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  • • Oliguric (urinary output < 400 mL/d) and nonoliguric

    • Mortality in surgical ICU of 50-90%

    • Etiologies of parenchymal disease include:

    • -Acute tubular necrosis

      -Pigment nephropathy

      -Nephrotoxic agents

      -Acute rejection following transplantation

      -Prerenal and postrenal causes

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Symptoms and Signs

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  • • Diminished urinary output

    • Altered mental status

    • Abdominal pain

    • Edema

    • Prolonged bleeding time secondary to platelet dysfunction

    • Tenderness over transplant allograft

    • Hypertension

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Laboratory Findings

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  • • Elevated creatinine

    • Hyperkalemia

    • Hyperphosphatemia

    • Elevated blood urea nitrogen

    • Urine osmolarity isotonic with serum levels

    • Urine sodium > 40

    • Fractional excretion of sodium > 3%

    • Hyponatremia

    • Hypocalcemia

    • Metabolic acidosis

    • Anemia

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Imaging Findings

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  • Renal US: Shows dampened waveform in arterial thrombosis or diastolic reversal of flow in venous obstruction or allograft rejection post-transplantation

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  • • Duration since transplantation

    • Underlying critical illness in acute renal failure

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Rule Out

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  • • Renal artery or vein thrombosis immediately post-transplant

    • Ureter obstruction or leak post-transplant

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  • • History and physical exam

    • Serum and urine creatinine

    • Serum and urine sodium

    • Serum potassium

    • Serum phosphate

    • Renal US

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Surgery

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Indications

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  • • Removal of allograft if hyperacute rejection

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Medications

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  • • Optimization of cardiac output

    • Diuresis and renal replacement therapy (intermittent hemodialysis, continuous venovenous hemofiltration and dialysis if hemodynamically unstable)

    • Adequate nutrition

    • Treatment of underlying disease

    • Pulse corticosteroids and/or OKT3 for acute allograft rejection

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Prognosis

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  • • 50-90% mortality (highest if oliguric)

    • 90% recover renal function if survive underlying inciting illness (recovery unlikely if > 6 weeks postresolution of illness)

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Prevention

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  • • Avoidance of nephrotoxic agents and maintain organ perfusion in critically ill

    • Adequate immunosuppression and compliance post-renal transplant

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References

Zacharias M. et al. Interventions for protecting renal function in the perioperative period. Cochrane Database of Systematic Reviews. 2008. (4):CD003590.
Rabindranath K. Adams J. Macleod AM. Muirhead N. Intermittent versus continuous renal replacement therapy for acute renal failure in adults. Cochrane Database of Systematic Reviews 2007. (3):CD003773.

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