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GI, liver, kidney > Aki > Flashcards

Aki Flashcards

1
Q

What is AKI

A

Abrupt disruption of kidney function including but not limited to acute renal failure

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2
Q

Which kidney is higher?

A

Left

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3
Q

Which peritoneal section are the kidneys

A

Retroperitoneal

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4
Q

Functions of the kidney

A

Acid base balance
Hormone regulation
Electrolyte balance
Blood pressure regulation
Toxin removal
Water balance

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5
Q

Where is both H+ and HC03- secreted in the kidney?

A

Proximal tubule

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6
Q

Where is H+ secreted in the kidney?

A

Proximal tubule and collecting ducts

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7
Q

What electrolyte determines ECF volumeV

A

Sodium

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8
Q

Perfusion of what allows the functioning of RAAS

A

Juxtaglomerular apparatus

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9
Q

How does the kidney regulate BP?

A

Volume of ECF (with sodium)
RAAS

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10
Q

What causes ADH secretion

A

Detection of increased plasma osmolality by hypothalamus

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11
Q

Where is ADH secreted from

A

Posterior pitusitarh gland

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12
Q

What toxins does the kidney remove?

A

Urea
Creatinine
Drug metabolites

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13
Q

How are toxins filtered by the kidney?

A

Glomerular filtration
Passive diffusion
Active transport

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14
Q

What can high urea cause

A

Uraemia encephalopathy
Uraemia pericarditis

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15
Q

What is the criteria for an AKI?

A

Rise in serum creatinine 26micromol/L or greater in 48 hours
50% greater rise in serum creatinine (more than 1.5x baseline) in last 7 days
Fall in urine output <0.5ml/kg/hour for > 6 hours - catheterised

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16
Q

What signs and symptoms should u suspect AKI in

A

N+V, diarrhoea, signs dehydration
Reduced urine output or colour change
Confusion, fatigue, drowsiness

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17
Q

What are methods of staging for AKI?

A

RIFLE criteria
KDIGO system

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18
Q

What is second stage AKI defined by?

A

100-199% creatinine rise from baseline in 7 days
Urine output <0.5ml in 12 hours

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19
Q

What criteria is 3rd stage AKI?

A

200% creatinine rise, 354 micro mil/L or more with acute rise
Urine output <0.3ml/kg/hr 24 hours, anuria for 12 hours

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20
Q

Risk factors for AKI

A

Diabetes
Emergency surgery
Intraperitoneal surgery
CKD if eGFR <60
Heart failure
Age over 65
Liver
Use nephrotoxic drugs

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21
Q

drugs need to stop in AKI

A

DAMN
Diuretics
ACEis/ARBs
Metformin
NSAIDs

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22
Q

Causes of loss of glomerular filtration rate (features of AKI)

A

Circulating volume overload
Hyperkalaemia
Acidosis

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23
Q

What reduces hydrostatic pressure in the glomerulus?

A

Hypotension
Renal artery stenosis
ACEi - efferent arteriole dilation
NSAIDs - afferent arteriole dilation
(NSAID +ACEi BAD)

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24
Q

What increases hydrostatic pressure in glomerulus

A

Urinary tract obstruction, hypertension

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25
Q

What do kidneys vitally control in the short term?

A

Maintenance of electrolyte homeostasis
Fluid homeostasos
Excretion of toxins
Regulation of acid base balance

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26
Q

Long term kidney functions

A

Hormone production
-> anaemia, renal bone disease

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27
Q

Pre-renal causes of AKI

A

Blood supple - hypovolaemia (haemorrhage), hypotension (sepsis, dehydration, shock)
Decreased circulating volume = cirrhosis, congestive HF
Medications - NSAIDs
Third space loss/intersitiial fluid loss
Narrowing of renal artery - thrombosis, stenosis
Hepatorenal syndrome

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28
Q

What is hepatorenal syndrome?

A

Rapid deterioration in kidney function in people with fulminant or fulminant hepatic failure. Caused due to back up in splanchic circulation, portal veins. Need liver transplant, otherwise manage with dialysis.

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29
Q

Investigations pre renal cause of AKI

A

Bloods, U+Es, LFTs, bone profile, CK, FBC, CRP
Dipstick analyisis
ECG
CXR
Urinary creatinine/serum creatinine
Urine osmolarity
Sediment
Renal doppler US
Fractional excretion of Na

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30
Q

Renal causes of AKI

A

Acute tubular necrosis
Acute intersistitial nephritis
Glomerular disease
Glomerulonephritis
Intratubular obstruction
Polycystic kidney disease

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31
Q

What is acute tubular necrosis?

A

Death of epithelial cells of renal tubules
Most common cause of AKI
Reversible - cells can regenerate. Week to a month recovery

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32
Q

Cuaes of acute tubular necrosis

A

Ischamia secondary to hypoperfusion
-shcok, sepsis, dehydration
Direct damage from toxins
-Gentomycin, radiology contrast dye, NSAIDs

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33
Q

What do you find on urinalysis in acute tubular necrosis?

A

Muddy brown cast

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34
Q

What is acute interstitial nephiritis and what causes it?

A

Inflammation of nephrons - hypersensitivity reaction atypical
-Autoimmune
-Drugs - NSAIDs, penicillin
Infection - TB, pneumonia
Sarcoidosis

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35
Q

What often presents alongside acute interstiial nephritis if caused by NSAIDs?

A

Nephrotic syndrome

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36
Q

Nephrotic vs nephritic syndromes

A

Both glomeruklar diseases
Nephrotic is a loss of protein -> hypoalbuniaemia -> oedema
Nephritic - lose blood, cause HPTN
https://geekymedics.com/nephrotic-vs-nephritic-syndrome/

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37
Q

What is goopasteurs syndrome?

A

Rare autoimmune disease where antibodies attack basement membrane in kidney andlungs leading to haemoptysis, glomerulonephritis and acute renal failure.
anti-GBM antibody
https://rarediseases.info.nih.gov/diseases/2551/goodpasture-syndrome/

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38
Q

Glomerular diseases causes of AKI

A

Nephrotic and nephritic syndrome
Good pastuers syndrome
Systemic autoimmune eg IgA vasculitis, granulomatosis with polyangitis
Inflammation of glomeruli and small blood vessels

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39
Q

What is intratubular obstruction?

A

Increase tubular pressure by increasing eGFR
Large protein deposits eg rhabdomyolysis and myeloma cuase blockage

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40
Q

Investigations renal causes of AKI

A

History and exam
Bloods
Urinalysis
US
Nephrology for biopsy

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41
Q

Post renal causes of AKI

A

Urinary retnetion - obstruction
Renal calculus
Pyelonephrosis
Pelvic mass
Enlarged prostate
Carcinomas
Blood clot in ureter - catheter trauma, cancer
Stricture
Neurogenic bladder - ketamine

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42
Q

Investigations post renal causes

A

CT no contrast
CTKUB for renal calculi = gold standard.

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43
Q

What does dilatation of the ureters on CT suggest?

A

Hydronephrosis

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44
Q

What calculi will not show up on CT?

A

Uric acid - not radioopaque

45
Q

What presentation suggests an AKI?

A

N+V or diarrhoea, evidence of dehydration
Reduced urine output or change colour
Confusion, fatigue, drowsiness

46
Q

How do you stage an AKI?

A

RIFLE criteria
KDIGO system
AKIN

47
Q

RIFLE staging

A

RISK - 1.5 x creatinine / GFR decrease >25% / <0.5ml x 6 hrs
INJURY- 2 x creatinine / >50% decline GFR, <0.5ml/kg/hr urine in 12hrs
FAILURE -
3x SCR or >75% decreased GFR or if baseline SCR >353.6umol/L or increased by >44.2
<0.3mol/kg/hr, 24 hrs or anuria x 12hrs
Persistent ARF =
Loss of kidney function
Complete loss >4 weeks
End stage kidney disease >3 months

48
Q

Risks for AKI

A

Emergency surgery
INtraperitoneal surgery
CKD ie eGFR < 60
Diabetic
HF
>65
liver
Nephrotoxic drug use

49
Q

What to look for in bloods AKI

A
  • Anaemia
  • Biochem
  • Increase UR + Cr
  • Increased potassium, phosphate
  • Decrease Ca, HC03, albumin
  • ABGs go deeper - anion gal = sodium -(chloride and HC03-)
  • Normal = 4-13
  • Higher anion gap >12
50
Q

Management on AKI

A

Stop offending drugs - DAMN
IV fluids
Improve renal perfusion
Treat precipitants
Monitor U+Es and fluid balance closely

51
Q

Indications fro renal replacement therapy

A

AEIOU
Acidosis
Electrolytes - refractory hyperkalaemia
Intoxication
Overload - pulm oedema
Uraemia - encephalopathy, pericarditis

52
Q

What can use to monitor kidney function

A

eGFR
CrCl 0 estimation of eGFR, slightly higher than true value, some creatinine secreted in porximal tubule adds to calue

53
Q

DAMN drugs

A

Diuretics - exacerbate dehydration and hypopefusion

ACEis/ARBs → vasodilation efferent arteriole, hypoperfusion, aspirin (aminoglycosides - gentomycin)

Metformin → lactic acidosis, methotrexate

NSAIDs → prostaglandin vasodilation reduced, renal hypopeefysion

54
Q

Other offending drugs

A

Statins, CCBs,

55
Q

Summary of causes of acute kidney injury

A

Pre-renal (most common) — due to reduced perfusion of the kidneys and leading to a decreased glomerular filtration rate (GFR).
Intrinsic renal — structural damage to the kidney, eg tubules, glomeruli, interstitium, and intrarenal blood vessels. damaging renal cells
Post-renal — acute obstruction of urine flow resulting in increased intratubular pressure and decreased GFR

56
Q

Groups at higher risk of AKI

A

> 65
Prev AKI
CKD
Symptoms or history urological obstruction - at risk conditions
HF, liver disease, DM
Sepsis., Hypovolaemia.
Oliguria
Cancer and cancer therapy
Immunocompromise
Toxins
In last week:
Nephrotoxic drug - (NSAIDs), (ACE) inhibitors, (ARBs), and diuretics.
Exposure to iodinated contrast agents

57
Q

Complications of AKI

A

Hyperkalaemia
Electolyte imbalances - hyperphosphatemia, magnesaemia, hypnatremia, calcemia
Metabolic acidosis
Volume overload - peripheral and pumonary oedema
Uraemia
CKD and end stage renal disease

58
Q

Predictors for CKD after AKI

A

older age, lower baseline eGFR, higher baseline albuminuria, and higher stages of AKI

59
Q

Symtpoms of uraemia and how treat

A

Confusion, lethargy, altered LOC
Dialysis

60
Q

Presentation of metabolic acidosis

A

altered LOC, circulatory collapse, hyperventialtion

61
Q

Hyperkalaemia presentation

A

Asymptomatic until severe
Muscle weakness, paralysus, cardiac arrhytmias, cardiac arrest

62
Q

When there is an illness with no clear acute componenet, which features would make you suspect an AKI?

A

Chronic kidney disease (stage 3B, 4, or 5), or urological disease.
New onset or significant worsening of urological symptoms.
Symptoms or signs of multi-system disease - kidneys and other organ systems
Symptoms of complications of AKI

63
Q

What test can flag AKIs early?

A

AKI warning stage test result from electronic detection systems in a lab
3 stages measuring creatinine levels
Determines how quickly admit/patient is monitored how often

64
Q

What to do if no creatinine prev abailvabe

A

Repeat within 48-72 hours and compare

65
Q

What to consider in people who take trimethoprin?

A

False positives for serum creatinine - increases but does not affect eGDR

66
Q

Volume status assessment

A

Fluid intake and losses.
Peripheral perfusion (capillary refill time).
Heart rate/blood pressure (and any postural changes).
Jugular venous pressure.
Moistness of mucous membranes, skin turgor.
Changes in urination pattern.
For peripheral oedema and pulmonary crackles

67
Q

Questions to ask about possible underlying causes

A

Current symptoms, if the person is unwell
underlying obstructive cause
History of CVSD increasing the risk of impaired renal perfusion.
Symptoms of an underlying inflammatory process
Drug history
Possibility of rhabdomyolysis

68
Q

What does a negative urinalysis but AKI symptoms indicate?

A

Pre renal cause

69
Q

Symptoms of urinary obstruction

A

(for example lower urinary tract symptoms, bloating from a pelvic mass, renal colic).

70
Q

Symptoms of underlying inflammatory process

A

(for example vasculitic rash, arthralgia, epistaxis, or haemoptysis).

71
Q

Causes of rhabdomyolysis

A

skeletal muscle injury, muscle overexertion, crush injury, prolonged immobility.

72
Q

Why are patients with neuroglogical deficits more likely to get an AKI?

A

fLUID INTAKE more difficult to regulate themselves or regulated by a carer

73
Q

WHat is oliguria

A

(urine output less than 0.5mL/kg/hour).

74
Q

COmplications of UTI

A

Hyperkalaemia + other electrolyte disturbances
Pulmonary oedema
Metabolic acidosis
Uraemic pericarditis, encephalopathy

75
Q

electrolyte disturbances caused by AKI

A

Hyperkalaemia
Hyperphosphatemia
Hypermagenesiumia
Hyponatremia
Hypocalcemia

75
Q

Pre renal causes AKI

A

Hypovolaemia
Decreased cardiac output
Drugs that reduce BP

76
Q

Renal causes AKI

A

Drugs
Vascular
Glomerular - nephritits, good pasteur
Tubular - ischaemia, meyloma, contrast agent
Interstitiatl - interstitial nephritis eg ascending UTI

77
Q

Obstructions that can cause AKI

A

Renal stones, pyelonephrosis, blocked cathertet, pelvic mass, enlarged prostate, cervical carcinoma, ,retroperitoneal fibrosis

78
Q

Urine investgiatones - bedside AKI

A

Dipstick
Microscopy, culture and sensitivity
Electrolytes abd somolalilty

79
Q

What test for on dipstick for AKI

A

Blood
Protein
Leucocytes
Nitrities
Glucose
Detects glomerulonephritis, acute pyelonephritis and intersitital nephritits

80
Q

Bloods in AKI

A

FBC
U+Es
LFTs
Creatinine kinase
Immunology
CRP/ESR
Virology
ABG
Blood culture - sepsis

81
Q

What can increased eosinophils suggest in AKI>

A

Acute intertitial nephritis, cholesterol embolisation and vasculitis

82
Q

What suggests thrombocytic microangiopathy in bloods

A

Decreased platelets
Haemolytic anaemia

83
Q

Why chcek for creatinine kinase in AKI

A

Rhabdomyolysis

84
Q

Immunology tests in SLE

A

ANA, anti-DsDNA, decreased C3, C4

85
Q

What condition suggests ANCA

A

Granulomatosis with polyangitis

86
Q

Imaging for AKI adn why

A

CXR - rule out oedema
US KUB - urinary retention
Doppler US - assess renal artery
MRA - renal vascular occlusion

87
Q

Presentation of AKI

A

Nausea, vomitting, dehydration, confusion, oliguria or anuria

88
Q

AKI warning stage 1

A

Creatinine >1.5 x baseline OR >26mol<48 hrs

89
Q

AKI warning stage 2

A

Current creatinine >2 x baseline level

90
Q

AKI warning stage 3

A

Current creatinine >3 x baseline
OR 1.5 x baseline and >354 umol/L

91
Q

What is azotemia

A

High levels of nitrogenous compounds in the blood

92
Q

Neurogenic causes of postrenal AKI

A

DM
MS
Spinal cord compression
Cauda equina
Anticholinergics
Sympathomimetic drugs

93
Q

Clinical signs of AKI

A

Oliguria, anuria
Hypovolaeia signs
Volume overload - HPTN, pulmonary/peripheral oedema
Uraemia - encephalopathy, ecchymosis (platelet dysfunction)
Post renal obstrucution - tender/palpable bladder

94
Q

Bedside investigations AKI

A

Urine dipstick
Urine micoscopy
Urine osmolality and electrolytes
ECG

95
Q

Urine studies

A

Urinalysis
Urinary PCR or nephritic screen
Urine volume/output
Microscopy and sediment - cast, crystals
Urine osmolarity and specific gravity
Urine eosiniphil count - AIN evaluation

96
Q

Bloods in AKI

A

FBC - Hb, platelets, WCC
U+Es - Creatnine, urea, potassium, sodium
ABG/VBG

For intrinsic:
CK
Vasculitis screen - ANCA, ANA
Clotting
Blood film
Complement
Immunoglobulins
Serum electrophroesus
Virology (hep B/C)

97
Q

Imaging for AKI

A

US - key fo robstructive pathology
non contrast CT for urinary stones
CXR
Renal dopplers
MR angiography
CT urogram

98
Q

Indications for renal biopsy

A

Intra renal AKI cause or sus rapid progressive glomerulonephritis -
Unexplained renal impairment
- Unexplained glomerular haematuria
- Renal masses - urology
- Renal transplant
- Rejection
- Dysfunction
- Connective tissue diseases
- Treatment monitoring/research

99
Q

General management AKI

A

Withdrawal nephrotoxic meds (DAMN) + adjust renally cleared drug doses
Fluid resus + monitoring
Catheterise to monitor output
Evidence of spesis
Daily U+Es
Treat causes and complications

100
Q

What to do in pulmonary oedema patients with AKI

A

Can give diuretics - weigh up benefits and risks

101
Q

What is considered in AIN or RPGN to slow progression

A

Immunosupression

102
Q

Indications for renal replacement therapy

A

A - acid 0- Metabolic acidosis <7.15 or worsening
E - electrolytes - Refractory electrolyte abnormalities - hyperkalemia >6.5
I - intoxication - Presence of dialysable toxins
O - Overload - Refractory fluid overload
U -Uraemia - End organ uraemic complications - pericarditis, encephalopathy

103
Q

What substances are dialysable in intoxication

A

Methanol, ethylene glycol, lithium, ASA
Any severe posisonning or drug overdose suitable

104
Q

Types of continious renal replacement therapy

A

Cont. venovenous haemodialysis - CVVHD
Cont, venovenous haemofiltration - CVVHF
Cont venovenous haemodiafiltration - CVVHDF

105
Q

Complications AKI

A

Fluid overload
Electrolyte derangement
Metabolic acidosis
End organ complications
CKD
End stage renal disease

106
Q

Treatment for rhabdomyolysis

A

IV fluids - 0.9% sodium chloride at 10-15ml/kg/hr to achieve urine (>100ml/hr),adding f sodium bicarbonate 1.4% to maintain urinary pH> 6.51.
AND regularly monitor CK and U+Es

107
Q
A

GI, liver, kidney (50 decks)

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