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Yr3 Medicine- Renal > AKI > Flashcards

AKI Flashcards

1
Q

Define an AKI

A

Acute kidney injury is an acute- occurring over hours to days- drop in kidney function

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2
Q

There are many different AKI criterias; describe the NICE criteria for an AKI

A
  • Rise in creatnine of >/=26umol/L in 48hr
  • Rise in creatinine of >/=50% in 7 days
  • Urine output of <0.5ml/kg/hour for >6hrs
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3
Q

There are many different AKI criterias; describe the KDIGO criteria

A

*Idea that this uses ____ x baseline

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4
Q

State some risk factors for developing an AKI

*HINT: think about conditions, drugs etc…

A
  • CKD
  • Previous AKI
  • Heart failure
  • Diabetes
  • Liver disease
  • Older age (>65yrs)
  • Cognitive impairment
  • Nephrotoxic medications e.g. NSAIDs, ACEinhibitors, ARBs, diuretics, aminoglycosides
  • Use of contrast medium e.g. in CT scans
  • Neurological/cognitive impairment leading to decreased fluid intake
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5
Q

State some causes of AKI

*Make sure you classify causes into 3 main categories and explain what is meant by each category

A

Pre-renal: inadequate blood supply to kidneys resulting in reduced filtration rate:

  • Dehydration
  • Hypotension (e.g. shock)
  • Heart failure
  • Renal artery stenosis

Renal: intrinsic renal disease/damage to glomeruli, renal tubules or interstitium resulting in reduced filtration rate:

  • Glomerulonephritis
  • Interstitial nephritis
  • Acute tubular necrosis
  • Tumour lysis syndrome
  • Rhabdomyolysis

Post-renal: obstructon to outflow of urine causing back pressure into kidney and reduced renal function- known as obstructive uropathy:

  • Kidney stones
  • Masses causing external compression of ureters e.g. cancers in abdo, pelvis
  • Ureter or urethral strictures
  • Enlarged prostrate (e.g. BPH or cancer)
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6
Q

What are the symptoms & signs of an AKI- consider what each symptom might suggest about caue of AKI

A
  • Dizziness (suggesting pre-renal AKI)
  • Thirst (suggesting pre-renal AKI)
  • Reduced urine output
  • Lower urinary tract symptoms e.g. hesitancy, urgency, frequency (suggestive of obstructive uropathy)
  • Loin pain
  • Hypotension
  • Pulmonary or peripheral oedema
  • Features of uraemia (pericarditis, encephalopathy)
  • Arrhythmias due to electrolyte imbalances
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7
Q

What investigations would you do if you suspect AKI, include:

  • Bedside
  • Bloods
  • Imaging

NOTE: this list isn’t exhautive, other potential investigations will be discussed on alternative flashcard

A

Bedside

  • Urine dip stick: look for infection and/or inflammation
  • Urinalysis: urine culture to check for infection
  • BMs: check for diabetes
  • Monitor urine output
  • ECG: hyperkalaemia is common complication
  • VBG/ABG: check for acidosis, check lactate if ?sepsis

Bloods

  • FBC: WCC
  • U&E: urea, creatinine, electrolytes
  • LFTs: ?hepatorenal syndrome
  • CRP:infection
  • Blood culture:?sepsis
  • Coagulation: ?conditions with AKI and abnormal clotting e.g. HUS, thrombotic thrombocytopenic purpura
  • CK: ?rhabdomyolysis

Imaging

  • Ultrasound KUB: look for obstruction
  • CXR: to rule out infections e.g. pneuomonia, cardiomegaly of HF
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8
Q

What does leucocytes & nitrates suggest on urine dipstick?

What does protein & blood suggest on urine dipstick?

A
  • Leucocytes & nitrates suggest infection
  • Protein & blood suggest acute nephritis (but could also be infection)
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9
Q

If there is blood & protein on urine dipstick, in pt with suspected AKI, what further investigations would you request?

A

Suggests acute nephritis so look for antibodies:

  • c-ANCA & p-ANCA:​: vascultitis
  • anti-GBM: Goodpasture’s/anti-GBM disease
  • ANA, C3 & C4:b lupus nephritis
  • Serum immunoglobulins & electrophoresis: myeloma
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10
Q

If you suspect post-streptococcal GN as cause of AKI, what further investigation would you do?

A

Anti-streptolysin O Titres

*NOTE: post streptococcal glomerulonephritis often develops about 10-14 days after skin or throat infeciton with group A beta haemolytic Streptococci. It is immune systems response that causes glomerulonephritis- not the bacteria itself

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11
Q

If a pt has an AKI and also has thromboyctopenia what conditions would you consider as cause?

What further investigations would you request?

A

Consider:

  • Haemolytic uraemic syndrome
  • Thrombotic thrombocytopenic purpura
  • Disseminated intravascular coagulopathy

You would need to request haemolysis screen (includes blood film, LDH, bilirubin, reticulocytes, haptoglobin) and call renal SpR urgently

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12
Q

What is haptoglobin?

What is it used to assess?

Intepret low, normal & high results

A
  • Protein that binds to free Hb, that has been released by destroyed RBCs, and transports the haemoglobin back to liver where it can be broken down and products re-used or excreted
  • Used to assess haemolytic anaemia
  • Results need to be interpretted alongside Hb and reticulocytes
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13
Q

When would you consider checking cyroglobulins in a pt with supsected AKI?

A
  • Unexplained rash
  • Peripheral neuropathy
  • Hypocomplementaemia
  • Known hepatitis C
  • +ve RhF
  • History of lymphoproliferative disease
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14
Q

What blood tests must you do daily for someone with an AKI?

A
  • FBC
  • U&E
  • LFTs
  • Bone profile
  • CRP
  • Serum bicarb
  • CK (if rhabodmyolysis suspected)

*UHL policy states do U&Es, bone, venous bicarb daily

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15
Q

Ultrasound of kidneys is only necessary if you think the cause of AKI is obstructive; true or false?

A

True

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16
Q

Discuss how you should approach the management of an AKI

*HINT: not asking for specific management just asking for a general approach

A

1.) Is there a life threatening cause or complication that needs treating urgently?

  • Sepsis?
  • Pulmonary oedema? (needs early referral to renal as may need dialysis)
  • Hyperkalaemia

2.) Try to identify underlying cause and treat it

3.) Stop nephrotoxic medications if possible & consider renal doses of any necessary medications

4.) Refer to specialist for consideration of renal replacemen therapy

5.) Consider ICU

17
Q

Discuss the management of a:

  • Pre-renal
  • Renal
  • Post-renal

… AKI

A

Aspects of management common to all includes fluid balance, management of acidosis and hyperkalaemia.

Pre-renal

  • IV fluids
  • Try to manage condition that is causing decreased perfusion to kidneys e.g. manage heart failure, manage D&V,

Renal

  • Treat underlying cause e.g. immunosupressants for glomerulonephritis

Post-renal

  • Relieve obstruction
  • Catheterise
18
Q

What medications should be stopped in AKI?

A
19
Q

Ensuring adequete fluid status in a pt with AKI can be difficult; discuss the difficulties of managing fluids in AKI

A
  • Pt may look overloaded but may have intravascular depletion (due to third space losses); assess JVP and BP to guide you
  • If overloaded need diuretics but don’t want to compromise BP
  • If need diuretics, often need large dose due to decreased GFR; large doses of diuretics can be nephrotoxic

Idea that it is a fine balancing act

20
Q

State the 4 main complications of an AKI and for each explain how they arise

A
  • Hyperkalaemia: decreased filtration, decreased renal excretion
  • Fluid overload which may manifest as heart failure and pulmonary oedema: decreased filtration, decreased losses
  • Metabolic acidosis: decreased removal of acids from blood, bicarb used up
  • Uraemia: decreased urea excretion
21
Q

State 2 potential consequences of uraemia

A
  • Encephalopathy
  • Pericarditis
22
Q

State some indications for renal replacement therapy

A
  • Hyperkalaemia refractory to medical therapy
  • Metabolic acidosis refractory to medical therapy
  • Fluid overload refractory to diuretics (anuric)
  • Uraemic pericarditis
  • Uraemic encephalopathy
  • Intoxications
23
Q

State some situations in which you would seek advice/review from renal team

A
  • AKI not responding
  • AKI with complications: hyperkalaemia, fluid overload, acidosis
  • AKI with difficult fluid balance e.g. HF, pregnancy
  • AKI with possible intrinsic renal disease
  • AKI with hypertension
24
Q

What are the most common causes of AKI

A

Pre-renal= most common

e.g. Sepsis, cardiogenic shock, other hypovolaemia, hepatorenal syndrome

Yr3 Medicine- Renal (8 decks)

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