AKI

Question 1

What is AKI?

Answer 1

Acute Kidney Injury
abrupt decline in kidney function in 7 days or less

Question 2

What is AKD?

Answer 2

Between 7 and 90 days after an AKI event before CKD

Question 3

AKI Stage 1 Scr

Answer 3

1.5 - 1.9 times baselines
OR
>/= 0.3 mg/dl increase

Question 4

AKI Stage 1 UO

Answer 4

< 0.5 ml/kg/hr for 6 - 12 hours

Question 5

AKI Stage 2 SCr

Answer 5

2.0 - 2.9 times baseline

Question 6

AKI Stage 2 UO

Answer 6

<0.5 ml/kg/hr >/= 12

Question 7

AKI Stage 3 SCr

Answer 7

3.0 times baseline
OR
>/= 4.0 increase
OR
Initiation of renal replacement therapy
OR
In pts <18 y/o dec in GFR <35MLMIN

Question 8

AKI Stage 3 UO

Answer 8

<0.3 ml/kg/hr FOR >/=24 hrs
OR
Anuria for >/= 12 hrs

Question 9

AKI Functional Damage

Answer 9

• Increase in biomarkers (SCr, BUN)
• Change in glomerular/tubular function
• Absence of true damage to kidney

Question 10

AKI Kidney Damage

Answer 10

• Presence of glomerular/tubular injury
• Identified by novel biomarkers
  - NGAL (proximal tubule)
  - TIMP2 and IGFBP7 (cell cycle arrest)
  - KIM 1 (proximal tubule)

Question 11

Risk Factors of AKI

Answer 11

• Age >65 years
• African American ethnicity
• CKD
• DM
• Nephrotxin use
• Decreased effective circulatory volume (HF, cirrhosis, blood loss)

Question 12

Gen Prevention of AKI

Answer 12

• Maintain euvolemia and normal Elytes
  
  • isotonic crystalloids
  • balanced crystalloids maybe vs saline
• Maintain organ perfusion (MAP > 65 mmHg)
  
  • Vasopressors
• Avoid nephrotoxins
  
  • Aminoglycosides, amphotericin, iodinated contrast, vancomycin, etc)

Question 13

Prevention of Contrast Induced AKI

Answer 13

• Isotonic Na containing crystalloids
  - 1 ml/kg/hr 12 hrs prior and post
• Na bicarbonate (harm potential)
• N-acetylcysteine (mod data;no benefit)
• Vitamin D

***Decreasing data

Question 14

Diuretics in AKI

Answer 14

• No benefit
• To manage edema or HyperK
• Resistance common
  
  • increase dose

Question 15

Dopamine in AKI

Answer 15

• Increase renal blood flow and urine output
  
  • “renal dose dopamine” - 1 - 3 mcg/kg/min
• No change in AKI outcome
• Increases risk of arrhythmias and hypotension

Question 16

Fenoldapam

Answer 16

Oral dopamine receptor agonist studied and shown no benefit with increased risk of hypotension

Question 17

AKI Treatment (Supportive Care)

Answer 17

Maintain fluid, elytes, acid/base homeostasis
BP management
Avoid nephrotoxic meds
Kidney replacement therapy
Nutritional support

Question 18

Treatment of hemodynamic AKI

Answer 18

Intravascular volume repletion
(Goal: >0.5 ml/kg/hr)
Temp hold meds: ACEi/ARB/NSAIDs/SGLT2is, calcineurin inhbitors
(Restart when kidney back baseline)

Question 19

Diagnosis of Pre-Renal AKI

Answer 19

FeNa <1%
OR
FeUrea <35% (on loop diuretic)

Question 20

Treatment of Pre-Renal AKI

Answer 20

Intravascular volume repletion
(Goal: >0.5 ml/kg/hr)
Temp hold meds: Thiazide and loop diuretics
(Restart when kidney back baseline)

Question 21

Treatment of Intrinsic AKI

Answer 21

If med caused - stop med and DO NOT RESTART

Glomerulonephritis
Acute Tubular Necrosis
Tubulointerstitial nephritis
Vasculitis

Question 22

Glomerulonephritis Treatment

Answer 22

Immunosuppresion

Question 23

Acute Tubular Necrosis Treatment

Answer 23

Supportive Care

Question 24

Tubulointerstitial nephritis Treatment

Answer 24

Glucocorticoids
- Prednisone 0.5 - 1 mg/kg/day x 3-8 weeks then taper

Question 25

Vasculitis Treatment

Answer 25

Immunosuppression

Question 26

Treatment of Post-Renal AKI

Answer 26

Relieve obstruction
- Acute: Foley catheter, nephrostomy tube
- Chronic: treat underlying cause (BPH, cancer)

Question 27

Kidney Replacement Therapy

Answer 27

treatment for severe/prolonged AKI
- CKRT -continuous kidney replacement therapy
- IHD -intermittent hemodialysis

Question 28

How to assess kidney function in AKI

Answer 28

DO NOT USE SCr
Use Urine Output

Question 29

SCr in AKI kidney function assessment

Answer 29

DO NOT USE SCr
- Lags behind GFR by 1- 2 days
- EARLY AKI - OVERestimates GFR
- RECOVERY phase - UNDERestimates GFR

Question 30

Urine output in AKI kidney function assessment

Answer 30

No drug dosing guidelines
oliguric vs non-oliguric is benchmark
Anuria = GFR <10 ml/min

Question 31

Initiation and Extension Phase Assessment

Answer 31

need higher doses of hydrophilic drugs (ABx) due to to large Vd

Question 32

Maintenance Phase Assessment

Answer 32

may rely on SCr calculation for GFR

Question 33

Recovery Phase Assessment

Answer 33

increase doses of renally eliminated drugs