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Flashcards in 11.2: Clinical I Deck (40):
1

Definition of AKI?

Any of the following renal changes within 48 hours:
1. Serum Cr. increase > .3 mg/dl
2. % increase serum Cr. > 50%
3. Oliguria 6 hours

2

What is RRT?

- Renal replacement therapy: Dialysis

3

What is AKI often associated with?

1. Critically ill patients
2. Septic patients: 50% with bacteremic septic shock
3. MSOD: mult. syst. organ dysfunction

4

3 categories of AKI?

1. Prerenal
2. Intrinsic renal
3. Postrenal

5

Types of prerenal failure / azotemia?

1. Absolute decrease in BV: hemorrhage / depletion
2. Low ECV: relative decrease in BV: CHF / cirrhosis
3. Renal stenosis / occlusion
4. Impaired autoregulation: NSAID/ACEI/ARB

6

Types of intrinsic renal failure?

1. Vascular
2. Acute glomerular disease
3. AIN: acute interstitial nephritis
4. ATN: acute tubular necrosis

7

Types of postrenal failure

1. Bladder outlet obstruction
2. Bilateral ureteral obstruction
3. Unilateral ureteral obstruction

8

Most common causes of AKI?

1. Prerenal azotemia
2. Ischemic ATN
***75% of all cases
- Thought that prerenal azotemia becomes ischemic ATN

9

What is prerenal azotemia?

- Appropriate physiologic response to renal hyperperfusion: success not failure

10

What does prerenal azotemia progress to?

Ischemic ATN

11

What is normal renal autoregulation in response to drop in BP? What mediates this?

1. Dilation of afferents: NO and prostaglandins
2. Constriction of efferents

12

What antagonizes auto dilation of renal afferents? efferents

Affernets: COX I/II inhibitors: NSAIDS
Efferents: ACEI / ARBs

13

What is the NSAID effect?

- NSAIDs cause tonic constriction of renal afferent
- If volume / ECV drops, kidney is compromised as cannot respond
- Drop in GFR

14

Who is at greatest risk for postrenal failure?

1. Older men with prostate disease
2. Solitary kidney
3. Intra abdominal pelvic cancer

15

What is post renal intervention sequelae?

1. Post obstructive diuresis > 4L / day
- Lose ability to concentrate urine
2. Hyper K / Cl RTA that can become chronic

16

How do diagnose postrenal failure?

1. Physical exam: dullness to percusion in superpubic area, fullness / discomfort here
- Easier in skinny ptn.
- Urge to urinate when push in area
2. Increased post void residual volume: ultrasound
- Hard to tell with ascites

17

Two types of ATN?

1. Ischemic
2. Nephrotoxic
**Sepsis surgery and toxic exposures can cause

18

Two types of AIN?

1. Drug associated
2. Non drug associated

19

Vascular causes of intrinsic renal failure?

1. Malignant Htn.
2. HUS / TTP
3. Vasculitis

20

Definition of malignant HTN?

- BP > 180 / 120
- Evidence of end organ damage must be occurring

21

What is hypertensive urgency?

High BP but not yet any sign of end organ injury

22

Two general types of glomerular diseases?

1. Nephritic: Inflammatory, sedimentation, blood, casts
2. Nephrotic: Proteinuria

23

Main causes of drug related acute interstitial nephritis?

Medications:
1. PPIs
2. NSAIDs
3. Antimicrobials

24

Classic triad of Acute interstitial nephritis?

1. Fever
2. Rash
3. Peripheral eosinophilia: urine too

25

What is urine eosinophils indicative of?

Acute interstitial nephritis

26

What is abdominal jugular reflex?

- Ptn at 30 degrees
- Push on abdomen sustained, if it goes up by 4cm means they are over loaded on fluids

27

What are S3 gallop and abdominal jugular reflux highly predictive of?

CHF

28

What are two highly predictive exam findings for CHF?`

1. S3
2. Abdominal jugular reflux

29

Urinalysis in PRA vs. ATN?

ATN: abnormal, tubular epithelial casts
PRA: usually normal, maybe non specific hyaline casts

30

Urine osmolality in PRA vs. ATN?

PRA: Very high
ATN: middle of road

31

Urine Na and FENa and FE urea in PRA and ATN?

PRA: low
ATN: high

32

Should Cr. be measured in AKI?

- No, is only reliable in steady states
- AKI is not a steady state

33

What does BUN ration > 10:1 indicate?

Prerenal Azotemia

34

What BUN:Cr. ration means prerenal azotemia?

> 10:1

35

What does BUN ration 10:1 indicate?

ATN
- Also can be normal or chronic kidney disease

36

What BUN:Cr. ration means ATN?

10:1

37

What nutritional support is given in AKI?

1. Ensure carb intake to prevent protein breakdown

38

General indications for hemodialysis?

"AEIOU"
1. Acidosis
2. Electrolyte imbalance: usually HYPER K
3. Intoxication syndrome
4. Overload: pulmonary edema
5. Uremia

39

AKI prognosis?

1. Most recover
2. 10% Irreversible

40

How to prevent AKI?

1. Manage volume status and CO
2. Avoid nephrotoxins
3. Give prophylaxis with radiographic contrast
4. Prophylaxis for chemotherapy