIC AMBULATORY PD (CAPD) 10-15%) 10-15% Causes of Death on Dialysis Causes of Death on Dialysis - Survival 10-15% 10 - Survival 10-15% 10

yearsyears CCF Hypotension HPTNCCF Hypotension HPTN Sepsis CVASepsis CVA D. Mellitus Pericardiol effusions tamponadeD. Mellitus Pericardiol effusions tamponade

Page 46: Renal Failure

BLEEDING SuicideBLEEDING Suicide ►►RENAL TRANSPLANTATIONRENAL TRANSPLANTATION – 25-30% – 25-30% ►►CADAYER TRANSPLANTCADAYER TRANSPLANT ►►LIVING RELATED DONORLIVING RELATED DONOR PATIENT SURVIVAL TREATMENT ESRDPATIENT SURVIVAL TREATMENT ESRD This depends on course, race, age, sex, This depends on course, race, age, sex,

comobidity etc.comobidity etc.

Page 47: Renal Failure

5YEARS5YEARS 10YERS10YERS DIALYSIS (HD/HF/CAPD) 25-30% 10-15%DIALYSIS (HD/HF/CAPD) 25-30% 10-15% 1st cadaver transp. (60-70%) 76-85%1st cadaver transp. (60-70%) 76-85% 54-80%54-80% 1st Living related (30-40%) 85-95% 1st Living related (30-40%) 85-95% 75-90%75-90%

Page 48: Renal Failure

ADVANTAGES TRANSPLANTATION OVER ADVANTAGES TRANSPLANTATION OVER DIALYSISDIALYSIS

For ESRD –depends on cases, sex , age For ESRD –depends on cases, sex , age etcetc

►►Longer survival 54-90% Survival c/c Longer survival 54-90% Survival c/c ESRD 10-15% 10year survival by ESRD 10-15% 10year survival by HD/HF/CAPDHD/HF/CAPD

►►Improve quality of life- reversal f Improve quality of life- reversal f complications of ESRD in patients on complications of ESRD in patients on dialysis – Infertility, sexual function.dialysis – Infertility, sexual function.

Anaemia metabolism abnomalties, renal Anaemia metabolism abnomalties, renal osteodystrophy, neuropathy paosteodystrophy, neuropathy pa

Patients general feel better after Patients general feel better after transplant and can be rehabilitated transplant and can be rehabilitated

Page 49: Renal Failure

CAUSES AND MANAGEMENT OF CAUSES AND MANAGEMENT OF OBSTRUCTIVE URAEMIA IN WEST OBSTRUCTIVE URAEMIA IN WEST

AFRICAAFRICA

BY BY

PROF. E. D. YEBOAHPROF. E. D. YEBOAH

MA BCHIR MD (CANTAB) FRCS MA BCHIR MD (CANTAB) FRCS FWACS FICS FMCS FGAFWACS FICS FMCS FGA

UNIVERSITY OF GHANA MEDICAL UNIVERSITY OF GHANA MEDICAL SCHOOLSCHOOL

Page 50: Renal Failure

OBJECTIVESOBJECTIVES

ESTABLISH THE CAUSES OF ESTABLISH THE CAUSES OF OBSTRUCTIVE RENAL FAILURE AT OBSTRUCTIVE RENAL FAILURE AT KBTH AND SUBREGIONKBTH AND SUBREGION

THE INVESTIGATIONS THE INVESTIGATIONS IMMEDIATE/AND DEFINITIVE IMMEDIATE/AND DEFINITIVE MANAGEMENT OF OBSTRUCTIVE MANAGEMENT OF OBSTRUCTIVE URAEMIAURAEMIA

PROGNOSIS OF THE VARIOUS PROGNOSIS OF THE VARIOUS AETIOLOGICAL TYPES AETIOLOGICAL TYPES

Page 51: Renal Failure

S1S1 AETIOLOGY OF ACUTE AETIOLOGY OF ACUTE OBSTRUCTIVE RENAL FAILURE OBSTRUCTIVE RENAL FAILURE

(RF)(RF)

ACUTE RETENTION OF URINE (ARU)ACUTE RETENTION OF URINE (ARU) BPH, Urethral Stricture, PUV CaP BPH, Urethral Stricture, PUV CaP BILATERAL URETERIC OBSTRUCTIONBILATERAL URETERIC OBSTRUCTION

– IATROGENIC LIGATION/INJURY OF URETERS IATROGENIC LIGATION/INJURY OF URETERS (O&G/SURG)(O&G/SURG)

– PELVI-URETERIC JUNCTION (PUJ) OBSTRUCTIONPELVI-URETERIC JUNCTION (PUJ) OBSTRUCTION– URETERIC STONESURETERIC STONES– LOWER URETERIC BILHARZIASIS (VS)LOWER URETERIC BILHARZIASIS (VS)– PAPILLARY NECROSIS (HbSS/SC DM) MULTIPLE PAPILLARY NECROSIS (HbSS/SC DM) MULTIPLE

MYELOMATOSISMYELOMATOSIS

Page 52: Renal Failure

S2S2 AETIOLOGY ACUTE ON AETIOLOGY ACUTE ON CHRONIC/CHRONIC OBSTRUCTIVE CHRONIC/CHRONIC OBSTRUCTIVE

RFRF

BILATERIAL URETERIC OBSTRUCTIONBILATERIAL URETERIC OBSTRUCTION– IATROGENIC BILATERAL LIGATION/INJURY IATROGENIC BILATERAL LIGATION/INJURY

URETERS (O&G/SURG)URETERS (O&G/SURG)– STONES, VS, PUJ, RETROPERITONEAL STONES, VS, PUJ, RETROPERITONEAL

FIBROSISFIBROSIS– PELVIC MALIGNANCY – CaP, CaB, Ca CERVIXPELVIC MALIGNANCY – CaP, CaB, Ca CERVIX

BLADDER OUTLET OBSTRUCTION BLADDER OUTLET OBSTRUCTION (B.O.O.)(B.O.O.)

BPH, US, PUV, CaP, CaB BPH, US, PUV, CaP, CaB

Page 53: Renal Failure

S3S3 MANAGEMENT STRATEGIES OF MANAGEMENT STRATEGIES OF OBSTRUCTIVE URAEMIAOBSTRUCTIVE URAEMIA

COMPLETE UROLOGICAL EVALUATIONCOMPLETE UROLOGICAL EVALUATION HISTORY PHYSICAL, FLUID INPUT, OUTPUT HISTORY PHYSICAL, FLUID INPUT, OUTPUT

BALANCE, WEIGHINGBALANCE, WEIGHING COMPLETE URINALYSIS – COMPLETE URINALYSIS –

MACROSCOPIC/MICROSCOPIC CHEMISTRY CLSMACROSCOPIC/MICROSCOPIC CHEMISTRY CLS BLOOD B/F C/S U+E CREATININE CREATININE BLOOD B/F C/S U+E CREATININE CREATININE

CLEARANCECLEARANCE IMAGING:IMAGING: PLAIN ABDOMINAL & PELVIC XRAY PLAIN ABDOMINAL & PELVIC XRAY

RADIONUCLEOTIDE SCANRADIONUCLEOTIDE SCAN USG (B-MODE/DOPPLER COLOUR DUPLEX) IVU + USG (B-MODE/DOPPLER COLOUR DUPLEX) IVU +

NEPHROTOMOGRAMNEPHROTOMOGRAM VCURG, URETHROGRAM, RETROGRADE URETERO-VCURG, URETHROGRAM, RETROGRADE URETERO-

PYELOGRAMPYELOGRAM

Page 54: Renal Failure

S4S4 MANAGEMENT ACUTE MANAGEMENT ACUTE OBSTRUCTIVE URAEMIAOBSTRUCTIVE URAEMIA

BILATERAL URETERIC OBSTRUCTIONBILATERAL URETERIC OBSTRUCTION PCN, DOUBLE J URETERIC STENTING, URETERIC PCN, DOUBLE J URETERIC STENTING, URETERIC

CATHETERISATION FOR DRAINAGE, CATHETERISATION FOR DRAINAGE, NEPHROSTOMY – URETEROSTOMYNEPHROSTOMY – URETEROSTOMY

ARU - BOOARU - BOO URETHRAL CATHETER DRAINAGE – PUV, BPH, URETHRAL CATHETER DRAINAGE – PUV, BPH,

CaPCaP SUPRAPUBIC DRAINAGESUPRAPUBIC DRAINAGE TAP/STAB TAP/STAB

CYSTOSTOMY/OPEN CYSTOSTOMY/OPEN CYSTOSTOMY/VESICOSTOMY/URETHROSTOMY CYSTOSTOMY/VESICOSTOMY/URETHROSTOMY BPH, CaP, PUV URETHRAL/STRICTURE BPH, CaP, PUV URETHRAL/STRICTURE (US)/CALCULUS TUMOUR (US)/CALCULUS TUMOUR

Page 55: Renal Failure

MANAGEMENT OBSTRUCTIVE RF MANAGEMENT OBSTRUCTIVE RF (ACUTE/CHRONIC)(ACUTE/CHRONIC)

DRAINAGE ACCUMULATED URINEDRAINAGE ACCUMULATED URINE URETHRAL URETHRAL CATHETERCATHETER

Suprapubic, cystostomy, urethrostomy, PCN, Suprapubic, cystostomy, urethrostomy, PCN, Nephrostomy Double J stenting, ureterostomy.Nephrostomy Double J stenting, ureterostomy.

DIETDIET low protein avoid K and electrolyteslow protein avoid K and electrolytes Remove blood and Nitrogenous products from GITRemove blood and Nitrogenous products from GIT SPECIAL MEASURESSPECIAL MEASURES IV Drip, Ion exchange resin, IV IV Drip, Ion exchange resin, IV

Glucose/insulinGlucose/insulin DIALYSISDIALYSIS HD/HF –PD HD/HF –PD TREAT CAUSE OF OBSTRUCTIONTREAT CAUSE OF OBSTRUCTION BOO, URETERIC BOO, URETERIC

OBSTRUCTIONOBSTRUCTION END STAGE RENAL DISEASEEND STAGE RENAL DISEASE CABPD/HD – RENAL CABPD/HD – RENAL

TRANSPLANTATION TRANSPLANTATION

Page 56: Renal Failure

DEFINITIVE MANAGEMENT DEFINITIVE MANAGEMENT URETERIC OBSTRUCTIONURETERIC OBSTRUCTION

IATROGENIC LIGATION/INJURYIATROGENIC LIGATION/INJURY Laparotomy Remove sutures, BILATERAL STENTING, Laparotomy Remove sutures, BILATERAL STENTING,

DOUBLE J. STENT BILATERAL URETERONEO DOUBLE J. STENT BILATERAL URETERONEO CYSTOSTOMY CYSTOSTOMY BOARI FLAP/PSOAS HITCH BOARI FLAP/PSOAS HITCH

BILHARZIAL OBSTRUCTION Acute Praziquental BILHARZIAL OBSTRUCTION Acute Praziquental Chronic – Uretero-neocystotomy Chronic – Uretero-neocystotomy Boari Flap Psoas Boari Flap Psoas Hitch, Bilateral uretero-ileocystoplastyHitch, Bilateral uretero-ileocystoplasty

BILATERAL PUJ OBSTRUCTIONBILATERAL PUJ OBSTRUCTION Pyeloplasty Pyeloplasty Endoscopic pyelotomyEndoscopic pyelotomy

URETERIC STONESURETERIC STONES ESWL Endoscopic ESWL Endoscopic ureterolithotomy/lithotripsy open ureterolithotomy/lithotripsy open uretero/pyelolithotomyuretero/pyelolithotomy

CaPCaP PCN, Double J stent, Bilateral uretero- PCN, Double J stent, Bilateral uretero-neocyctostomy – TUIP/TURP Hormonal RXneocyctostomy – TUIP/TURP Hormonal RX

INCURABLE PELVIC DISEASEINCURABLE PELVIC DISEASE PCN Double J stent. PCN Double J stent. Ureterostomy Urinary Diversion (Conduit etc) Ureterostomy Urinary Diversion (Conduit etc)

Page 57: Renal Failure

DEFINITIVE RX B.O.O.DEFINITIVE RX B.O.O.

PUVPUV Vesicostomy Endoscopic Fulguration Vesicostomy Endoscopic Fulguration USUS Dilation, Int Urethrotomy Dilation, Int Urethrotomy

UrethroplastyUrethroplasty BPHBPH TUIP/BNI TURP OPEN TUIP/BNI TURP OPEN

PROSTATECTOMYPROSTATECTOMY CaPCaP TUIP/BNI TURP HORMONAL RX TUIP/BNI TURP HORMONAL RX URETHRAL CALCULUSURETHRAL CALCULUS URETHROLITHOTOMY URETHROLITHOTOMY

INT URETHROTOMY/URETHROPLASTY INT URETHROTOMY/URETHROPLASTY INCURABLE DISEASEINCURABLE DISEASE URETHROSTOMY/SC URETHROSTOMY/SC

Page 58: Renal Failure

CAUSES OBSTRUCTIVE UROPATHY CAUSES OBSTRUCTIVE UROPATHY KBTH JAN 2002 – FEBRUARY 2003 KBTH JAN 2002 – FEBRUARY 2003

n = 50 M47F3n = 50 M47F3

nn %% BILATERAL URETERIC LIGATION/INJURYBILATERAL URETERIC LIGATION/INJURY 2 2 4 4 BILATERAL URETERIC URETERIC OBSTRUCTION BV VSBILATERAL URETERIC URETERIC OBSTRUCTION BV VS

2 2 4 4 BILATERAL PUJ OBSTRUCTIONBILATERAL PUJ OBSTRUCTION 1 1 2 2 BPHBPH 14 14 28 28 CaPCaP 1212 24 24 CaBCaB 1010 20 20 USUS 6 6 12 12 PUVPUV 33 6 6

5050 100100

Page 59: Renal Failure

PRESENTATION/ASSNS OBSTRUCTIVE PRESENTATION/ASSNS OBSTRUCTIVE URAEMIAURAEMIA

URAEMIA BUN 15 – 90 mmol/LURAEMIA BUN 15 – 90 mmol/L Serum Creat 213 – 2350 umol/LSerum Creat 213 – 2350 umol/L Creat clearance 80-30 ml/minCreat clearance 80-30 ml/min CROUCROU 4040 ARUARU 6 6 HPTNHPTN 2424 ANAEMIAANAEMIA 2929

Page 60: Renal Failure

MORTALITY OBSTRUCTIVE MORTALITY OBSTRUCTIVE URAEMIA n=50URAEMIA n=50 10/50 = (20%) 10/50 = (20%)

CaPCaP 4 4 CaBCaB 3 3 PUVPUV 2 2 BPHBPH 1 1 1010 ====

Page 61: Renal Failure

CONCLUSIONSCONCLUSIONS

COMONNEST CAUSES OF COMONNEST CAUSES OF OBSTRUCTIVE UROPATHYOBSTRUCTIVE UROPATHY

BILATERAL URETERIC OBSTRUCTIONBILATERAL URETERIC OBSTRUCTION IATROGENIC LIGATION. VS, PUJ, IATROGENIC LIGATION. VS, PUJ,

URETERIC CALCULI, CaP, CaBURETERIC CALCULI, CaP, CaB BOOBOO BPH US PUV CaP CaB BPH US PUV CaP CaB MORTALITY HIGH IN CANCER CASES MORTALITY HIGH IN CANCER CASES

70%70% due to CaP/CaB. 30% BPH PUV due to CaP/CaB. 30% BPH PUV