Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC, CEN, CNRN, CMSRN, NP
Education Specialist
LRM Consulting
Nashville, TN
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
Definition
rapidly progressive
potentially reversible
cessation of renal function
UO < 0.5 mL/kg/hr
Renal Failure Index (RFI)
RFI = UNa x SCr/UCr
Intrepretation
RFI < 1 (prerenal failure)
RFI > 1 (intrarenal failure)
Fraction Excreted Sodium
(FENa)
FENa = Una X PCr / Pna X Ucr x 100
Intrepretation
FENa < 1 (prerenal failure)
FENa > 1 (intrarenal failure)
Renal Failure Index (RFI)
RFI = UNa x SCr/UCr
Example
RFI < 1
UNa < 20 mEq/L
FENa < 1%
UCr/SCr > 30
Renal Failure Index (RFI)
RFI = UNa x SCr/UCr
Example
RFI > 1
UNa>40 mEq/L
FENa > 2-3%
UCr/SCr<20
Renal Biomarkers
Urine interleukin – 18 (IL – 18)
Urine or blood NGAL
neutrophil gelatinase – associated lipocalin
Increase 24 to 48 hours earlier than creatinine
Prerenal Etiology (PRE)
most common type
 volume
 cardiac function
use of vasopressors
Prerenal Etiology (PRE)
Diagnostics
BUN/Creatinine ratio
RFI/FENa
urinalysis
Postrenal (POST)
obstructive process
• structural
• functional
lower tract or bilaterally
in upper tracts
Intrinsic
Diagnostics
BUN/Creatinine ratio
RFI/FENa
urinalysis
Intrinsic - kidney
acute tubular necrosis
(hypoxic or nephrotoxic)
glomerular disorders
(AGN), rhabdomyolysis,
postinfectious
Intrinsic - kidney
Vascular lesions – blood
flow compromise (HUS)
Interstitial nephritis
(AIN) reactions to drugs
or infections
Intrarenal Etiology
Diagnostics
BUN/Creatinine ratio
RFI/FENa
urinalysis
Treatment
underlying cause
prevention on injury
high risk patient
hydration
limit exposure
Management Principles
maintain fluid balance
manage hyperkalemia
• glucose & insulin
• calcium gluconate
• sodium bicarbonate
Clinical Manifestations
hyperkalemia
hypocalcemia
hypermagnesemia
hyperphosphatemia
uremia
acid – base imbalance
Management Principles
control hypertension
in presence of
encephalopathy
bicarbonate for
severe acidosis (pH <
7.2)
manage anemia
Renal Replacement
Therapies
Treatment
Replacement Therapies
acidosis
HCO3 < 10 mEq/L
K+ > 6.5 mEq/L
need high protein diet
deteriorating
Treatment:
Types
hemodialysis
peritoneal dialysis
continuous renal
replacement therapy
Treatment
fluid balance
anticoagulation
prevent clotting
prevent blood loss
ultrafiltration
Rhabdomyolysis
 Causes




trauma
burns
compression syndrome
infection
Rhabdomyolysis
 Causes




vascular occlusion
prolonged shock
electrolyte disorders
drugs (cocaine, alcohol)
Rhabdomyolysis
 Clinical Manifestations
 myalgias
 muscle swelling &
weakness
 DIC
 color of urine
Rhabdomyolysis
 Lab Values




elevated muscle enzymes
hyperkalemia
hyperphosphatemia
hypocalcemia
Rhabdomyolysis
 Treatment
 volume replacement
 treat electrolyte
abnormalities
 protect renal perfusion
 alkalinization of urine
 fasciotomy
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
Case Study 1
Vital Signs (Supine)
Vital Signs (Sitting)
BP 96/50
HR 110
RR 20
Temp 99°F
BP 72/38
HR 140
Case Study 1
 Physical Exam:





tenting of the skin
sunken eyes
dry mucous membranes
flat jugular veins
epigastric tenderness
Case Study 1
Serum Electrolytes
ABGs
Na
K
Cl
CO2
Glucose
Creatinine
BUN
pH
PaCO2
PaO2
SaO2
HCO3
134
2.6
70
41
80
4.5
112
7.55
50
90
95%
40
Case Study 1
Urine Chemistries
Na
K
Cl
Creatinine
Urea
Osmolality
15
40
<10
200
2000
700
Urinalysis
Color
dk amber
pH
5.0
SG
1.020
Ketones
+
Protien
Blood
-
Sediment
WBC
RBC
Casts
0-1
0-1
None
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
Case Study 2
Serum Electrolytes
ABGs
Na
K
Cl
CO2
Creatinine
BUN
Ca
Mg
PO4
pH
PaCO2
PaO2
SaO2
HCO3
141
6.7
104
7
4.5
20
5.0
2.0
11.2
7.11
27
97
98%
7
Case Study 2
Serum Enzymes
CK
LDH
4,780
812
Hematology Values
Hct
WBC
Clotting Profile
30
PT
18,400 PTT
Platelets
28
>180
80,000
Case Study 2
Urinalysis
Color
SG
pH
Reddish brown
1.008
5.0
Sediment
RBC
WBC
Casts
0-1
4-5
granular
& epithelial
Urine Chemistries
Urine Na
Urine Osm
42
280