Mise au point sur l’IRA

Dans le cadre du programme romand d’enseignement postgradué de médecine intensive la Dre Ponte a parlé de la physiopathologie de l’insuffisance rénale aiguë avec comme cadre de discussion:

• Mécanismes physiopathologiques conduisant à l’IRA
• Possibilités et limites du traitement de l’IRA
• Moyens de prévention de l’IRA

Voici son excellente présentation: « IRA: le point en 2010 »

D’autres articles sur l’IRA dans la page « Dialyse aiguë » ainsi que quelques sujets traités dans des billets et en particulier celui-ci « Prévention du déclin et protection de la fonction rénale aux soins intensifs »

☞ N’oubliez pas la philosophie néphrologique à adopter en cas d’insuffisance rénale aiguë !!!

If on every consult for acute kidney injury you limited your differential to pre-renal azotemia, obstruction and run-of-the-mill ischemic ATN you would be capable of reaching the right diagnosis 95% of the time. Common causes of renal failure are common. All the time we spend learning and teaching about glomerulonephritis, interstitial nephritis, vasculitis and the other zebras of acute renal failure is usually time wasted. However, your job as a consult nephrologist is to try and find these diagnosis in every case of acute renal failure. Try to fit the clinical scenario into one of these other diagnosis. Because if you are not actively looking for an alternative, rare diagnosis you will never find one.

• When you see community acquired pneumonia and the ICU intern mentions that there was a lot of blood during the intubation your mind needs to starting thinking about pulmonary-renal syndromes. Ask the family about a history of sinusitis, pay extra-attention to the red cells on the U/A, fire off that ANCA and anti-GBM ab. It is the job of the nephrologist to consider this diagnosis, if you don’t no one will and a week later when the ICU and ID teams begin scratching their collective heads on why this patient is not behaving like a typical pneumonia you will have the reason and prevent a low yield bronchoscopy because you will have the serologic evidence you need and you can get the renal biopsy for the win.

The cryptic case of acute kidney injury starts off just like the banal case of acute renal failure, a rise in creatinine. If you open your eyes to the faint threads that don’t quite fit the standard narrative you will be more receptive to seeing the clues you need to make that rare diagnosis.