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Causes
- renal ischaemia
- particularly susceptible with cholestatic jaundice
- often double insult
- Rhabdomyolysis
- Liver Failure
- Drugs
- renal toxins
Mechanisms
- entry of calcium into cells
- induction of nitric oxide
- increased production of intracellular proteases
- activation of phospholipase A2, increasing production of
free-fatty acids
- reperfusion injury
- vasoconstriction
- liberation of toxic endothelial factors
- damage from vasodilator endotoxins
- reduced prostaglandin production
- tubular obstruction by desquamated cells and casts
Reduced Glomerular Filtration Rate by
- glomerular contraction
- reflex afferent arteriolar spasm
- 'back leak' of filtrate
- obstruction of tubule
Clinical Course
- oliguria common
- recovery of function 7-21 days
- delayed by continuing sepsis
- GFR remains low but urine output increases
- may be up to 6 weeks before full recovery
Clinical Features
Symptoms
- anorexia
- nausea
- vomiting
- pruritus
- intellectual clouding
- drowsiness
- fits
- coma
- haemorrhagic episodes
- infection
Signs / Biochemistry
Treatment
- keep em alive until kidneys recover!!!
- early transfer to nephrologist / intensivist with access to haemodialysis
- don't need a catheter (and increases risk of sepsis)
- Good nursing / physiotherapy
- fluid balance
- daily body weight
- Emergencies
- hyperkalaemia
- Pulmonary Oedema
- will probably need haemodialysis unless diuretics work
- Sepsis
- avoid nephrotoxic drugs
- appropriate alterations of drug dosage
- Diet
- sodium and potassium restriction
- if trying to avoid haemodialysis then protein below 40g / day
- Haemodialysis
Prognosis
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