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Y2 Renal > Acute kidney injury > Flashcards

Acute kidney injury Flashcards

1
Q

What is classified as acute kidney injury

A

<48 hours reduction in kidney function = increase in serum creatinine by >26.4 µm/l or by >50% or reduction in urine output

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2
Q

What are the types of causes of AKI

A

Prerenal
Intrinsic (renal)
Post-renal

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3
Q

What is the pre renal cause of AKI

A

Impaired blood flow to the kidney = reduction in perfusion

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4
Q

What conditions can cause pre renal AKI

A

Hypovolaemia - haemorrhage / burns / vomiting / diarrhoea
Hypotension
Drugs - ACEi, ARB, NSAID, COX-2
Renal artery stenosis

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5
Q

What conditions can cause hypotension

A

Sepsis
Anaphylaxis
Cardiogenic shock

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6
Q

What are the drugs that can cause pre renal AKI

A

NSAID
COX-2
ACEi
ARB

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7
Q

How does ACEi cause pre-renal AKI

A

Because ACEi causes vasodilation of the efferent arteriole hence prevents vasoconstriction as a compensatory mechanism for low perfusion pressure (which leads to low perfusion)

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8
Q

How does NSAID cause pre-renal AKI

A

It causes vasoconstriction of the afferent arteriole = reduction in perfusion

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9
Q

What is the renal cause of AKI

A

Diseases that causes inflammation or damage to cells of the kidney structures - glomeruli, tubules, interstitium of kidneys

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10
Q

What causes intrinsic (renal) AKI

A

Glomerulonephritis
Acute tubular necrosis
Acute interstitial nephritis
Drugs (damage tubules and interstitium)
Contrast exposure (from imaging)
Rhabdomyolysis (damage tubules)

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11
Q

What can be damaged through contrast exposure

A

Tubules

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12
Q

What causes acute tubular necrosis

A

Sepsis
Severe dehydration -> shock
Rhabdomyolysis
Drug toxicity
Contrast exposure

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13
Q

Which drug can cause acute tubular necrosis

A

Gentamicin

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14
Q

What conditions can cause interstitial nephritis

A

TB infection
Sarcoidosis

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15
Q

What is the post renal cause of AKI

A

due to obstruction of urine flow leading to back pressure and thus loss of concentrating ability

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16
Q

What conditions causes post renal AKI

A

Ureteric stone
Urinary retention caused by benign prostatic hyperplasia / malignancy
External compression of the ureter

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17
Q

Which type of causes of AKI is the most common

A

Pre-renal

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18
Q

Which condition is the most common cause of AKI

A

Acute tubular necrosis

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19
Q

Risk factors of AKI

A

Other organ failure - HF, liver disease
History of AKI
Chronic kidney disease
>65 years old
Use of nephrotoxic drugs
Contrast exposure within the past week

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20
Q

What are the nephrotoxic drugs

A

NSAID
ACEi / ARB
Aminoglycosides (gentamicin, streptomycin)
Diuretics

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21
Q

Symptoms of AKI

A

May experience no symptoms
Reduced urine output
Pulmonary and peripheral oedema
Arrhythmias
Uraemia symptoms (itch, pericarditis, encephalopathy)

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22
Q

What are the uraemia symptoms

A

Itch
Pericarditis
Encephalopathy

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23
Q

What is the diagnostic criteria of AKI

A

Rise in creatinine of 26 µmol/L or more in 48 hours
OR
> 50 % rise in creatinine over 7 days
OR
Fall in urine output to <0.5 ml/kg/hour for more than 6 hours in adults (8 hours in children)
OR
> 25% fall in eGFR in children or young adults in 7 days

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24
Q

What is the staging criteria used for AKI

A

KDIGO (Kidney Disease: Improving Global Outcomes)

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25
Q

Describe stage 1 AKI

A

Increase in creatinine to 1.5-1.9 times baseline
OR
Increase in creatinine by ≥26.5 µmol/L
OR
Reduction in urine output to <0.5 mL/kg/hour for ≥ 6 hours

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26
Q

Describe stage 2 AKI

A

Increase in creatinine to 2.0 to 2.9 times baseline
OR
Reduction in urine output to <0.5 mL/kg/hour for ≥12 hours

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27
Q

Describe stage 3 AKI

A

Increase in creatinine to ≥ 3.0 times baseline
OR
Increase in creatinine to ≥353.6 µmol/L
OR
Reduction in urine output to <0.3 mL/kg/hour for ≥24 hours
OR
The initiation of kidney replacement therapy
OR
In patients <18 years, decrease in eGFR to <35 mL/min/1.73 m2

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28
Q

Investigations for AKI

A

Bloods - U+E, serum creatinine
Arterial blood gas
Urinalysis
Renal ultrasound if suspect urinary tract obstruction / no other identifiable cause
Autoantibodies
ECG
CXR

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29
Q

What may arterial blood gas show in AKI

A

Hypoxia if there is pulmonary oedema

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30
Q

What may ECG show in AKI

A

Hyperkalaemia
- tall T waves
- wide QRS
- Flattening of P waves

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31
Q

What electrolyte imbalance does AKI cause

A

Hyperkalaemia
Hyperphosphataemia
Acidosis

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32
Q

Management of AKI

A

ABCDE
- correct hypoxia / hyperkalaemia / hypovolaemia / sepsis
Identify which type of AKI it is and treat

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33
Q

Management of pre-renal AKI

A

give fluids if the patient is hypovolaemic
- 0.9% NaCl
give IV antibiotics if the patient is septic
Correct hyperkalaemia
Stop nephrotoxic drugs.

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34
Q

What are the nephrotoxic drugs that should be stopped in AKI

A

NSAID (except aspirin at cardiac protective dose 75mg)
Aminoglycosides
ACEi
ARB
Diuretics

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35
Q

What are the drugs that may be required to be stopped in AKI because it increases risk of toxicity (it is not nephrotoxic)

A

Metformin
Lithium
Digoxin

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36
Q

How do you correct hyperkalaemia

A
  1. IV calcium gluconate
  2. IV insulin + dextrose / Nebulised salbutamol
  3. Calcium resonium / loop diuretics / dialysis
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37
Q

How is calcium resonium adminsitered in treating hyperkalaemia

A

Enema / orally

Enema is more effective

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38
Q

What is the function of IV calcium gluconate in correcting hyperkalaemia

A

Stabilisation of cardiac membrane

It DOES NOT lower potassium level

39
Q

What are the agents used to remove potassium from the body to treat hyperkalaemia

A

Calcium resonium
Loop diuretics
Dialysis - for AKI with persistent hyperkalaemia

40
Q

What is the effect of IV insulin and nebulised salbutamol in treating hyperkalaemia

A

Short term shift in potassium to intracellular fluid compartment

It lowers K+ for a short time. K+ will still come out of the ICF eventually so removal of K+ is needed by other agents

41
Q

Management of renal AKI

A

give fluids if the patient is hypovolaemic
- 0.9% NaCl
give IV antibiotics if the patient is septic
Correct hyperkalaemia
Stop nephrotoxic drugs.
Nephrology review to identify uncommon causes of renal AKI

42
Q

Management of post-renal AKI

A

catheterisation and urologist review

43
Q

What are the indications for haemodialysis (AEIOU)

A

Acidosis (severe metabolic acidosis with pH < 7.20)
Electrolyte imbalance (persistent hyperkalaemia > 7 mmol)
Intoxication (poisoning)
Oedema (refractory pulmonary oedema)
Uraemia (encephalopathy or pericarditis)

44
Q

What is classified as chronic kidney disease

A

Reduction in kidney function or structural damage or both, present for more than 3 months

45
Q

Causes of chronic kidney disease

A

diabetic nephropathy
hypertension
chronic glomerulonephritis
chronic pyelonephritis
polycystic kidney disease
Alport syndrome
SLE
Vasculitis - GPA, EGPA, MPA

46
Q

What is pyelonephritis

A

infection of one or both kidneys

47
Q

What are the most common causes of CKD

A

Hypertension
Diabetic nephropathy

48
Q

Symptoms of CKD

A

Usually asymptomatic
May be symptomatic with pruritus, nausea, oedema, muscle cramps at severe late stage (stage 4 or 5)

49
Q

What is used to stage CKD

A

eGFR

50
Q

What are the variables in eGFR calculation

A

Serum creatinine
Age
Gender
Ethnicity

51
Q

Why is serum creatinine used in AKI rather than eGFR

A

Because eGFR calculations assume that the level of creatinine in blood is stable over days hence eGFR is not used in a unsteady state such as AKI

52
Q

What factors may affect the eGFR calculation

A

Severely malnourished
Severely overweight
Bodybuilder
Past organ transplant / amputees
Eating red meat 12 hours prior to sample being taken

53
Q

Describe Stage 1 CKD

A

> / 90 eGFR with some sign of kidney damage

No sign of damage = not CKD

54
Q

Describe Stage 2 CKD

A

eGFR 60-90 ml/min with some sign of kidney damage

No sign of damage = not CKD

55
Q

What tests are used to indicate kidney damage for CKD classification

A

Urinary ACR
Renal ultrasound
Urinalysis - Haematuria/proteinuria

56
Q

Describe stage 3a and 3b CKD

A

3a: eGFR 45-59 ml/min with moderate reduction in kidney function

3b: eGFR 30-44 ml/min with moderate reduction in kidney function

57
Q

Describe stage 4 CKD

A

eGFR 15-29 ml/min with severe reduction in kidney function

58
Q

Describe stage 5 CKD

A

eGFR < 15ml/min = kidney failure

59
Q

Investigations for CKD

A

U+E
Urinalysis
Renal ultrasound

60
Q

What are the complications of CKD (CRF HEALS)

A

Cardiovascular disease
Renal osteodystrophy
Fluid (oedema)

Hypertension
Electrolyte disturbance
Anaemia
Leg restlessness
Sensory neuropathy (parasthesia)

61
Q

What is the main cause of death in patients with CKD

A

Cardiovascular disease

62
Q

Management of CVD risk in CKD

A

Smoking cessation, weight loss
Control hypertension
Correct hyperlipidaemia

63
Q

What are the electrolyte disturbances in CKD

A

Hyperkalaemia
Hyperphosphataemia
Low vitamin D
Hypocalcaemia

64
Q

What causes low vitamin D in CKD

A

because the conversion of vitamin D to its active form occurs in the kidneys

65
Q

What is renal osteodystrophy

A

Skeletal complications of CKD
- osteomalacia
- Osteoporosis
- secondary / tertiary hyperparathyroidism
- spinal osteosclerosis (due to hyperparathyroidism)

66
Q

What is the other name for spinal osteosclerosis

A

Rugger jersey spine - due to hyperparathyroidism

67
Q

What causes osteomalacia in CKD

A

low vitamin D
high phosphate level

68
Q

Why is there hyperphosphataemia in CKD

A

Because the kidneys normally excrete phosphate

69
Q

How does hyperphosphataemia cause osteomalacia

A

high phosphate level drags calcium from bones

70
Q

Management of electrolyte imbalance and parathyroid hormone levels for CKD

A

Reduce diet intake of phosphate
Phosphate binders
Vitamin D tablets

71
Q

Example of phosphate binders

A

sevelamer

72
Q

Function of sevelamer (phosphate binder)

A

Binds to dietary phosphate and prevent its absorption

has benefits in reducing uric acid and lipids

73
Q

What are the vitamin D tablets used for CKD

A

Alfacalcidol
Calcitriol

74
Q

What is the most common cause of anaemia in CKD

A

Reduced erythropoietin levels

75
Q

Management of anaemia in CKD

A

Check iron status before administration
1. Oral iron
2. IV iron if oral iron is insufficient
3. ESA (erythropoiesis-stimulating agents) + IV iron

76
Q

Management of hypertension in CKD

A

ACEi / ARB
Aim for 140/90

77
Q

Management of dyslipidaemia in CKD

A

Atorvastatin
Increase dose if 40% reduction in non-HDL cholesterol is not achieved and eGFR is 30 ml/min/1.73 m2 or more

78
Q

Why is it important to control hypertension and hyperlipidaemia

A

Because it can contribute to accelerated CKD progression
And it can increase risk of CVD

79
Q

CKD increases the risk of which type of malignancies

A

Renal tract cancer
Thyroid gland cancer

80
Q

Causes of hyperkalaemia

A

AKI
CKD
Addison’s
Rhabdomyolysis
Drugs

81
Q

What drugs can cause hyperkalaemia

A

Aldosterone antagonists (spironolactone / eplerenone)
ACEi / ARB
Heparin
Ciclosporin
Beta blockers in renal failure patients

82
Q

Symptoms of hyperkalaemia

A

fatigue
Muscle weakness
Palpitations
Chest pain

(very non-specific)

83
Q

Investigations for hyperkalaemia

A

Bloods- U+E, eGFR, serum creatinine
ECG

84
Q

What is the ECG pattern in hyperkalaemia

A

Tall T waves
Widened QRS
Flattening / absence of P waves

85
Q

What is rhabdomyolysis

A

A condition where skeletal muscle tissue breaks down and releases breakdown products into the blood

86
Q

Causes of rhabdomyolysis

A

Seizures
Prolonged immobility
Extremely rigorous exercise beyond the person’s fitness level
Crush injury
Drugs - statin

87
Q

What drug interactions can cause rhabdomyolysis

A

Statins can interact with
- clarithromycin
- colchicine

88
Q

What is released by the muscle cells in rhabdomyolysis

A

Myoglobin
Potassium
Phosphate
Creatine kinase

89
Q

Symptoms of rhabdomyolysis

A

Muscle aches and pain
Red-brown urine
Oedema
Fatigue
Confusion

90
Q

How is rhabdomyolysis usually presented

A

A patient who has had a fall / prolonged seizure and is found to have AKI on admission

91
Q

Investigations for rhabdomyolysis

A

CK level
Urine - red-brown
ECG - to assess for hyperkalaemia
U+E - for AKI and hyperkalaemia

92
Q

What level of CK suggests rhabdomyolysis

A

CK significantly elevated - at least 5 times the upper normal limit

2-4 times is not rhabdomyolysis

93
Q

What are the results suggesting rhabdomyolysis

A

CK level at least 5 times higher
Myoglobinuria - red-brown urine
Hypocalcaemia
Hyperphosphate
Hyperkalaemia
metabolic acidosis

94
Q

Management of rhabdomyolysis

A

rapid IV fluids

Y2 Renal (12 decks)

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