Acute Kidney Dz

Question 0

RIFLE (Risk Inj Failure Loss EndStage Renal Dz=ESRD)

Answer 0

Can dx spectrum of kid impairment/injury
Based on changes in serum CREATININE and UO
Severity classes; Risk, Inj, Failure (FIF)
Outcome classes: Loss, ESRD

Question 1

Acute Kidney Injury AKI

Answer 1

Sudden decline in rx , GFR -> to go hospital

• failure ot excrete metabolic waster
• inability to maint fluid and electrolytes balance
• impaired acid-base regulation

Question 2

Dx criteria: AKIN: Acute Kid Inj Network

Answer 2

Modification of RIFLE
Risk category: addition of 0.3 mg or higher increase in serum CREAT
Missed Dx of Inj and Failuer in RIFLE

Question 3

Dx Limitations

Answer 3

Concordance btw serum CREAT and UP not established
Poor correlation betw AKI stage and GFR
Relies on relative changes in serum Creat
Independent of cause of AKI

Question 4

RIFLE

Answer 4

Risk: Incr Cr x1.5 or GFR decrby >25% UO50% UO 75% OR Cr>4.0 (with acute rise of 0.5)
UO 4wk
E: ESRD = end stage renal dz

Question 5

AKIN

Answer 5

stage 1: inc Cr x 1.5 UO < 0.5 x 6 hr
stage 2: inc Cr x 2 UP 4 (with acute rise of .5) UO < .3 x 24 hr or ———————————————————anuria x 12 hr
Stage 3 = dialysis

Question 6

Nonoliguric
Oliguric
Anuric

Answer 6

nonoliguric > 400 mL/24 hr
Oliguric < 400 / 24 hrs
Anuric < 100 / 24 hrs

Question 7

3 sources of injury

Answer 7

Prerenal
Intrarenal
Postrenal

Question 8

Prerenal injury

Answer 8

Inadequate perfusion to kidney:
Vascular deplesion (decreased volume):
---------true: Hemmorhage, GI: V/D, NG tube, pancreatitis; Renal (DKA, Addison's dz (dicr Aldo: decr volume); Cutaneous (burns, sweating)
---------effective: decr. Effective Circulating Volume: normovolemic, hypervolemic; vasoDILATION (sepsis=dilate, cirrhosis causes Ascites, anaphylactic shock decr TPR); decr CO (aortic stenosis); renal vasoCONSTRICTION (renal artery stenosis, FMD=familial muscular dz)

Question 9

NSAIDS and ACE-I/ARB affect which arteriole in the glomerulus

Answer 9

NSAIDS: Afferent arteriole
ACE ARB: Efferent
A doesn’t equal Afferent

Question 10

Intrarenal injury

Answer 10

glomerular
interstitial
vascular
TUBULAR (most)

Question 11

Tubular Intrarenal Injury

Answer 11

1) Ishemic due to HTN, Sepsis = Acute Tubular Necrosis
2) Nephrotoxic due to
- —- meds: aminoglycosides, Amphotericin B, Cisplatin, CONTRAST
- —- CAST nephropathy (pathology in nephrons): Mult Meyloma (rare)
- —- Rhabdomyolysis (often): 92 yo fell, ironman (inc myoglobin)

Question 12

CONTRAST nephropathy

Answer 12

renal TUBULAR epithilial cell toxicity and renal ischemia of medulla

• # 2 cause of acute kid injury in hosp pts
• Risks: age, dehydration, PRE-EXIST RENAL DZ, REPEATED CONTRAST, comorbid DM, CHF

Question 13

prevention of contrast nephropathy

Answer 13

HYDRATION is key
Acetylcysteine - antidote to tylenol
NaHCO3- sodium bicard - still controvercial

Question 14

Postrenal Injury

Answer 14

OBSTRUCTION (most) due to :
retroperitoneal fibrosis
bladder outlet obstruction
stones
tumors (press on ureter, urethra, bladder, kidney)
clots
BPH (older men)
Can have any or all

Question 15

hypotension (decreased vol) would lead to

Answer 15

Acute Tubular necrosis (part of Intrarenal)

Question 16

Increased BUN and Cr may bd due to

Answer 16

Effective Volume depletion (dehydration?) = type of prerenal inj

Question 17

Matastasis can lead to

Answer 17

Obstruction (Postrenal injury)

Question 18

Prerenal vascular (vol) depletion can be 2 types

Answer 18

True: GI, burn, sweating
Effective vol depletion: decr Effect circ vol
vasoDILATION (sepsis, cirrhosis, anaphylactic shock)
decr CO
renal vasoCONSTRICTION (renal artery stenosis, FMD)

Question 19

Acute Interstitial Dz is going to be which: prerenal intra or post

Answer 19

intrarenal

Question 20

primary blood exams performed in AKI

Answer 20

BUN
ELECTROLYTES (high K, high Ca)
CBC with diff: EOSINOPHILS to ro infection (interstitial nephritis)
Phosphorus, high
Uric Acidd (in ppl with gout)

Question 21

2nd blood exams

Answer 21

Albumin, ANA, Anti DS DNA Ab, complement (low bc fighting), ANCA, ANti GMB, antistreptolysin O titler, Hep B and C - bc need to ro if want dialysis

Question 22

UA sediment

Answer 22

Muddy brown CASTS: PATHOGNOMIC OF TUBULAR INJURY
Can get random electrolytes
Eosinophils (in Acute Interstitial Nephritis)

Question 23

Urine prot/urine creat ration < 30 can be done by

Answer 23

24 hr or spot as effective

must be early morning sample

Question 24

FENa Fractional Excretion of Na

Answer 24

3 % suggests intrarenal (ATN acute tubular necrosis)

Question 25

BUN/creat ration is >20.1 and FENa is 3% in | <20.1 and FENa is 1-3 in

Answer 25

PRErenal Intrinsic/intrarenal (Acute tubular necrosis) POSTrenal

Question 26

When to use radiology (CT and MRI)

Answer 26

little value in CR and MRI | CT may be used if retroperitoneas FIBROSIS (WHY?)

Question 27

When can you use gadolinium with GFR

Answer 27

>30

Question 28

Which is the go to scan

Answer 28

CT (do after labs) - no contrast, bed side, non-invasive -> see obstruction right away (necrosis, stone, tumor), infection (pyelonephritis)

Question 29

Biopsy in Acute Kid Dz

Answer 29

Not needed to dx AKI Use if unexplained Chronic Kid Dz, unexp worsening Acute KInj, Nephrotic syndrome, Acute nephritic symdrome. DON"T if: solitary native kid, bellding diathesis (anticoag dz), hydronephrosis, pyelonephritis (bc can spread infection), renal tumor can spread

Question 30

Biopsy is CI in

Answer 30

solitary native kid, bellding diathesis (anticoag dz), hydronephrosis, pyelonephritis (bc can spread infection), renal tumor can spread

Question 31

In captain Ohagan: takes thiazide, hx bladder CA and BCG?, UTI one week ago tx with Bactrim: present to ED with fever, dysuria, BP low, HR high, H/H low, BUN high, Cr 1.9 then 2.2, WBC high, UA: large leukocytes, WBC, TooNumerousToCount (TNTC), few RBC

Answer 31

Dx: sepsis due to UTI but Cr goes up to 2.2 on day 3; First tx with vol resuscitation to improve BP and HRvc hypoThyroid??? Order: Phosphorus, Uric Acid, LDH (hemolytic anemia) WNL (within normal limits) Urinary sediment: muddy brown granular casts = intrinsic/tubular FEna 4% > 3 so intrarenal US neg for pyelonephritis

Question 32

Brown muddy casts are a sign of which type of renal injury

Answer 32

Tubular injury (intrarenal)

Question 33

Which type of renal injury would be corrected with fluid resuscitation

Answer 33

Prerenal

Question 34

Mngt of acute Kid injury

Answer 34

Volume/hydration Avoid nephrotoxins: NSIADS, Lasix decreases K, RENAL DOSING OF ACE Has decreased albumin so feed then If uremia - kid failure and dialysis or kid replacement

Question 35

Meds concerns

Answer 35

``` Vancomycin Getamycin (aminoglycoside?), ACE i, K+ supplements (want to decrease K?) OTC NSAIDS, supplements (DVT prophylaxic meds have to be renally dosed) ```

Question 36

Meds that cause false + rise in Cr?

Answer 36

Trimethoprim (Bactrim) | Cefoitin (pepsid)

Question 37

Nutrition

Answer 37

``` Protein restriction is controversial bc AKI have protein deficit RESTRICT FLUID (could have fluid overload bc of kid dysfx) LOW K (due to vomiting and diahrrehia?) ```

Question 38

Complication mngt

Answer 38

-volume depletion -volume overload -Electrolytes: HYPERK+ is number 1, most impt HYPOCa and Hyperphosphate -metabolic acidosis -uremia leads to bleeding disorders

Question 39

When to tx HyperK

Answer 39

- makes BP go up - peaked T waved - tx based on clin presentation/findings - EKG finding determine urgency (get baseline EKG)

Question 40

3 principles of HyperK mngt

Answer 40

-stabilize cardio if EKG changes (for ppl with K >5.5): IV Calcium fast (shot) or Ca Gluconate if can wait -Chasers: Drive extracellular K into cells with insuline and sugar D50W, Beta 2 Agonist (albuterol), NaHCO3- sod bicard (controversial) -Remove excess K with diuretics - Lasix if produce urine, Cation exchange resins (KYEXALATE (bind to K and poop out)), dialysis

Question 41

If Hyper K >5.5 and peaked T wave

Answer 41

actively tx, | if flat P wave, then what ?

Question 42

K uptake by cells is increased by

Answer 42

Beta 2 agonists - albuterol insulin plus sugar d50W poss sod bicarb

Question 43

Kayexalate does what?

Answer 43

cation exchange resin - binds K and poop out

Question 44

Albuterol, beta 2 agonist does what?

Answer 44

moves K into cells to tx HyperK

Question 45

Incidations for Dialysis | AEIOU

Answer 45

Acid-base disturbance (met acidosis) Electrolyte abnormalities (HyperK with EKG changes) Ingested toxins Overload (fluid) refractory to diuretics (common)- bc not responding Uremia (not just BUN) : with AMS (altered mental status), Seizures, Pericarditis

Question 46

Most likely cause of death in AKI

Answer 46

INFECTION is 1 2. Cardiovascular events 3. GI, pulm, neuro complication 4. HyperK or dialysis related