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Renal II > Acute Kidney Injury and Chronic Kidney Disease > Flashcards

Acute Kidney Injury and Chronic Kidney Disease Flashcards

1
Q

Acute Kidney Injury (Previously known as: Acute Renal Failure)

A

DEFINITION:
- INCREASE in Serum Creatinine +/- DECREASE in Urine OUTPUT over HOURS OR DAYS!!!!

EFFECTS:

  • Electrolyte Disturbances
  • Acid-Base Disturbances (Metabolic Acidosis)
  • INABILITY to Excrete Nitrogenous Waste
  • Intravascular VOLUME OVERLOAD
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2
Q

Case #1

  • A 20 y/o female college student presents to the ER after FAINTING.
  • HPI: A classmate witnessed the event and accompanied her to the ER and stated patient awakened immediately after passing out and did not sustain any trauma. The patient reported RECURRENT EPISODES OF DIZZINESS the past 24 hrs.
  • She states she has had N/V (NAUSEA and VOMITING) for the past two days, and hasn’t been able to eat or drink much of anything
  • NO diarrhea
  • She has had GENERALIZED BODY ACHES since the GI symptoms started, but denies any specific pain in abdomen
  • She DENIES menstrual changes or vaginal drainage, and her last menstrual period was 4 weeks ago
  • Classmate says the “stomach flu” has been going around
  • Single, lives in dorm

• PREVIOUSLY HEALTHY, no prescription or OTC
(over‐the‐counter) meds

  • NKDA (No Known Drug Allergies)
  • No tobacco, alcohol or drug use
  • PMH, PSH and family history negative
A

1) What is wrong with the Patient:
A) ORTHOSTATIC HYPOTENSION:
- Dehydration (Aka VOLUME CONTRACTION or EXTRACELLULAR VOLUME DEPLETION “ECVD”)

  • Due to FLUID LOSSES from NAUSEA and VOMITING

2) Another Diagnostic Test that would be Helpful would be:
A) SERUM ELECTROLYTES , BUN, and CREATININE:
- First Dagonistics in addition to Urine to DETERMINE Sodium, Potassium, Chloride levels that can be affected by DEHYDRATION (due to her Nausea/ Vomiting), BUN/ Cr will tell you if RETAINING NITROGENOUS WASTE and RETAINING CREATININE, indicating ACUTE KIDNEY INJURY!!!!!!!!!!

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3
Q

FeNa

A
  • Fractional EXCRETION of Sodium is calculated using a random Urine Sample close to time of the Blood Draw- helps sort between PRE-RENAL and INTRINSIC RENAL:

(Una / Pna) / (Ucr / Pcr) x 100

*** If LESS THAN 1% means TUBULES INTACT and are Sodium Avid i.e. retaining Sodium as would be expected in DEHYDRATION (PRE-RENAL!!!!!!)

*** If GREATER THAN 1 - 2% means TUBULAR FUNCTION NOT INTACT (INTRINSIC!!!!)

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4
Q

Many Ways to Categorize Renal Disease

A
  • Pre-Renal vs Intrinsic (Renal) vs Post-Renal
  • Tubular vs Glomerular: based on FIRST AREAS AFFECTED, ultimately ALL OF KIDNEY will be AFFECTED
  • Underlying etiology eg HYPERTENSIVE Nephropathy, Diabetic Nephropathy
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5
Q

Significance of Pre-Renal Determination

A
  • Pre-Renal Origin suggests that Tubules and Glomeruli were NOT THE INITIAL LOCATION of Pathology, though they will eventually become affected and possibly permanently
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6
Q

BUN/ Creatinine in AKI

A
  • Elevation in serum Creatinine (Cr) by 50% (if baseline known) or by 0.5 - 1.0 mg/dL (Affected by Muscle Mass available to Generate Cr)
  • Blood Urea Nitrogen (BUN) also ELEVATED due to RETENTION of NITROGENOUS WASTES
    a) Elevated Bun = AZOTEMIA

b) Elevated BUN PLUS CONFUSION = UREMIA!!!!!!

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7
Q

Glomerular Filtration Rate (GFR)

A
  • GFR can be estimated by prediction equations that take into account NOT ONLY the Serum Creatinine BUT ALSO Age, Gender, Race, and Body Size
  • Prediciton Equations:
    1) Children: SCHWARZ and Counahan Barrett!!!!!!

2) Adults: MRDR and Crockcoft-Gault!!!!!!

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8
Q

MRDR Study Equation for eGRF

A 
• eGFR =
175 x (SCr)^‐1.154 x (age)^‐0.203 x 0.742 [if female] x 1.212 [if Black]

• Abbreviations / Units:
– MDRD = MODIFIED DIETARY APPROACH TO RENAL DISEASE

– eGFR (estimated Glomerular Filtration Rate) = mL/min/1.73 m2

– Scr (standardized serum creatinine) = mg/dL

– age = years

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9
Q

Pre-Renal

A

* ANYTHING THAT COMPROMISES RENAL PERFUSION!!!!!!***

1) HYPOVOLEMIA: Dehydration, Viral Syndromes, Acute Pancreatitis, Diuretics
2) LOW CARDIAC OUTPUT: CHF!!!!
3) ALTERED RENAL/ SVR RATIO: Sepsis, Cirrhosis
4) RENAL HYPOPERFUSIN WITH IMPAIRED AUTOREGULATION: NSAIDS!!!!!
5) HYPERVISCOSITY SYNDROME (Rare): Myeloma

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10
Q

Effective Volume Depletion (3rd Spacing)

A
  • Results in DECREASED KIDNEY PERFUSION as seen in Pre-Renal Injury!!!!!
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11
Q

Treatment (Pre Renal)

A

1) HYPOVOLEMIA:
- FLUID Replacement IV
- As always, TREAT UNDERLYING CAUSE

2) Even with effective (Rahter than true) Volume Depletion such as Pancreatitis, Large Quantities of IV FLUIDS are INDICATED, WITH CLOSE MONITORING FOR SYSTEMIC VOLUME OVERLOAD

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12
Q

Intrinsic Renal Failure

A

1) RENOVASCULAR OBSTRUCTION: Renal Artery OBSTRUCTION
- Ex: Embolism, Dissecting Aortic Aneurysm

  • renal Artery Stenosis can be classified as PRE-RENAL or INTRINSIC RENAL
    2) DISEASE OF GLOMERULI or MICROVASCULATURE: Can occur from ACCELERATED HYPERTENSION!!!
    3) ACUTE TUBULAR NECROSIS (ATN): Can occur from IODINATED CONTRAST DYE- used with CT’s, Vascular Studies, IVP’s (Intravenous Pyelograms)
    4) INTERSTITIAL NEPHRITIS: Acute Pyelonephritis, NSAIDS, also can be contrast Dye induced, other drugs
    5) INTRATUBULAR DEPOSITION and OBSTRUCTION: Myeloma
    6) RENAL ALLOGRAFT REJECTION
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13
Q

Case #2- 72 y/o Female

  • Presents to the ER with MIDSTERNAL CHEST PAIN that radiates into left shoulder, has lasted about an hour, resting helps, worse with increased activity. No similar previous episodes. Initially COLD SWEATS AND TROUBLE BREATHING
  • PMH: DM‐2 controlled on an oral agent, Hyperlipidemia controlled on oral statin, HTN controlled on a thiazide diuretic
  • Remainder of history neg, NKDA
  • Cardiology took her emergently for cardiac cath, and was able to STENT the LAD (Left Anterior Descending) artery
  • She tolerated the procedure well and had no apparent changes through the night in the post cath unit
  • Blood pressure has remained controlled, BUT URINE SEEMS DARKER/ MORE CONCENTRATED
  • As you round the morning after admission with the hospitalist, you notice her BUN AND CREATININE are over 50% INCREASED compared to her ER results.
A

1) What would you see in the Urine Microscopy for the Diagnosis:
A) MUDDY BROWN CASTS:
- Tubular Damage is the MOST LIKELY INITIAL INSULT to the Kidneys AFTER CONTRAST, especially larger Volumes of Contrast.

  • As much as 300 to 400 mL for VENTRICULOGRAM, instead of Approx 40 to 75 cc to Examine Vessels
  • May have had NORMAL LAB PRIOR TO THIS, but her HTN and DM even though Controlled, STILL INCREASE her RISK for RENAL COMPROMISE!!!!
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14
Q

Case #3 - 72 y/o Male

  • Presents to your office with intermittent PINK- TINGED URINE and RIGHT MID-BACK PAIN for the past month, no pain, burning or change in stream w/ urination
  • PMH Prostatic hypertrophy, Peripheral Vascular Disease, HTN & Hyperlipidemia, controlled on current meds & follows for labs every 4 months
  • NKDA

• POSITIVE RIGHT FLANK TENDERNESS to percussion,
remainder abdominal exam normal

• 10 MONTHS AGO:
– Normal dipstick and negative microscopic

• 4 MONTHS AGO:
– BUN/Cr 16/1.0

• CURRENT:
– Dipstick + for blood
– Micro verified few RBC’s
– BUN/Cr 18/2.5

A

What would you next step be?
A) ULTRASOUND (Attention Kidneys)
- Non- Invasive, more affordable and accessible, and can determine KIDNYE SIZE, HYDRONEPHROSIS, and POSSIBLE MASES

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15
Q

Post-Renal “BLOCKAGE”

A

1) URETERIC:
- CALCULI (Stones), Blood Clot, Sloughed Papilla, CANCER, External Compression (Tumor, Retroperitoneal Fibrosis)

2) BLADDER NECK:
- Neurogenic Bladder, PROSTATIC HYPERTROPHY, Calculi, Cancer, Blood Clot

3) URETHRA:
- Stricture, Congenitaal Valve, Phimosis

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16
Q

If Acute Kidney Injury is UNRESPONSIVE to Conservative Measures:

A

A) Consider TEMPORARY HEMODIALYSIS in the Following:
- VOLUME OVERLOAD refractory to Diuretics

  • HYPERKALEMIA
  • ENCEPHALOPATHY otherwise UNEXPLAINED
  • PERICARDITIS, Pleuritus
  • Severe METABOLIC ACIDOSIS compromising RESPIRATORY or CIRCULATORY Function
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17
Q

Chronic Kidney Disease

A
  • Long standing, IRREVERSIBLE impairment of RENAL FUNCTION
  • UREMIA: Clinical syndrome resulting from PROFOUND LOSS of Renal Function
  • AZOTEMIA: Elevated Lab Value (BUN)
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18
Q

GFR (Glomerular Filtration Rate) Measured

A

A) Ccr (Creatinine Clearance): 24 Hour Urine sample measured for CREATININE in addition to Obtaining SERUM CREATININE
- Actual measured value obtained on 24 hour Urine more closely approximates the ACTUAL GFR than using the serum Cr along, as used in the following formula

B) Can use INULIN as Substance to measure, but has to be given IV and ASSAY FOR INULIN not available in most labs

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19
Q

GFR- Calculated “Abbreviated” MDRD Equation

A

= 186 x (SCr)^‐1.154 x (age)^‐0.203 x (1.210 if African American)

• MDRD considered MORE ACCURATE and PREFERABLE to Cockroft‐ Gault!!!!!!!!

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20
Q

GFR: Cockroft- Gault Equation

A

Male: [(140‐age) x wt (in kg)]/
(SCr x 72)

Female: 0.85 x Male CrCL

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21
Q

5 Stages of Chronic Kidney Disease

Level of GFR

A

1) Kidney DAMAGE with NORMAL or INCREASED GFR (Greater than or equal to 90)
2) Mild DECREASE in GFR (60 to 89)
3) Moderate DECREASE in GFR (30 0 59)
4) Severe DECREASE in GFR (15 - 29)
5) Kidney Failure aka ESRD (GFR less than 15 or on DIALYSIS)

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22
Q

Early Stage of Chronic Kidney Disease

A
  • Usually Symptom free
  • Overall function INTACT
  • RESERVE FUNCTION diminished
  • BUM/ Cr may even be in NORMAL RANGE
23
Q

Case #4- 58 y/o Female

  • Presents to the clinic to get established for ongoing care after moving to Kansas City
  • History of SARCOIDOSIS with INTERMITTENT HYPERTENSION and steroid related hyperglycemia
  • Laboratory was NORMAL
  • After a year in KC she has remained stable, on no medication and no HTN
  • Her eGFR (estimated Glomerular Filtration Rate) is 80 (CKD stage 2)!!!!!!!!!
A

1) What would you recommend for the Patient?
A) Give them an ACE INHIBITOR!!!!
- Poses kidney protection to DELAY PROGRESSION of CKD even if Blood Pressure DOES NOT Need Treatment

*** Start SLOW and Titrate up with he ACE Inhibitors, even if their BP is NORMAL

24
Q

Later Stages of Chronic Kidney Disease

A

A) Azotemia and accompanying symptoms/ signs

B) Reserve DECREASE sufficiently so sudden stress can induce further compromise:

  • Infection
  • Urinary Obstruction
  • Dehydration
  • Nephrotoxic Drugs
25
Q

Effects of Uremic Toxins on CELLULAR FUNCTION

A

1) REDUCTION in Transmembrane VOLTAGE
- INCR Intracellular Na+
- DECR Intracellular K+
- INHIBITION of Ca2+ Influx

2) Uremia and its effects are largely REVERSIBLE with DIALYSIS
3) Normal Erythrocytes incubated in UREMIC Serum DEMONSTRATE SIMILAR CHANGES

26
Q

Effects on Uremic Toxins on WHOLE BODY COMPOSITION

A

1) Osmotically INDUCED OVERHYDRATION of Cells
2) INCREASED EXTRACELLULAR Volume

3) Malaise, Anorexia, N/V/D:
- Protein and Calorie Malnutrition
- Negative Nitrogen Balance
- Profound LOSS OF LEAN BODY MASS and Fat Deposits

27
Q

Effects of Uremic Toxins on METABOLISM

A

1) HYPOTHERMIA (DECR active Na+ Transport)
2) Intracellular DEFICITS of K+
3) METABOLIC ACIDOSIS

28
Q

Effects of Uremic Toxins on NITROGEN AND LIPIDS

A

1) “PROTEIN INTOLERANCE”
- INCR Catabolism in Uremia
- DECR Elimination

2) HYPERTRIGLYCERIDEMIA, DECR HDL, Normal Cholesterol:
- DECR Removal by LIPOPROTEIN LIPASE
- INCR Lipogenesis
- Possibly INCR production by LIVER and INTESTINE

29
Q

Effects of Uremic Toxins on SODIUM and VOLUME HOMEOSTASIS

A

1) Total body content of Na+ and WATER and INCREASED MODESTLY- in STABLE Chronic Kidney Disease

2) EXCESSIVE SALT Ingestion can lead to:
- CHF
- Hypertension
- Ascites
- Edema

30
Q

Effect of Uremic Toxins on Na+ and Water

A

1) EXCESSIVE Water Ingestion:
- Hyponatremia
- Weight Gain

2) Recommended Fluid INTAKE PRE-DIALYSIS
- Urine Output plus 500 mL/ day

31
Q

POTASSIUM EFFECTS in Chronic Renal Disease

A

1) NORMAL until LATE STAGES:
- Adaptation in renal Distule Tubule and Colon = Sites where ALDOSTERONE enhances K+ Secretion

2) INCREASED K+ —-> CARDIAC ARRHYTHMIAS

3) Drugs that can INCREASE Serum Potassium:
A) ANTIKALIURETIC DRUGS:
- Spironolactone
- Triamterene
- Amiloride
- Trimethoprim
- Pentamidine

B) OTHERS:

  • ACE-I
  • Beta Blockers
32
Q

EXTRArenal Fluid Loss also contributes to CKD

A

1) IMPAIRED RENAL MECHANISM to CONSERVE Na+ and Water in CKD

2) VOMITING, DIARRHEA, FEVER:
A) VOLUME DEPLETION:
- Dry mucous Membranes, Dizziness, Syncope
- Tachycardia, DECR JVP 
- ORTHOSTASIS
- Cardiovascular COLLAPSE
33
Q

The Most Common COMPLICATION OF ESRD

A

1) HYPERTENSION as a RESULT of Primary Renal Disease or Effects on Kidney from SYSTEMIC DISEASE
2) CHRONIC Dialysis Patients also have a HIGHER INCIDENCE of Accelerated ATHEROSCLEROSIS which contributes to the HYPERTENSION!!!!!

3) If no HTN on Clinical Exam of ERSD patient, consider additional factors:
A) SALT WASTING form of RENAL DISEASE causing CKD
- Polycystic or Medullary Cystic Disease
- Chronic Tubulointerstitial Disease
- Papillary Necrosis

B) VOLUME DEPLETION

C) On ANTIHYPERTENSIVE Therapy AT THE TIME!!!!

34
Q

Associated Conditions - Pulmonary Congestion

A

1) UNIQUE FORM: even in absence of Volume Overload
A) Normal or mildly ELEVATED Intracardiac or Pulmonary Capillary Wedge Pressures

B) Chest X-Ray: “BUTTERFLY WING” distribution (Peripheral Vascular Congestion)
- Increased PERMEABILITY of Alveolar Capillary membranes

35
Q

Associated Conditions- Pericarditis

A

A) LESS FREQ with EARLY DIALYSIS
- Thought secondary to Metabolic Toxins

B) If occurs in well Dialyzed, likely VIRAL INFECTION or SYSTEMIC DISEASE

C) EFFUSION often HEMORRHAGIC!!!!!!

4) TREATMENT: Pericardiocentesis, Pericardioectomy

36
Q

Associated Conditions- Hematologic Anemia

A

A) NORMOCYTIC, Normochromic Anemia

B) Hemolysis- Uremic Patients

C) GI, Chronic Dialyzer Blood Loss

D) HYPERSPLENISM- Occasional

37
Q

Associated Conditions- Hematologic - Abnormal Hemostasis

A

A) Prolonged BLEEDING TIME

B) DECREASED Platelet Factor III activity

C) ABNORMAL Platelet Aggregation and Adhesiveness

D) IMPAIRED PROTHROMBIN Consumption

38
Q

Associated Conditions- Enhanced Susceptibility to Infection

A

A) LYMPHOCYTOPENIA

B) Atrophy of Lymphoid Structures

C) Neutrophil Production RELATIVELY UNIMPAIRED

D) Uremia impairs FUNCITON fo ALL LEUKOCYTES

39
Q

Bone Changes with Uremia

A

A) “RENAL RICKETS” - WIDENED Osteoid seams at GROWTH MARGINS

B) Osteitis Fibrosis Cystica- due to SECONDARY HYPERPARATHYROIDSIM

  • Osteoclastic Bone REsoprtion
  • Subperisteal Erosions
  • Terminal Phalanges, Long Bones, and Distal Clavicles

C) OSTEOSCLEROSIS

40
Q

Bone Changes in Long Term Dialysis

A

A) Dynamic or Aplastic Bone Disease

B) Aluminum- Induced OSTEOMALACIA

C) Dialysis- related AMYLOIDOSIS (DRA)

  • Carpal Tunnel Syndrome
  • Tenosynovitis of Hands
  • Shoulder Arthropathy
  • Bone Cysts
  • Cervical Spondyloarthropathy
  • Cervical Pseudotumors
41
Q

Case #5 - 42 y/o Female

  • INCREASING FATIGUE, Dyspnea, and Poor appetite
  • Developing ELEVATED BLOOD PRESSURE, lipids and swelling of extremities
  • Lab also showed HEMATURIA, RBC casts, increased potassium, low albumen and eGFR of 20
  • FH positive for multiple members with kidney problems and several on dialysis (most diabetics with 2 sisters already deceased)
  • What is your initial diagnosis?
A

** IDIOPATHIC NEPHROTIC SYNDROME!!!!!*****

  • No Diabetes, No PRIOR HTN
  • Renal Biopsy showed FSGS which comprises 15% of Nephrotic Syndromes
42
Q

FSGS

A
  • Progresses to Chronic Kidney Disease in 5 to 10 years

- NO PROVEN THERAPY, may see Trial of Steroid +/- Cytotoxic Agent

43
Q

Signs and Symptoms of Chronic Kidney Disease

A

A) SEVERITY depends on:
- Magnitude of LOSS in RENAL FUNCTION

  • RAPIDITY of LOSS

B) Anorexia

C) Weight Loss

D) Dyspnea

E) Fatigue

F) Pruritus

G) Sleep and Taste Disturbance

H) Confusion, Possess other forms of Encephalopathy

44
Q

Physical Exam in Chronic Kidney Disease

A
  • Hypertension
  • JVD
  • Pericardial +/- por Pleural Friction Rub
  • Muscle Wasting
  • Asterixis
  • Excoriations and Ecchymoses
45
Q

Labs in Chronic Kidney Disease

A
  • Potassium, Phosphate, Uric Acid ALL HIGH!!!!!!!!
  • Calcium, Albumen, and Hemoglobin ALL LOW!!!!!!!
  • METABOLIC ACIDOSIS!!!
46
Q

Treatment (Conservative) for Chronic Kidney Disease

A
  • AGGRESIVE Control of HYPERTENSION
  • ELIMINATE VOLUME OVERLOAD (Diuretics, Volume Intake Restriction)
  • EPO (rHuEPO), Recombinant Human ERYTHROPOIETIN
  • Phosphate Binders, Calcium Carbonate or Acetate
  • Restrict Dietary Potassium
  • Sodium Polystyrene Sulfonate (Kayexalate) binds Potassium
  • Ace-Inhibitors:
    a) Diabetes
    b) Significant PROTEINURIA (Greater than 1 gm/d)
  • Dietary Protein Restriction

-

47
Q

Dialysis Indications

A
  • UNRESPONSIVE to Conservative Measures
  • VOLUME OVERLOAD REFRACTORY to Diuretics
  • HYPERKALEMIA
  • ENCEPHALOPATHY otherwise UNEXPLAINED
  • PERICARDITIS, Pleuritis
  • Sever METABOLIC ACIDOSIS comprising RESPIRATORY or CIRCULATORY FUNCTION
  • Need for Fluids/ Drugs ALSO A CONSIDERATION!!!!
48
Q

Dialysis Methods

A

1) PERITONEAL DIALYSIS (PD) CYCLER vs DWELL TIME then DRAIN

2) INTERMITTENT HEMODIALYSIS (IHD)
- MOST COMMON Type used for AKI!!!!!!

  • Many Chronic Kidney Patients maintained on 3X/ Week (M-W-F)!!!!!!

3) NIGHT-TIME DIALYSIS
- In Center Hemodialysis
- In Home Hemodialysis

4) Continuous Renal Replacement Therapy (CRRT)
- If Intolerant to Intermittent Hemodialysis(IHD)
- May see in Extremely UNSTABLE ICU PATIENTS!!!!

49
Q

Complications of Peritoneal Dialysis

A
  • Peritonitis
  • Hyperglycemia
  • Hypertriglyceridemia
  • Obesity
  • Hypoproteinemia
  • Dialysis-related Amyloidosis
  • Insufficient CLEARANCE due to VASCULAR DISEASE or other Factors
50
Q

Complications of Hemodialysis

A
  • Hypotension
  • ACCELERATED Vascular Disease
  • Rapid Loss fo RESIDUAL RENAL FUNCTION
  • ACCESS THROMBOSIS
  • Access or Catheter Sepsis
  • Dialysis related Amyloidosis
  • Protein Caloria Malnutrition
  • Hemorrhage
  • Dyspnea/Hypoxemia
  • Leukopenia
51
Q

Renal Transplant ABSOLUTE CONTRAINDICATIONS

A

1) ACTIVE Glomerulonephritis
2) ACTIVE Bacterial or Other Infection
3) ACTIVE or VERY RECENT Malignancy
4) HIV
5) HEP B Surface Antigenemia
6) SEVERE COMORBIDITY (Vascular Disease)

52
Q

Renal Transplant RELATIVE CONTRAINDICATIONS

A

1) Older than 70 y/o
2) SEVERE PSYCHIATRIC Disease
3) Moderately SEVRE Degrees of COMORBIDITY
4) HEP C with CHRONIC HEPATITIS or CIRRHOSIS
5) NONCOMPLIANCE with DIALYSIS or other Treatment

6) PRIAMRY RENAL DISEASE:
- Primary Focal Sclerosis with PRIOR Recurrence in TRANSPLANT

  • Multiple Myeloma
  • Amyloid
  • Oxalosis
53
Q

Renal Transplant Complications

A

1) Rejection

2) Immunosuppression
- Infection
- Neoplasm

Renal II (5 decks)

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