Acute Kidney Injury

Question 1

Acute kidney injury (AKI) is generally defined as a sudden decline in renal function over … or …

Answer 1

Acute kidney injury (AKI) is generally defined as a sudden decline in renal function over hours or days.

Question 2

AKI is a common medical condition affecting up to 15% of emergency hospital admissions and the mortality associated with severe AKI can be up to 30-40%. A decline in renal function can lead to dysregulation of … balance, …-… homeostasis and e….

Answer 2

AKI is a common medical condition affecting up to 15% of emergency hospital admissions and the mortality associated with severe AKI can be up to 30-40%. A decline in renal function can lead to dysregulation of fluid balance, acid-base homeostasis and electrolytes.

Question 3

AKI may be classified by a number of systems including RIFLE and K….

Answer 3

AKI may be classified by a number of systems including RIFLE and KDIGO.

Question 4

Based on the KDIGO criteria, an AKI is defined by one of the following parameters:

Answer 4

An increase in serum creatinine by ≥ 26.5 micromol/L within 48 hours
An increase in serum creatinine to ≥ 1.5 times baseline within 7 days
Urine output < 0.5 mL/kg/hr for six hours

Question 5

The KDIGO criteria divide AKI into … stages.

Answer 5

Question 6

The aetiology of AKI can be categorised - what are these?

Answer 6

The aetiology of AKI can be categorised into pre-renal, intrinsic renal and post-renal causes.

Question 7

AKI is most commonly …-renal in nature, typically occuring secondary to renal hypoperfusion.

Answer 7

AKI is most commonly pre-renal in nature, typically occuring secondary to renal hypoperfusion.

Question 8

AKI is most commonly pre-renal in nature, typically occuring secondary to renal ….

Answer 8

AKI is most commonly pre-renal in nature, typically occuring secondary to renal hypoperfusion.

Question 9

Decreased renal … can be related to reduced circulating volume (e.g. hypovolaemia), reduced cardiac output (e.g. cardiac failure), systemic vasodilatation (e.g. sepsis) or arteriolar changes (e.g. secondary to ACE-inhibitor or NSAID use).

Answer 9

Decreased renal perfusion can be related to reduced circulating volume (e.g. hypovolaemia), reduced cardiac output (e.g. cardiac failure), systemic vasodilatation (e.g. sepsis) or arteriolar changes (e.g. secondary to ACE-inhibitor or NSAID use).

Question 10

Renal hypoperfusion causes …. of the renal parenchyma. Prolonged ischaemia can lead to intrinsic damage and the development of acute tubular necrosis (ATN). ATN is the most common cause of intrinsic renal AKI.

Answer 10

Renal hypoperfusion causes ischaemia of the renal parenchyma. Prolonged ischaemia can lead to intrinsic damage and the development of acute tubular necrosis (ATN). ATN is the most common cause of intrinsic renal AKI.

Question 11

Acute tubular necrosis (ATN) is the most common cause of … renal AKI.

Answer 11

acute tubular necrosis (ATN). ATN is the most common cause of intrinsic renal AKI.

Question 12

The hallmark of intrinsic renal AKI is structural damage. It may be categorised according to the location of the pathology:

Answer 12

The hallmark of intrinsic renal AKI is structural damage. It may be categorised according to the location of the pathology:

Vasculature
Glomerular
Tubulointerstitial

Question 13

Intrinsic renal AKI - vascular

Answer 13

Large vessels are typically affected by atherosclerotic disease, thromboembolic disease and dissections (e.g. aortic). Other important causes include renal artery abnormalities such as renal artery stenosis and renal artery thrombosis.

Small vessel disease can occur secondary to vasculitides (these typically lead to the development of glomerular disease), thromboembolic disease, microangiopathic haemolytic anaemias (e.g. disseminated intravascular coagulation) and malignant hypertension.

Question 14

Intrinsic renal AKI - glomerular

Answer 14

Glomerular pathology can be divided into primary (not associated with systemic disease) and secondary (associated with systemic disease) causes. Glomerular pathology can lead to a number of classical acute presentations (e.g. nephritic/nephrotic syndrome). They are also a major cause of chronic kidney disease (CKD).

Question 15

Intrinsic renal AKI - tubulointerstitial

Answer 15

Tubulointerstitial pathology causes damage to the renal parenchyma that can lead to scarring and fibrosis in the long-term. The most common tubulointerstitial cause of AKI is ATN, this frequently occurs secondary to prolonged renal hypoperfusion. Other tubulointerstitial causes include acute interstitial nephritis that can occur secondary to medications (e.g. NSAIDs, PPI’s, penicillins) and infections.

Question 16

Tubulointerstitial pathology causes damage to the renal parenchyma that can lead to scarring and fibrosis in the long-term. The most common tubulointerstitial cause of AKI is …, this frequently occurs secondary to prolonged renal hypoperfusion. Other tubulointerstitial causes include acute interstitial nephritis that can occur secondary to medications (e.g. NSAIDs, PPI’s, penicillins) and infections.

Answer 16

Tubulointerstitial pathology causes damage to the renal parenchyma that can lead to scarring and fibrosis in the long-term. The most common tubulointerstitial cause of AKI is ATN, this frequently occurs secondary to prolonged renal hypoperfusion. Other tubulointerstitial causes include acute interstitial nephritis that can occur secondary to medications (e.g. NSAIDs, PPI’s, penicillins) and infections.

Question 17

AKI secondary to post-renal causes result from … (often referred to as … …) and accounts for up to 10% of cases.

Answer 17

AKI secondary to post-renal causes result from obstruction (often referred to as obstructive uropathy) and accounts for up to 10% of cases.

Question 18

Obstruction to urinary flow can occur anywhere along the urinary tract from renal pelvis to urethra. Common causes of obstructive uropathy include … (3)

Answer 18

Obstruction to urinary flow can occur anywhere along the urinary tract from renal pelvis to urethra. Common causes of obstructive uropathy include urinary stones (urolithiasis), malignancy (inc. intraluminal, intramural and extramural tumours), strictures and bladder neck obstruction (e.g. benign prostatic hyperplasia).

Question 19

There are a number of risk factors that increase the likelihood of developing an AKI during hospital admission. - what are they? (10)

Answer 19

Age (> 65 years old)
History of AKI
CKD
Urological history (e.g. stones)
Cardiac failure
Diabetes mellitus
Sepsis
Hypovolaemia
Nephrotoxic drug use
Contrast agents

Question 20

These are the main risk factors for developing what?

Answer 20

AKI

Question 21

ATN can be divided into three stages:

Answer 21

Initiation: acute decrease in renal perfusion causing a reduced GFR
Maintenance: GFR remains low for days or weeks
Recovery: GFR recovers, regeneration of tubulointerstitial cells, polyuric phase may occur

Question 22

Acute tubular necrosis (ATN) has many causes, most of which can be thought as ‘…’ or ‘….’ in nature. … causes are those of pre-renal AKI described above. … causes include medications (aminoglycosides, chemotherapies), contrast, myoglobin (in rhabdomyolysis) and multiple myeloma.

Answer 22

Acute tubular necrosis (ATN) has many causes, most of which can be thought as ‘ischaemic’ or ‘nephrotoxic’ in nature. Ischaemic causes are those of pre-renal AKI described above. Nephrotoxic causes include medications (aminoglycosides, chemotherapies), contrast, myoglobin (in rhabdomyolysis) and multiple myeloma.

Question 23

An accurate fluid balance assessment is key in what?

Answer 23

An accurate fluid balance assessment is key. The patient’s fluid balance is suggestive of the underlying aetiology of AKI and may guide subsequent management.

Question 24

What is this representing?

Answer 24

Fluid balance - dehydration vs overload

Question 25

Pre-renal - AKI signs and symptoms (7)

Answer 25

``` Reduced capillary refill time Dry mucous membranes Reduced skin turgor Thirst Dizziness Reduced urine output Orthostatic hypotension ```

Question 26

How do we assess for fluid overload? (I.e what do we look for?) - 6

Answer 26

``` Ankle swelling Orthopnoea Paroxysmal nocturnal dyspnoea Dyspnoea Raised JVP Ascites ```

Question 27

``` Ankle swelling Orthopnoea Paroxysmal nocturnal dyspnoea Dyspnoea Raised JVP Ascites ``` All signs of what?

Answer 27

Fluid overload

Question 28

In patients with renal hypoperfusion in the context of hypervolaemia (e.g. cardiac failure), it is important to assess for …. ….

Answer 28

Fluid overload

Question 29

Those with intrinsic glomerular pathology may present with features of … syndrome (e.g. haematuria, proteinuria, oliguria and hypertension) or … syndrome (e.g. heavy proteinuria, hypoalbuminaemia and oedema).

Answer 29

Those with intrinsic glomerular pathology may present with features of nephritic syndrome (e.g. haematuria, proteinuria, oliguria and hypertension) or nephrotic syndrome (e.g. heavy proteinuria, hypoalbuminaemia and oedema).

Question 30

Patients with a … disease (e.g. acute interstitial nephritis) may complain of arthralgia, rashes and fever. Eosinophilia is frequently seen.

Answer 30

Patients with a tubulointerstitial disease (e.g. acute interstitial nephritis) may complain of arthralgia, rashes and fever. Eosinophilia is frequently seen.

Question 31

Patients with urinary … may present with classical loin-to-groin pain, haematuria, nausea and vomiting. Those with … problems may have lower urinary tract symptoms (e.g. dysuria, frequency, terminal dribbling, hesitancy). Obstruction at the … … might be associated with a palpable bladder and a tender suprapubic area.

Answer 31

Patients with urinary stones may present with classical loin-to-groin pain, haematuria, nausea and vomiting. Those with prostatic problems may have lower urinary tract symptoms (e.g. dysuria, frequency, terminal dribbling, hesitancy). Obstruction at the bladder neck might be associated with a palpable bladder and a tender suprapubic area.

Question 32

Basic assessment - AKI

Answer 32

Assess the current fluid status of the patient, looking for signs of hypo- or hypervolaemia including checking their urine output. Review their medical chart looking for any potential nephrotoxic drugs and their fluid status over the last few days (e.g. have they had a positive or negative fluid balance).

Question 33

Bedside investigations for AKI:

Answer 33

Urine dipstick Urine microscopy Urine osmolality and electrolytes ECG

Question 34

Bloods for AKI:

Answer 34

Basic blood tests should include an FBC, U&Es, bone profile and blood gas (venous/arterial). This allows a quick assessment of the extent of renal injury and the development of any potential complications like hyperkalaemia or metabolic acidosis. Other bloods can be completed depending on the suspected cause of AKI. Many of these look for intrinsic renal causes of AKI. ``` Creatine kinase Vasculitis screen (e.g. ANCA, ANA) Clotting Blood film Complement Immunoglobulins Serum electrophoresis Virology (hepatitis B/C) ```

Question 35

What is the key radiological investigation in the assessment of AKI?

Answer 35

The key radiological investigation in the assessment of AKI is ultrasound, which can look for evidence of obstructive uropathy (e.g. hydronephrosis). If there is a high degree of suspicion of urinary stones, a non-contrast CT may be completed.

Question 36

Other radiological investigations may include for AKI: (apart from ultrasound)

Answer 36

CXR (eg. looking for signs of overload) Renal dopplers (renal vascular assessment) Magnetic resonance angiography (renal vascular assessment)

Question 37

The management of an AKI should involve regular assessment and monitoring, controlling volume … and correcting … abnormalities and metabolic ….

Answer 37

The management of an AKI should involve regular assessment and monitoring, controlling volume dysregulation and correcting electrolyte abnormalities and metabolic acidosis.

Question 38

Patients with AKI can be staged according to the KDIGO criteria. It is suggested that patients who have stage … AKI or a suspected diagnosis that may require specialist intervention (e.g. glomerulonephritis, systemic vasculitis), be discussed with a nephrologist within 48 hours of detection. Patients with post-renal AKI may require discussion with a ...

Answer 38

Patients can be staged according to the KDIGO criteria. It is suggested that patients who have stage 3 AKI or a suspected diagnosis that may require specialist intervention (e.g. glomerulonephritis, systemic vasculitis), be discussed with a nephrologist within 48 hours of detection. Patients with post-renal AKI may require discussion with a urologist.

Question 39

In AKI, a regular assessment of the patients' fluid status should be completed including monitoring their urine output, which may require a … … and daily ….

Answer 39

Regular assessment of the patients' fluid status should be completed including monitoring their urine output, which may require a urinary catheter and daily weights.

Question 40

Regular assessment and monitoring of AKI: A baseline … should be recorded and serial … taken daily, increased to twice daily in more severe cases.

Answer 40

A baseline creatinine should be recorded and serial U&Es taken daily, increased to twice daily in more severe cases.

Question 41

What drugs should be stopped in an AKI?

Answer 41

Nephrotoxic drugs should be stopped (e.g. ACEi, NSAIDs, spironolactone) and regular prescriptions should be altered to reflect the change in creatinine clearance.

Question 42

Volume dysregulation in AKI - what do we do in a hypovolaemic patient?

Answer 42

If patients are hypovolaemic then intravenous fluids should be prescribed. The amount and type of fluids will depend on the clinical status of the patient.

Question 43

Volume dysregulation in AKI - what do we do in hypervolaemic patient?

Answer 43

If the patient is hypervolaemic they may require fluid restriction +/- the use of diuretics. Diuretics (e.g. furosemide) should be used carefully in renal impairment as they can be nephrotoxic.

Question 44

Severe hyperkalaemia, variably defined as >…. mmol/L, is a medical emergency.

Answer 44

Severe hyperkalaemia, variably defined as >6.5 or 7 mmol/L, is a medical emergency.

Question 45

The management of hyperkalaemia is critical to avoid potential life-threatening arrhythmias. It involves:

Answer 45

Protection of the myocardium: 10ml of 10% calcium gluconate. Reduce extracellular potassium: aim is to drive potassium into the intracellular compartment. Insulin (e.g 10 units ACTRAPID in 100ml 20% dextrose) and beta agonists (e.g. 2.5mg nebulised salbutamol) are given. Additional: stop or adjust potassium-sparing or potassium-containing medications. Resins can reduce potassium absorption but these take hours/days to have effect.

Question 46

Other electrolyte problems (apart from hyperkalaemia) in AKI include hypo… and hyper...

Answer 46

Other electrolyte problems (apart from hyperkalaemia) in AKI include hypocalcaemia and hyperphosphataemia.

Question 47

The handling of acid-base is impaired in the setting of AKI due to a … in the GFR. This can results in a metabolic acidosis. Depending on the severity of acidosis and associated clinical state, choices for management involve the use of sodium bicarbonate or dialysis.

Answer 47

The handling of acid-base is impaired in the setting of AKI due to a reduction in the GFR. This can results in a metabolic acidosis. Depending on the severity of acidosis and associated clinical state, choices for management involve the use of sodium bicarbonate or dialysis.

Question 48

The handling of acid-base is impaired in the setting of AKI due to a reduction in the GFR. This can results in a … …. Depending on the severity of … and associated clinical state, choices for management involve the use of sodium bicarbonate or dialysis.

Answer 48

The handling of acid-base is impaired in the setting of AKI due to a reduction in the GFR. This can results in a metabolic acidosis. Depending on the severity of acidosis and associated clinical state, choices for management involve the use of sodium bicarbonate or dialysis.

Question 49

What is most common acid-base disturbance associated with acute kidney injury?

Answer 49

Metabolic acidosis is the most common acid-base disturbance associated with acute kidney injury, developing as the result of impaired excretion of the daily load of metabolic fixed acid.

Question 50

Complications of AKI (4)

Answer 50

The major complications that can occur in association with AKI include hyperkalaemia, fluid overload, metabolic acidosis and uraemia.

Question 51

The development of uraemic complications in AKI (e.g. encephalopathy, pericarditis), hyperkalaemia, fluid overload or metabolic acidosis that are refractory to medical therapy warrant urgent ….

Answer 51

The development of uraemic complications (e.g. encephalopathy, pericarditis), hyperkalaemia, fluid overload or metabolic acidosis that are refractory to medical therapy warrant urgent dialysis.

Question 52

RENAL DRS 26 - A useful mnemonic for assessment and management of any patient presenting with an acute kidney injury.

Answer 52

Question 53

Pre-renal causes of AKI

Answer 53

Reduced circulating volume (e.g. hypovolaemia). Reduced cardiac output (e.g. cardiac failure). Systemic vasodilatation (e.g. septic shock). Drugs altering glomerular haemodynamics (e.g. ACE-i / NSAIDs).

Question 54

By what mechanism do NSAIDs adversely affect renal function? Potentiation of anti-diuretic hormone (ADH) Prevents prostaglandin mediated vasodilation of the afferent arteriole and decreased renal perfusion pressure Prevents prostaglandin mediated vasodilation of the efferent arteriole and decreased renal perfusion pressure Increased expression of Na+/K+/2Cl- co-transporter channels in the ascending loop of Henle Direct glomerular injury

Answer 54

Prevents prostaglandin mediated vasodilation of the afferent arteriole and decreased renal perfusion pressure

Question 55

NSAIDs result in unopposed constriction of the afferent arteriole and decreased renal perfusion pressure through the inhibition of … synthesis.

Answer 55

NSAIDs result in unopposed constriction of the afferent arteriole and decreased renal perfusion pressure through the inhibition of prostaglandin synthesis.

Question 56

Non-steroidal anti-inflammatory drugs, NSAIDs (e.g. ibuprofen, naproxen) adversely affect renal blood flow and have direct effects on the renal tubules, promoting natriuresis. NSAIDs impair prostaglandin synthesis by inhibition of …-… and …-…

Answer 56

Non-steroidal anti-inflammatory drugs, NSAIDs (e.g. ibuprofen, naproxen) adversely affect renal blood flow and have direct effects on the renal tubules, promoting natriuresis. NSAIDs impair prostaglandin synthesis by inhibition of COX-1 and COX-2.

Question 57

Importantly, renal prostaglandins cause … in the kidneys. Under normal conditions, they are not important in the regulation of renal perfusion. However, in renal hypoperfusion, the synthesis of prostaglandins is increased to help prevent ischaemia secondary to ….

Answer 57

Importantly, renal prostaglandins cause vasodilatation in the kidneys. Under normal conditions, they are not important in the regulation of renal perfusion. However, in renal hypoperfusion, the synthesis of prostaglandins is increased to help prevent ischaemia secondary to vasoconstriction.

Question 58

Prostaglandins help maintain renal blood flow through a variety of mechanisms: (3)

Answer 58

Results in vasodilation of the afferent arteriole and increased renal perfusion pressure. Decreases expression of Na+/K+/2Cl- co-transporter channels in the ascending loop of Henle, leading to salt and water retention. Impairs antagonism of anti-diuretic hormone (ADH).

Question 59

Results in vasodilation of the afferent arteriole and increased renal perfusion pressure. Decreases expression of Na+/K+/2Cl- co-transporter channels in the ascending loop of Henle, leading to salt and water retention. Impairs antagonism of anti-diuretic hormone (ADH). How are these mechanisms maintained?

Answer 59

Prostaglandins help maintain renal blood flow through a variety of mechanisms

Question 60

``` Oliguria is defined as which of the following? Urine output < 70 mls / hr Urine output < 35 mls / hr Urine output < 1.0 mls / kg / hr Urine output < 0.5 mls / kg / hr Urine output < 0.1 mls / kg / hr ```

Answer 60

Oliguria is defined as urine output < 0.5 mls / kg / hr.

Question 61

In a typical 70 kg patient, this means a urinary output < … mls / hour is considered oliguria. Due to interpatient variability, it is more appropriate to diagnose oliguria based on mls / kg / hr rather than exact amounts.

Answer 61

In a typical 70 kg patient, this means a urinary output < 35 mls / hour is considered oliguria. Due to interpatient variability, it is more appropriate to diagnose oliguria based on mls / kg / hr rather than exact amounts.

Question 62

Based on the KDIGO classification, if a urinary output < 0.5 mls / kg / hr continues for > … hours, it is consistent with a diagnosis of acute kidney injury.

Answer 62

Based on the KDIGO classification, if a urinary output < 0.5 mls / kg / hr continues for > 6 hours, it is consistent with a diagnosis of acute kidney injury.

Question 63

Based on the KDIGO classification, if a urinary output < ….mls / kg / hr continues for > 6 hours, it is consistent with a diagnosis of acute kidney injury.

Answer 63

Based on the KDIGO classification, if a urinary output < 0.5 mls / kg / hr continues for > 6 hours, it is consistent with a diagnosis of acute kidney injury.

Question 64

According to the KDIGO criteria, which of the following does not meet the requirements for an acute kidney injury (AKI)? An increase in serum creatinine by ≥ 26.5 micromol / L within 48 hours An increase in serum creatinine by ≥ 1.5 times within 7 days Urine output < 1.0 ml / kg / hour for 12 hours Urine output < 0.5 ml / kg / hour for 6 hours Patient requiring renal replacement therapy (RRT)

Answer 64

Urine output < 1.0 ml / kg / hour for 12 hours (correct answer)

Question 65

You see an 83-year-old male who is 5 days post-surgery for a traumatic neck of femur fracture. His catheter was removed yesterday as he was mobilising. He has since developed a painfully distended abdomen and the nurse reports that he has not passed urine. ``` What is the most appropriate next course of action? A Clinical examination B Bladder scan C Abdominal X-ray D Emergency dialysis E Urinary catheter ```

Answer 65

A - clinical exam This patient has developed acute urinary retention post a failed ‘trial without catheter’ (TWOC). A patient complaining of acute abdominal pain requires a clinical assessment with an ABC approach if appropriate followed by a history and clinical examination. In this scenario, it is likely the patient has developed urinary retention and will need placement of a urinary catheter. A bladder scan (US) is a useful bedside test that allows you to estimate the volume of urine in the bladder.

Question 66

Approximately, what is the percentage reduction in glomerular filtration rate (GFR) required for creatinine to begin to rise?

Answer 66

50% A greater than 50% reduction in GFR is needed before creatinine begins to rise.

Question 67

A greater than …% reduction in GFR is needed before creatinine begins to rise.

Answer 67

A greater than 50% reduction in GFR is needed before creatinine begins to rise.

Question 68

An 84-year-old woman is being treated for a simple urinary tract infection (UTI). Her latest blood results come back from the lab. Sodium: 143 (135-145) Potassium: 6.8 (3.3-5.5) Creatinine: 210 (< 90) Urea: 10.6 (2.5-8.0) You perform an ECG which is shown below.

Answer 68

This patient should be placed on cardiac monitoring and given IV calcium gluconate over a period of 5-10 minutes. This patient is suffering from hyperkalaemia, most likely secondary to an acute kidney injury from her UTI. Despite there being no changes on her ECG, a K+ > 6.5 warrants urgent attention. Calcium gluconate protects the myocardium from the deleterious effects of hyperkalaemia. ECG changes, if present, include tall tented T-waves, a wide QRS complex and eventually a sinusoidal pattern and asystole. A dextrose and insulin infusion +/- nebulised salbutamol constitutes the next stage in management. Refractory hyperkalaemia is an indication for emergency dialysis, but it is not indicated at this point.

Question 69

A 25-year-old male presents to A&E with general malaise and bilateral thigh pain. This has been ongoing for 5 days after participating in a spinning class for the first time. He has been taking naproxen for the last 3 days without relief. He also complains of passing dark brown urine. Bloods demonstrate a raised creatinine kinase (CK) level of 14,980 U/L (26-192 U/L) with an eGFR of 20. What is the most likely diagnosis? ``` A Exercise-induced nephropathy B Renal artery stenosis C Exercise-induced myalgia D Naproxen-induced AKI E Rhabdomyolysis ```

Answer 69

This patient is likely suffering from an AKI secondary to exercise-induced rhabdomyolysis. Rhabdomyolysis refers to the breakdown of skeletal muscle. Muscular pain or discomfort is common, alongside dark urine due to myoglobinuria. Diagnosis is confirmed by an elevated serum creatine kinase (CK) level. Fluid hydration is the mainstay of therapy.

Question 70

Which of the following is not considered an indication for emergency dialysis? ``` A Refractory pulmonary oedema B Refractory hyperkalaemia C Severe metabolic acidosis D Anuria > 12 hours E Severe uraemia ```

Answer 70

Anuria is not an indication for emergency dialysis. The indications for emergency dialysis include: 1. Refractory pulmonary oedema 2. Refractory hyperkalaemia 3. Severe metabolic acidosis 4. Severe uraemia +/- complications

Question 71

The indications for emergency dialysis include: 1. Refractory … … 2. Refractory …. 3. Severe …. …. 4. Severe u… +/- complications

Answer 71

The indications for emergency dialysis include: 1. Refractory pulmonary oedema 2. Refractory hyperkalaemia 3. Severe metabolic acidosis 4. Severe uraemia +/- complications

Question 72

You review an 89-year-old female with a urinary tract infection complicated by an acute kidney injury (AKI). She is currently being treated with IV fluids and IV co-amoxiclav on the high-dependency unit (HDU). Her regular medications include paracetamol, sertraline, bisoprolol, cholecalciferol, GTN spray, lisinopril and ibuprofen. Which combination of medications are particularly deleterious in AKI? ``` A Bisoprolol and GTN spray B Sertraline and cholecalciferol C Ibuprofen and lisinopril D Ibuprofen and paracetamol E Lisinopril and bisoprolol ```

Answer 72

ACE-Inhibitors (e.g. lisinopril) and NSAIDs (e.g. ibuprofen) are a particularly nephrotoxic combination in the setting of AKI. Both agents adversely affect the bodies ability to autoregulate renal blood flow. Other potentially deleterious agents include diuretics and angiotensin-receptor blockers (ARBs). Importantly many medications require adjustment in the advent of impaired renal function and severe illness.

Question 73

….-Inhibitors (e.g. lisinopril) and … (e.g. ibuprofen) are a particularly nephrotoxic combination in the setting of AKI.

Answer 73

ACE-Inhibitors (e.g. lisinopril) and NSAIDs (e.g. ibuprofen) are a particularly nephrotoxic combination in the setting of AKI.

Question 74

AKI can occur when there is a sudden … in glomerular filtration rate (GFR).

Answer 74

AKI can occur when there is a sudden decrease in glomerular filtration rate (GFR).

Question 75

GFR is maintained by sufficient blood flow into the kidneys, functioning nephrons and a clear pathway for outflow of urine from the kidney. If there are alterations to this system, an … can occur. At the glomerular level, GFR is dependent on a … … between the incoming blood at the afferent capillaries and the pressure in Bowman’s space.

Answer 75

GFR is maintained by sufficient blood flow into the kidneys, functioning nephrons and a clear pathway for outflow of urine from the kidney. If there are alterations to this system, an AKI can occur. At the glomerular level, GFR is dependent on a pressure gradient between the incoming blood at the afferent capillaries and the pressure in Bowman’s space.

Question 76

Pre-renal AKI occurs when there is … perfusion to the kidney. This can occur in hypovolaemic, euvolaemic or hypervolaemic states.

Answer 76

Pre-renal AKI occurs when there is reduced perfusion to the kidney. This can occur in hypovolaemic, euvolaemic or hypervolaemic states.

Question 77

Causes of pre-renal AKI include:

Answer 77

Absolute hypovolaemia: haemorrhage, over-diuresis, vomiting and diarrhoea Low effective arterial blood volume (EABV): heart failure, cirrhosis, sepsis, third spacing of fluid Anatomical: renal artery stenosis Drug-induced: NSAIDs, ACE inhibitors, diuretics

Question 78

Intra-renal AKI occurs when there is a structural or functional change at the level of the nephron. This can occur independently or as a transformation of a pre-renal AKI. Causes of intra-renal AKI include:2

Answer 78

occurs due to ischaemic or toxic injury to the cells of the proximal convoluted tubules Acute interstitial nephritis (AIN): most often eosinophilic nephritis that can be drug-induced (e.g. NSAIDs, penicillin), infection-induced (e.g. tuberculosis, legionella) or immune-mediated (e.g. sarcoidosis, SLE or IgG-related disease (IgG4-RD)) Glomerular disease: includes nephrotic and nephritic syndromes which may be primary renal disease (e.g. anti-glomerular basement membrane (anti-GBM), or part of systemic disease with immune complex deposition (e.g. IgA vasculitis) or without immune complex deposition (e.g. granulomatosis with polyangiitis (GPA)) Intra-tubular obstruction: multiple myeloma with paraprotein, pigment (e.g. rhabdomyolysis) Other: scleroderma renal crisis, malignant hypertension

Question 79

Post-renal AKI is associated with an obstructive pathology leading to congestion of the kidneys. Causes of post-renal AKI can be divided anatomically:

Answer 79

Ureters: nephrolithiasis, retroperitoneal fibrosis Bladder: bladder cancer Prostate: benign prostatic hyperplasia (BPH), prostate cancer Urethra: urethral stricture External: retroperitoneal mass, ovarian tumours

Question 80

Unless there is a … kidney, a unilateral obstruction may not cause post-renal AKI as the unaffected kidney may be able to compensate for the reduced function of the affected kidney. This puts patients with a … kidney at increased risk of AKI.3

Answer 80

Unless there is a solitary kidney, a unilateral obstruction may not cause post-renal AKI as the unaffected kidney may be able to compensate for the reduced function of the affected kidney. This puts patients with a solitary kidney at increased risk of AKI.3

Question 81

Risk factors for acute kidney injury include:

Answer 81

Chronic kidney disease (adults with an eGFR < 60 ml/min/1.73 m2 are at high risk) Heart failure Liver disease Diabetes History of acute kidney injury Oliguria (< 0.5 ml/kg/hour) Neurological or cognitive impairment or disability, which may mean limited access to fluids because of reliance on a carer Hypovolaemia Use of drugs that can cause or exacerbate kidney injury (Table 1) Use of iodine-based contrast media within the past week Symptoms or history of urological obstruction, or conditions that may lead to obstruction Sepsis Deteriorating early warning scores Age 65 years or over

Question 82

ACE inhibitors Angiotensin receptor blockers (ARBs) Cyclosporin NSAIDs Tacrolimus What nephrotoxic effect do these medications have?

Answer 82

GFR alteration Affect the vascular tone of the afferent and efferent arterioles, altering interglomerular blood flow

Question 83

Aminoglycosides Amphotericin B Cisplatin What nephrotoxic effect do these medications have?

Answer 83

Tubular cell toxicity Direct toxicity to the epithelial cells of the proximal convoluted tubules

Question 84

NSAIDs Rifampin What nephrotoxic effects do these medications have?

Answer 84

Interstitial nephritis Inflammatory reaction within the interstitium of the kidney

Question 85

Acyclovir Ampicillin What nephrotoxic effects do these medications have?

Answer 85

Crystal nephropathy Can result in precipitates of insoluble crystals

Question 86

NSAIDs can be implicated in multiple causes of renal impairment so their use should be restricted in patients at risk of AKI: Pre-renal: NSAIDs block … mediated vasodilation of the afferent arteriole, which limits the kidney’s ability to regulate local blood flow Intra-renal: NSAIDs can cause … … … (AIN) Post-renal: long term NSAID use can cause renal papillary … where the medullary papilla sloughs off, causing obstruction to urine flow

Answer 86

Pre-renal: NSAIDs block prostaglandin mediated vasodilation of the afferent arteriole, which limits the kidney’s ability to regulate local blood flow Intra-renal: NSAIDs can cause acute interstitial nephritis (AIN) Post-renal: long term NSAID use can cause renal papillary necrosis where the medullary papilla sloughs off, causing obstruction to urine flow

Question 87

Important areas of the history for suspected AKI to cover include:

Answer 87

Reason for admission to hospital (e.g. sepsis, burns) Underlying medical conditions (e.g. heart failure, cirrhosis, SLE) Use of medications known to be nephrotoxic (e.g. NSAIDs, diuretics, penicillin, cisplatin) Recent imaging investigations using iodinated contrast, particularly if delivered arterially (e.g. CT with contrast, angiogram) Lower urinary tract symptoms (e.g. frequency, urgency, incomplete emptying) Known to have a solitary kidney

Question 88

Typical clinical findings of AKI may include:

Answer 88

Oliguria or anuria Signs of hypovolaemia: dry mucous membranes, reduced skin turgor, tachycardia, hypotension Signs of volume overload: hypertension, pulmonary oedema, peripheral oedema, elevated jugular venous pulse Signs of uraemia: ecchymosis due to platelet dysfunction, uraemic encephalopathy (e.g. asterixis, confusion, seizures) Signs of post-renal obstruction: palpable or tender distended bladder

Question 89

AKI is detected biochemically by checking …

Answer 89

AKI is detected biochemically by checking urea and electrolytes. Subsequent investigations are guided by history and examination, but an algorithmic approach will yield baseline information that can guide tailored/specialised testing.

Question 90

Many hospitals are using an ABCDE checklist to prompt AKI management:

Answer 90

``` A: Address drugs B: Boost blood pressure C: Calculate fluid balance D: Dip urine E: Exclude obstruction ```

Question 91

Renal replacement therapy (RRT) is indicated in more severe cases of AKI:8

Answer 91

Metabolic acidosis pH < 7.15 or worsening acidaemia Refractory electrolyte abnormalities (hyperkalaemia >6.5mmol) Presence of dialysable toxins (toxic alcohols, aspirin, lithium) Refractory fluid overload (diuretic resistant fluid overload in setting of AKI) End-organ uraemic complications (e.g. pericarditis, encephalopathy, uraemic bleeding)

Question 92

Indications for RRT can be remembered by the mnemonic AEIOU:

Answer 92

``` Acidosis Electrolyte abnormalities Ingested toxins Fluid Overload Uraemia ``` Additionally, note that oligo/anuria will often accelerate the need for RRT.

Question 93

The … criteria are the most commonly used criteria for diagnosing AKI, with an increase in serum creatinine and reduced urine production being the key diagnostic features.

Answer 93

The KDIGO criteria are the most commonly used criteria for diagnosing AKI, with an increase in serum creatinine and reduced urine production being the key diagnostic features.

Question 94

Recognition and management of AKI are essential to prevent permanent damage or progression to …

Answer 94

Recognition and management of AKI are essential to prevent permanent damage or progression to chronic kidney disease (CKD).