Renal Failure
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Transcript of Renal Failure
RENAL FAILURERENAL 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
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
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
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
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
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
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
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
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.
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
((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
(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
(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
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
(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
(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
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
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
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
CLASSIFICATION OF CAUSES CLASSIFICATION OF CAUSES OF ACURE RENAL FAILUREOF ACURE 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.
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)
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%
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
(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
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
(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
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
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)
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
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
(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
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
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.
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
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
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
(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
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.
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)
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
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
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
►►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
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.
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%
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
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
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
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
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
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
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
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
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)
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
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
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
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 ====
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