java barcode scanner library Serum BUN:Cr ratio Urinary indices UNa (mEq/L) FENa (%) Urine osmolality (mosm/kg) Urinary sediment in Objective-C

Encoder QR Code in Objective-C Serum BUN:Cr ratio Urinary indices UNa (mEq/L) FENa (%) Urine osmolality (mosm/kg) Urinary sediment

Serum BUN:Cr ratio Urinary indices UNa (mEq/L) FENa (%) Urine osmolality (mosm/kg) Urinary sediment
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< 20:1 > 20 >1 250 300 Granular (muddy brown) casts, renal tubular casts
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BUN:Cr, blood urea nitrogen:creatinine ratio; UNa, urinary concentration of sodium; FENa, fractional excretion of sodium
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Kidney Disease A Prerenal Azotemia
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Prerenal azotemia is the most common cause of acute renal failure, accounting for 40 80% of cases, depending on the population studied It is due to renal hypoperfusion This is an appropriate physiologic change If it can be immediately reversed with restoration of renal blood flow, renal parenchymal damage does not occur If hypoperfusion persists, ischemia can result, causing intrinsic renal failure Decreased renal perfusion can occur in one of three ways: a decrease in intravascular volume, a change in vascular resistance, or low cardiac output Causes of volume depletion include hemorrhage, gastrointestinal losses, dehydration, excessive diuresis, extravascular space sequestration, pancreatitis, burns, trauma, and peritonitis Changes in vascular resistance can occur systemically with sepsis, anaphylaxis, anesthesia, and afterload-reducing drugs ACE inhibitors prevent efferent renal arteriolar constriction out of proportion to the afferent arteriole; thus, GFR will decrease Nonsteroidal anti-inflammatory drugs (NSAIDs) prevent afferent arteriolar vasodilation by inhibiting prostaglandin-mediated signals Thus, in cirrhosis and congestive heart failure, when prostaglandins are recruited to increase renal blood flow, NSAIDs will have particularly deleterious effects Epinephrine, norepinephrine, high-dose dopamine, anesthetic agents, and cyclosporine also can cause renal vasoconstriction Renal artery stenosis causes increased resistance and decreased perfusion Low cardiac output is a state of low effective renal arterial blood flow This occurs in states of cardiogenic shock, congestive heart failure, pulmonary embolism, and pericardial tamponade Arrhythmias and valvular disorders can also reduce cardiac output In the ICU setting, positive pressure ventilation will decrease venous return, also decreasing cardiac output When GFR falls acutely, it is important to determine whether acute renal failure is due to prerenal or intrinsic renal causes The history and physical examination are important, and urinalysis can be helpful The BUN:creatinine ratio will typically exceed 20:1 due to increased urea reabsorption In an oliguric patient, another useful index is the fractional excretion of sodium (FENa) With decreased GFR, the kidney will reabsorb salt and water avidly if there is no intrinsic tubular dysfunction Thus, patients with prerenal failure should have a low fractional excretion percent of sodium (< 1%) The FENa is calculated as follows: FENa = clearance of Na+/GFR = clearance of Na+/creatinine clearance: Urine sodium /Plasma sodium F E Na = --------------------------------------------------------------- 100% Urine creatinine /Plasma creatinine Oliguric states are more accurately assessed with this formula than nonoliguric states because the kidneys do not avidly reabsorb water and sodium in nonoliguric states (Oliguria is defined as urinary output < 400 500 mL/d, or < 20 mL/h) Diuretics can cause increased sodium excretion Thus, if the FENa is high within 12 24 hours after diuretic administration, the cause of acute renal failure may not be accurately predicted Acute renal failure due to glomerulonephritis can have a low FENa because sodium reabsorption and tubular function may not be compromised Treatment of prerenal azotemia depends entirely on its cause, but maintenance of euvolemia, attention to serum potassium, and avoidance of nephrotoxic drugs are the
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benchmarks of therapy This involves careful assessment of volume status, drug usage, and cardiac function
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B Postrenal Azotemia
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Postrenal azotemia is the least common cause of acute renal failure, accounting for approximately 5 10% of cases, but is important to detect because of its reversibility It occurs when urinary flow from both kidneys, or a single functioning kidney, is obstructed Each nephron has an elevated intraluminal pressure, causing a decrease in GFR Causes include urethral obstruction, bladder dysfunction or obstruction, and obstruction of both ureters or renal pelvises In men, benign prostatic hyperplasia is the most common cause Patients taking anticholinergic drugs are particularly at risk Bladder, prostate, and cervical cancers as well as retroperitoneal processes and neurogenic bladder can also cause obstruction Less common causes are blood clots, bilateral ureteral stones, urethral stones or stricture, and bilateral papillary necrosis In patients with a single functioning kidney, obstruction of a solitary ureter can cause postrenal azotemia Patients may be anuric or polyuric and may complain of lower abdominal pain Obstruction can be constant or intermittent and partial or complete On examination, the patient may have an enlarged prostate, distended bladder, or mass detected on pelvic examination Laboratory examination may initially reveal high urine osmolality, low urine sodium, high BUN:creatinine ratio, and low FENa These indices are similar to a prerenal picture because extensive intrinsic renal damage has not occurred After several days, the urine sodium increases as the kidneys fail and are unable to concentrate the urine thus, isosthenuria is present The urine sediment is generally benign Patients with acute renal failure and suspected postrenal azotemia should undergo bladder ultrasonography and bladder catheterization if hydroureter and hydronephrosis are present along with an enlarged bladder These patients often undergo a postobstructive diuresis, and care should be taken to avoid dehydration Rarely, obstruction is not diagnosed by ultrasonography For example, patients with retroperitoneal fibrosis from tumor or radiation may not show dilation of the urinary tract If suspicion does exist, a CT scan or MRI can establish the diagnosis Prompt treatment of obstruction within days by catheters, stents, or other surgical procedures can result in complete reversal of the acute process
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