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Medicine year 3 ANNA > AKI > Flashcards

Flashcards in AKI Deck (26)
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1
Q

What are the causes of AKI?

A
  1. Pre-renal - i.e. reduced renal perfusion
    • E.g. diarrhoea & vomiting, dehydration, sepsis, renal artery stenosis
  2. Renal - i.e. damage to renal tubules or glomeruli
    • E.g. nephrotoxic drugs, rhabdomyolysis, NSAIDs/ACEI, GN
  3. Post-renal - i.e. obstruction
    • E.g. prostatic hypertrophy, renal stones, pelvic Ca
2
Q

What is the SALFORD treatment of AKI?

A
  • S – treat cause, often sepsis but not always
  • A – stop nephrotoxic drugs (e.g. ACEI, ARBs, NSAIDs, metformin, diuretics) & review doses of other meds
  • L – labs – daily U&Es
  • F – intravenous fluids
  • O – Obstruction consider US scan, catheter, examine for distended bladder
  • R – referral to ICU / renal for RRT
  • D – Urine dipstick – if blood & protein on dipstick consider ‘renal’ causes or UTI, e.g. glomerulonephritis
3
Q

What is the staging of an AKI?

A
4
Q

What stage is this AKI?

Baseline creatinine 72 µmol/l increase to 200 µmol/l

A

stage 2

5
Q

What history Qs are important with suspected AKI?

A
  • Nephrotoxic drug use within the last week (especially if hypovolaemic)
    • NSAIDS
    • ACEIs
    • angiotensin II receptor antagonists (ARBs),
    • diuretics
  • Exposure to iodinated contrast agents within the past week
  • Any causes / symptoms of dehydration e.g.
    • Lack of mobility
    • Sepsis
    • Oliguria
  • PMH inlc:
    • heart failure
    • liver disease
    • diabetes mellitus
    • CKD
    • History of AKI
  • Symptoms of retention / obstruction e.g.
    • hesitancy
    • weak stream
    • intermittency
    • straining to void
    • terminal dribble
    • prolonged urination
6
Q

What should you look for on examination of an AKI patient?

A

General:

  • Rash
  • Uveitis
  • Joint swelling

Assessment of volume status

  • Drowsy, yawning and thirsty
  • Core temperature
  • Peripheral perfusion (capillary refill)
  • Heart rate
  • Blood pressure (lying and standing)
  • Jugular venous pressure

Signs of renovascular disease

  • Audible abdominal bruits
  • Impalpable peripheral pulses

Abdominal examination

  • Palpable bladder
7
Q

What is the normal value for creatinine?

A

70-150micromol/L

8
Q

What are the signs of kidney damage?

A

Many patients with early AKI may experience no symptoms. However, as renal failure progresses the following may be seen:

  • reduced urine output
  • pulmonary and peripheral oedema
  • arrhythmias (secondary to changes in potassium and acid-base balance)
  • features of uraemia (for example, pericarditis or encephalopathy)
9
Q

What is the urine dip important for?

A
10
Q

What investigations should we do for AKI (after U&Es)?

A
  • Urinanalysis - all patients with suspected AKI should have urinanalysis
  • Imaging - if patients have no identifiable cause for the deterioration or are at risk of urinary tract obstruction they should have a renal ultrasound within 24 hours of assessment.
11
Q

How do you treat hyperkalaemia?

A
  • Initially 10–20 mL, calcium gluconate injection 10%
  • soluble insulin (5–10 units) with 50 mL glucose 50% given over 5-15 minutes
12
Q

What is Acute Tubular Necrosis (ATN)?

A

ATN:

  • the most common cause of acute kidney injury (AKI) seen in clinical practice
  • death of tubular epithelial cells
  • usually due to ischaemia due to hypoperfusion of kidneys
  • can also be due to nephrotoxics or sepsis

3 phases:

  1. Oliguric
  2. Maintenance
  3. Polyuric recovery
13
Q

What are the features of ATN?

A
  • features of AKI: raised urea, creatinine, potassium
  • muddy brown casts in the urine
14
Q

When should you refer to a nephrologist?

A
  1. Renal tranplant
  2. ITU patient with unknown cause of AKI
  3. Vasculitis/ glomerulonephritis/ tubulointerstitial nephritis/ myeloma
  4. AKI with no known cause
  5. Inadequate response to treatment
  6. Complications of AKI
  7. Stage 3 AKI (see guideline for details)
  8. CKD stage 4 or 5
  9. Qualify for renal replacement hyperkalaemia / metabolic acidosis/ complications of uraemia/ fluid overload (pulmonary oedema)
15
Q

What are the stages of ATN?

A

Oligouric phase:

  • he kidneys produce less than 500 mls of urine per day.
  • Patients in this phase are vulnerable to fluid overload and electrolyte imbalance especially potassium.
  • Creatinine levels usually rise quite rapidly during this phase.

Maintenance phase:

  • The patient is no longer oligouric and this increased urinary output helps maintain fluid and electrolyte balance.
  • Creatinine level are usually stable or rise very slowly.

Polyuric recovery phase:

  • In this phase the kidneys produce large quantities of dilute urine, so large in fact patients can become hypovolaemic and unwell.
  • There are a number of causes for this phase postulated
  • Patients are also susceptible to electrolyte loss (e.g. hypokalemia) in this phase.
  • Creatinine levels falls swiftly in this phase.
16
Q

when is hyperkalaemia classified as acute severe hyperkalaemia (emergency treatment required)?

A

plasma-potassium concentration above 6.5 mmol/litre or in the presence of ECG changes

17
Q

What are the causes of hyperkalaemia?

A
  1. acute kidney injury
  2. drugs:
    • potassium sparing diuretics,
    • ACE inhibitors,
    • angiotensin 2 receptor blockers,
    • spironolactone,
    • ciclosporin,
    • heparin
  3. metabolic acidosis
  4. Addison’s disease
  5. rhabdomyolysis
  6. massive blood transfusion
18
Q

What ECG changes occur with hyperkalaemia?

A
  1. Tall tented T waves
  2. Widened QRS
  3. Prolonged PR
  4. Loss/flattening of P waves
  5. ‘sine-wave’ appearance
19
Q

What is Sepsis?

A

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to an infection

20
Q

What are the high, moderate and low risk criteria for sepsis in the history?

A
21
Q

What are the high, moderate and low risk criteria for sepsis in the resp and BP?

A
22
Q

What are the high, moderate and low risk criteria for sepsis in the circulation obs?

A
23
Q

What are the high, moderate and low risk criteria for sepsis in the skin?

A
24
Q

What are the 3 tests and 3 treatments of the Sepsis 6?

A

Tests:

  1. Blood cultures
  2. ABG
  3. Urine output

Management:

  1. IV antibiotics
  2. Fluids
  3. Oxygen
25
Q

Who are at risk of sepsis?

A
  • the very young (under 1 year) and older people (over 75 years) or people who are very frail
  • people who have impaired immune systems because of illness or drugs, including:
    • people being treated for cancer with chemotherapy (see recommendation 1.1.9)
    • people who have impaired immune function (for example, people with diabetes, people who have had a splenectomy, or people with sickle cell disease)
    • people taking long-term steroids
    • people taking immunosuppressant drugs to treat non-malignant disorders such as rheumatoid arthritis
  • people who have had surgery, or other invasive procedures, in the past 6 weeks
  • people with any breach of skin integrity (for example, cuts, burns, blisters or skin infections)
  • people who misuse drugs intravenously
  • people with indwelling lines or catheters.
26
Q

What is SIRS?

A

systemic inflammatory response syndrome

Two or more of the following:

  1. Temperature <36ºC or >38ºc
  2. Tachycardia = HR >90bpm
  3. Respiratory rate >20 per minute or PaCO2 <4.3 kPa
  4. White Cell Count >12 x 109/L or <4 x 109/L