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Creating QR-Code in Objective-C 2 Conditions affecting serum creatinine independently of glomerular filtration rate

Table 22 2 Conditions affecting serum creatinine independently of glomerular filtration rate
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Condition Conditions elevating creatinine Ketoacidosis Cephalothin, cefoxitin Flucytosine Other drugs: aspirin, cimetidine, probenecid, trimethoprim Conditions decreasing creatinine Advanced age Cachexia Liver disease Physiologic decrease in muscle mass Pathologic decrease in muscle mass Decreased hepatic creatine synthesis and cachexia Noncreatinine chromogen Noncreatinine chromogen Noncreatinine chromogen Inhibition of tubular creatinine secretion Mechanism
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Table 22 3 Conditions affecting BUN independently of GFR
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Increased BUN Reduced effective circulating blood volume (prerenal azotemia) Catabolic states (gastrointestinal bleeding, corticosteroid use) High-protein diets Tetracycline Decreased BUN Liver disease Malnutrition Sickle cell anemia SIADH BUN, blood urea nitrogen; GFR, glomerular filtration rate; SIADH, syndrome of inappropriate antidiuretic hormone
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underlying cause Azotemia can cause nausea, vomiting, malaise, and altered sensorium Hypertension is rare, but fluid homeostasis is often altered Hypovolemia can cause prerenal disease, whereas hypervolemia can result from intrinsic or postrenal disease Pericardial effusions can occur with azotemia, and a pericardial friction rub can be present Effusions may result in cardiac tamponade Arrhythmias occur especially with hyperkalemia The lung examination may show rales in the presence of hypervolemia Acute renal failure can cause nonspecific diffuse abdominal pain and ileus as well as platelet dysfunction; thus, bleeding is more common in these patients The neurologic examination reveals encephalopathic changes with asterixis and confusion; seizures may ensue
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nine clearance overestimates GFR, as mentioned above, while the urea clearance underestimates GFR Therefore, an average of the two more accurately approximates the true GFR
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ACUTE RENAL FAILURE
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ESSENTIALS OF DIAGNOSIS
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Sudden increase in BUN or serum creatinine Oliguria often associated Symptoms and signs depend on cause
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B Laboratory Findings
Elevated BUN and creatinine are present, though these elevations do not in themselves distinguish acute from chronic renal failure Hyperkalemia often occurs from impaired renal potassium excretion The ECG can reveal peaked T waves, PR prolongation, and QRS widening A long QT segment can occur with hypocalcemia Anion gap metabolic acidosis (due to decreased organic acid clearance) is often noted Hyperphosphatemia occurs when phosphorus cannot be secreted by damaged tubules either with or without increased cell catabolism Hypocalcemia with metastatic calcium phosphate deposition may be observed when the product of calcium and phosphorus exceeds 70 mg/dL Anemia can occur as a result of decreased erythropoietin production over weeks, and associated platelet dysfunction is typical
General Considerations
Five percent of hospital admissions and 30% of intensive care unit (ICU) admissions carry a diagnosis of acute renal failure, and it will develop in 25% of hospitalized patients Acute renal failure is defined as a sudden decrease in renal function, resulting in an inability to maintain fluid and electrolyte balance and to excrete nitrogenous wastes Serum creatinine is a convenient marker In the absence of functioning kidneys, serum creatinine concentration will typically increase by 1 15 mg/dL daily although with certain conditions, such as rhabdomyolysis, serum creatinine can increase more rapidly Acute renal failure is also called acute kidney injury, since it may be a more appropriately descriptive term
Clinical Findings
A Symptoms and Signs
The uremic milieu of acute renal failure can cause nonspecific symptoms When present, they are often due to azotemia or its
Classification & Etiology
Acute renal failure can be divided into three categories: prerenal azotemia, intrinsic renal disease, and postrenal azotemia Identifying the cause is the first step toward treating the patient (Table 22 4)
Table 22 4 Classification and differential diagnosis of acute renal failure
Intrinsic Renal Disease Prerenal Azotemia Etiology Poor renal perfusion > 20:1 < 20 <1 > 500 Benign or hyaline casts Postrenal Azotemia Obstruction of the urinary tract > 20:1 Variable Variable < 400 Normal or red cells, white cells, or crystals Acute Tubular Necrosis (Oliguric or Polyuric) Ischemia, nephrotoxins Acute Glomerulonephritis Poststreptococcal; collagen-vascular disease > 20:1 < 20 <1 Variable Dysmorphic red cells and red cell casts Acute Interstitial Nephritis Allergic reaction; drug reaction < 20:1 Variable < 1; > 1 Variable White cells, white cell casts, with or without eosinophils
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