AKI

Question 1

Can you use eGFR to describe AKI?

Answer 1

No! eGFR formula assumes creatinine in steady state, not valid if changing. eGFR is not safe to use in drug dosing in AKI

Question 2

Which two measurements are key to assessing AKIs?

Answer 2

Serum creatinine and urine output

Question 3

How can causes of AKIs be divided?

Answer 3

Intrinsic, pre-renal, post-renal

Question 4

Which category of cause is responsible for all AKIs?

Answer 4

Pre-renal

Question 5

Name three examples of intrinsic causes of AKIs

Answer 5

1. Acute tubular injury- rhabdo, nephrotoxins, haemoglobinuria
2. Tubulointerstitial injury
3. Glomerulonephritis
4. Myeloma
5. Vasculitis

Question 6

Name three examples of nephrotoxins

Answer 6

Iodinated contrast, NSAIDs, gentamicin

Question 7

Name three examples of pre-renal causes of AKIs

Answer 7

1. Sepsis
2. Hypovolaemia
3. Hepatorenal syndrome
4. Cardiac failure
5. Hypotension

Question 8

Name three causes of hypovolaemia

Answer 8

1. Haemorrhage
2. Burns
3. Vomiting/diarrhoea
4. Diuretics

Question 9

Which three antibiotics should you be wary of in AKIs?

Answer 9

Trimethoprim, nitrofurantoin, gentamicin

Question 10

How does trimethoprim affect the kidney?

Answer 10

Increases creatinine

Question 11

Why should you be cautious with nitrofurantoin when there is an AKI?

Answer 11

Not excreted in urine if creatinine clearance <30 therefore inadequate urine concentration to treat UTI and risk of toxicity

Question 12

Name 5 clinical assessments that can be conducted to determine whether patient is hypovolaemia, euvolaemic, or hypervolaemic

Answer 12

1. Oedema
2. JVP
3. Mucous membranes
4. Skin turgor
5. Chest auscultation
6. Urine output
7. Weight
8. BP

Question 13

Name four investigations for AKIs

Answer 13

1. Urinalysis- blood/protein
2. Bicarbonate
3. Urine protein:creatinine ratio (uPCR)
4. Glomerulonephritis screen
5. Renal USS (within 24 hr unless clear signs of improvement)

Question 14

Name four components of the glomerulonephritis screen

Answer 14

1. ANCA (MPO/PR3)
2. ANA
3. Anti-GBP
4. RF
5. Myeloma screen

Question 15

Name three post-renal causes of AKI

Answer 15

1. Kidney stones
2. BPH
3. Tumours
4. Retroperitoneal fibrosis

Question 16

At what kidney failure stage should you refer to renal?

Answer 16

Stage III

Question 17

What are ECG features of hyperkalaemia?

Answer 17

Hypertented T waves, absent P waves, increased PR interval, broad QRS, BBB

Question 18

How to stage AKI?

Answer 18

1-3, compare current Cr to baseline, if 1.5-2x greater then stage 1, if 2-3x greater then stage 3, if >3x then stage 3. Note different staging system to CKD

Question 19

What are clinical signs (not symptoms) of CKD?

Answer 19

Uraemia, anaemia, vit D deficiency, K+, acidosis

Question 20

What is the management of CKDs?

Answer 20

EPO, fluid resus, ACEi, dietary advice

Question 21

What are the five indications for commencement of dialysis?

Answer 21

AEIOU: acidosis, electrolyte, ingestion, overload (HF), uraemia

Question 22

What are three ways of defining an AKI?

Answer 22

1. increase in SCr by >0.3 mg/dl within 48 hr
2. increase in SCr to >1.5 x baseline
3. Urine volume <0.5 ml/kg/hr for 6 hr

Question 23

What are the stages of AKI?

Answer 23

1-3 stage

1. 1.5-1.9 baseline SCr
2. 2-2.9
3. > 3

Question 24

Why is eGFR not used in AKIs?

Answer 24

serum creatine needs to be in steady state ~ HbA1C in diabetes

Question 25

What are the pre-renal causes of AKI?

Answer 25

1. volume depletion- vomiting, diarrhoea, diuretics, burns, haemorrhage 2. Cardiac pump failure 3. Sepsis 4. Medications 5. Hepatorenal syndrome (rare)

Question 26

What are the intrinsic causes of renal AKI based on site?

Answer 26

glomerulus- glomerulonephritis tubules- acute tubular necrosis, rhabdo renal vessels- renal artery stenosis, occlusion, renal vein thrombosis

Question 27

Which symptoms are associated with intrinsic causes of AKI?

Answer 27

rashes, painful eye (ANCA), paresthesia, foot drop, frank haematuria, swelling

Question 28

Investigations for AKI?

Answer 28

``` U+Es urine dip ABG/VBG Renal tract ultrasound Glomerulonephritis screen Myeloma screen Renal biopsy ```

Question 29

What are the complications of AKI?

Answer 29

electrolyte disturbance fluid overload metabolic acidosis uraemic

Question 30

What is the management of AKI?

Answer 30

``` correct hypovolaemia treat acute complications (hyperkalaemia, acidosis) r/v medications Optimise cardiac function Monitor fluid output Search for infections ```

Question 31

How can you assess volume status?

Answer 31

``` Pulse/BP/SpO2 Urine output Mucous membranes Weight Peripheral oedema/JVP Loss of skin turgor ```

Question 32

How can you distinguish AKI from CKD if patient has never undergone U+E blood testing?

Answer 32

renal size on US- CKD nephrons will appear smaller and cystic anaemia- anaemia of chronic disease hyperparathyroidism- association with CKD

Question 33

In which condition associated with AKI can you develop a petechial rash?

Answer 33

SLE, vasculitis

Question 34

In which condition associated with AKI can you develop a purpuric rash?

Answer 34

thrombotic thrombocytopenic purpura, systemic vasculitis, henoch schloenlein purpura

Question 35

Which poisons result in renal replacement therapy?

Answer 35

``` BLAST it out Barbiturates Lithium Alcohols Salicylates Theophyline ```

Question 36

What level of creatinine kinase would you suspect rhabdomyolisis?

Answer 36

very high, 10,000's