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Module 17 > Approach to Azotemia & Acute Kidney Injury SA > Flashcards

Approach to Azotemia & Acute Kidney Injury SA Flashcards

1
Q

what are the functions of the kidneys (6)

A
  1. filtration of blood and excretion of metabolic waste
  2. acid-base balance
  3. water/volume regulation
  4. electrolyte & mineral homeostasis
  5. blood pressure regulation
  6. erythropoitin release
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2
Q

what are the presentations of kidney disease (8)

A
  1. PUPD
  2. inappetance/weight loss
  3. depression
  4. GI signs: vomiting/nausea/diarrhea
  5. ascites/subcutaneous edema
  6. hematuria
  7. pain
  8. abdominal mass
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3
Q

what is azotemia

A

abnormal increase in the concentration of non-protein nitrogenous wastes in blood

increased urea and creatinine

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4
Q

what does azotemia suggest and what does it not equal

A

suggests failure of filtration and excretion of metabolic waste but doesn’t equal kidney disease

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5
Q

what are serum urea levels affected by (8)

A
  1. species
  2. age
  3. liver function
  4. dietary protein content (including GI bleeding)
  5. endogenous protein catabolism
  6. hydration
  7. renal function
  8. LUT function
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6
Q

what does serum creatinine decrease with

A
  1. reduced muscle mass
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7
Q

what does serum creatinine increase with (2)

A
  1. reduced renal clearance
  2. urine excretion failure (ex. urinary tract rupture)
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8
Q

what is glomerular filtration rate

A

flow rate of filtered fluid through the kidneys

defines the excretory function of the kidneys

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9
Q

what reduces GFR (3)

A
  1. decreased renal perfusion
  2. decreased renal function (ex. fewer nephrons)
  3. obstruction of urine flow
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10
Q

why is urea not ideal for assessing renal excretory function (GFR)

A

affected by many other factors (variable rate of synthesis)

although freely filtered it is reabsorbed in the tubules and collecting ducts at variable rate

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11
Q

why is creatinine better at measuring GFR

A

produced at constat rate

freely filtered with no reabsorption

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12
Q

what are the limitations of using creatinine as a measure of GFR (3)

A
  1. azotemia doesn’t develop until GFR has decreased to 25%
  2. relationship between creatinine & GFR is not linear and the change in serum creatinine must be considered in the light of the starting value
  3. doesn’t tell you why GFR has fallen
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13
Q

what does creatinine not discriminate between (4)

A
  1. cause of azotemia (not specific)
  2. acute kidney or chronic kidney disease
  3. reversible or irreversible renal failure
  4. causes of renal failure
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14
Q

what is SDMA

A

symmetric dimethylarginine

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15
Q

where does SDMA come from and where is it excreted

A

from protein degradation

renally excreted

marker of GFR

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16
Q

what are the clinical signs of azotemia

A

azotemia is a biochemical change

not all azotemic patients have clinical signs

severity of clinical signs not directly proportional to magnitude of increase

rate of accumulation has an effect on severity of signs

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17
Q

what are the clinical signs of uremia (6)

A

constellation of adverse clinical effects that develops as a consequence of severe renal excretory failure

severity of signs depends on magnitude of excretory failure and rate of deterioration

  1. inappetance
  2. depression
  3. vomiting/nausea
  4. halitosis
  5. oral ulceration/stomatitis
  6. diarrhea
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18
Q

are all uremic patients azotemic

A

yes

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19
Q

are all azotemic patients uremic

A

no

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20
Q

what are the causes of azotemia (3)

A
  1. pre renal: inadequate renal perfusion
  2. renal: intrinsic renal failure
  3. post renal: post-renal obstruction or rupture of urinary tract
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21
Q

what are pre renal azotemia causes (3)

A
  1. hypovolemia
  2. hypotension
  3. aortic/renal thromboembolism
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22
Q

what are renal causes of azotemia (2)

A
  1. nephron damage
  2. nephron loss
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23
Q

what are post-renal causes of azotemia (3)

A
  1. ureterolith
  2. urethrolith
  3. bladder rupture
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24
Q

how do you differentiate the causes of azotemia

A
  1. history
  2. clinical exam
  3. urinalysis

cannot use magnitude of azotemia to determine its cause

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25
Q

if the patient is not drinking and azotemic what type of azotemia is it likely

A

pre-renal

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26
Q

if the patient is experiencing increased losses and azotemic what type of azotemia is it likely

A

pre-renal

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27
Q

if the patient is dysuric and stranguria and is azotemic what type of azotemia is it likely

A

post-renal

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28
Q

what could be the reasons of failure to pass urine (2)

A
  1. not producing urine (renal)
  2. can’t pass urine (post-renal)
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29
Q

if there is evidence of dehydration on clinical exam what would the cause of azotemia be

A

pre-renal +/- renal +/- post-renal

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30
Q

if there is a grossly enlarged bladder on clinical exam what would the cause of azotemia be

A

post-renal

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31
Q

if there is localized subcutaneous fluid around perineum or ventral abdomen on clinical exam what would the cause of azotemia be

A

post-renal

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32
Q

if there is free peritoneal fluid (urine) on clinical exam what would the cause of azotemia be

A

post-renal

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33
Q

if there is difficult/impossible to pass urinary catheter on clinical exam what would the cause of azotemia be

A

post-renal

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34
Q

if there is active sediment with tubular casts on urinalysis what type of azotemia

A

renal

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35
Q

if there is hematuria on urinalysis what type of azotemia

A

renal or post renal

36
Q

if the USG is hypersthenuric what type of azotemia would this be

A

pre-renal

37
Q

if the patient has been healthly until recently would the renal azotemia be acute or chronic

A

acute

38
Q

if the patient has had months of PUPD would the renal azotemia be acute or chronic

A

chronic

39
Q

would acute or chronic renal azotemia patient have a history of occasional vomiting

A

chronic

40
Q

if the patient is experiencing anuria/oliguria and maybe polyuric is this a acute or chronic renal azotemia

A

acute

41
Q

if the patient has a history of weight loss is it likely acute or chronic renal azotemia

A

chronic

42
Q

on clinical exam what would the size of the kidneys be in acute renal azotemia

A

kidneys normal sized or large

may be painful

43
Q

on clinical exam what would the size of the kidneys be in chronic renal azotemia

A

kidneys usually small and non-painful

44
Q

what is the appearance of mucus membranes in acute renal azotemia

A

pink

45
Q

what is the appearance of mucus membranes in chronic renal azotemia

A

may be pale

46
Q

what would the coat condition in acute renal azotemia

A

good coat condition

47
Q

what would the coat condition in chronic renal azotemia

A

poor coat

48
Q

what would the body condition score of acute renal azotemia

A

normal body condition score

49
Q

what would the body condition score of chronic renal azotemia

A

poor body condition score

50
Q

would anemia be present in acute renal azotemia

A

not usually present

51
Q

would there be anemia in chronic renal azotemia

A

non-regenerative anemia usually

52
Q

what would the urine sediment be with acute renal azotemia

A

often contains cells, casts, debris

53
Q

what would the urine sediment be in chronic renal azotemia

A

usually negative

54
Q

would there be hyperkalemia in acute or chronic renal azotemia

A

in acute

55
Q

would there be metabolic acidosis in acute or chronic renal azotemia

A

acute

56
Q

what is the definition of renal disease

A

damage or functional impairement of kidneys

varying severity

57
Q

what is the definition of renal insufficiency

A

functional impairment not severe enough to cause azotemia, but sufficient to cause loss of renal reserve

58
Q

what is the definition of renal failure

A

functional imparment severe enough to cause azotemia

urine concnetrating ability usually impaired

59
Q

what is the definition of acute kidney injury

A

sudden, often reversible reduction of the elimination and metabolic functions of the kidneys

60
Q

what is the risk to the kidneys in acute kidney injury (4)

A
  1. huge blood flow
  2. roxins may be secreted/reabsorbed by tubular cells
  3. potential concentrating effects of toxins in urine
  4. play a role in biotransformation of drugs/toxins
61
Q

what are reduced renal perfusion causes of reduced renal perfusion (5)

A
  1. dehydration
  2. hypovolemia
  3. decreased cardiac output
  4. hypotension
  5. shock
62
Q

what are infectious causes of acute kidney disease (2)

A
  1. leptospirosis
  2. borreliosis (lyme disease)
63
Q

what are nephrotoxic drugs that can cause acute kidney disease (4)

A
  1. NSAIDs
  2. aminoglycosides
  3. doxorubicin (cats)
  4. cisplatin
64
Q

what are toxins that can cause acute kidney injury (3)

A
  1. lilies (cats)
  2. grapes/raisins (dogs)
  3. ethylene glycol
65
Q

what is the intiiation phase of acute kidney injury

A

something damages part of some of the nephrons leading to dysfunction

66
Q

what is the extension phase of acute kidney injury

A

ischemia, hypoxia, inflammation and cellular injury result in cell death and further nephron damage

clinical and laboratory abnormalities develop

67
Q

what is the recovery phase of acute kidney injury

A

gradually reversible renal lesions are repaired and viable nephrons hypertrophy

68
Q

what would the early presenting signs of acute kidney injury be

A

acute onset of signs of uremia

inappetance, depression, vomiting/nausea, halitosis, diarrhea

69
Q

what should you pay particular attention to during the clinical exam of a suspected acute kidney injury patient (4)

A
  1. hydraiton & volume status: often dehydrated
  2. oral examination: may have uremic ulcers, halitosis
  3. renal palpation: usually normal to large, may be painful
  4. bladder size and shape: urine production
70
Q

how would you diagnose acute kidney injury (4)

A
  1. identify azotemia
  2. reule out post-renal causes (history & clinical exam)
  3. identify reduced urine concentrating ability (urinalysis)
  4. differentiate acute from chronic kidney disease (history, clinical exam, lab findings, affects treatment and short and long term prognosis)
71
Q

what would the potassium values be in acute kidney injury

A

initially hyperkalemic

72
Q

what would the phosphate values be in acute kidney injury

A

initially normal, become hyperphosphatemic

73
Q

what would the calcium values be in acute kidney injury

A

may be high, low or normal

if markedly increased consider hypercalcemia as cause

74
Q

what would the PCV & TP values be in acute kidney injury

A

may be increased due to dehydration

75
Q

what can acute kidney injury appear as

A

hypoadrenocorticism (Addison’s disease)

often patients will have

azotemia (pre-renal)

hyperkalemia

minimally concentrated urine

76
Q

what additional observations are important during the clinical exam of acute kidney injury (5)

A
  1. urine output
  2. ocular exam (evidence of hypertensive retinopathy)
  3. blood pressure measurement
  4. rectal exam (neoplasia)
  5. peripheral lymph node palpation (neoplasia)
77
Q

what is oliguria

A

<0.25 ml/kg/hr

78
Q

what is polyuria

A

>2ml/kg/hr

79
Q

what is normal urine output

A

1-2ml/kg/hr

80
Q

what should you assess on renal ultrasound (4) when diagnosing acute renal injury

A
  1. renal size
  2. renal architecture
  3. size of renal pelvis
  4. renal blood flow
81
Q

what should you assess on abdominal radiography when diagnosing acute kidney injury (3)

A
  1. renal size
  2. renal mineralization
  3. ureteroliths
82
Q

what are the general principles of treating acute kidney injury (6)

A
  1. remove inciting cause
  2. restore renal perfusion
  3. monitor urine output & consider drugs to increase urine output (only if necessary)
  4. monitor electrolytes, acid-base balance, hydration status q6-8h or more and treat as necessary
  5. treat uremic complications and provide nutrition
  6. investigate underlying causes
83
Q

what fluid therapy would be used for acute renal injury

A

replace fluid deficits quickly (4-6hr)

0.9% saline usually

84
Q

what is the purpose of treating acute renal injruy with fluids

A

to try and remove pre-renal component

protect against further ischemic damage

85
Q

how do you increase urine output if patient is anuric

A

try mild volume expansion if no signs of overhydration (3-5% of patient’s body weight)

consider diuretic administration (frusemide or mannitol) –> don’t use until dehydration is corrected

86
Q

what is the mortality rate of kidney injury for cats and dogs

A

dogs 53%

cats 45%

depends on the cause

87
Q

what are potential risk factors of kidney disease (9)

A
  1. pre-existing renal disease
  2. dehydration
  3. sepsis
  4. hypotension
  5. decreased cardiac output
  6. trauma
  7. advanced age
  8. hypoalbuminemia
  9. use of potentially nephrotoxic drugs

Module 17 (31 decks)

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