AKI

Question 1

KDIGO definition for AKI

Answer 1

stage 1 - crt 1.5-1.9 x baseline or Cr >0.3; UOP < 0.5 ml/kg/h for 6-12 h

stage 2 - crt 2-2.9 x baseline; UOP < 0.5 ml/kg/h for >12 h

stage 3 - crt >3x baseline OR crt>4, OR initiation of HD; UOP <.3 ml/kg/hr for >24 h or anuria >12 h

Question 2

anuria

Answer 2

no UOP or < 100 ml/24 h

Question 3

oliguria

Answer 3

100-400 mls/24h

Question 4

polyuria

Answer 4

> 6L/24 h

Question 5

nonoliguria

Answer 5

greater than 400 ml/24 h

Question 6

prerenal AKI tx

Answer 6

1-2 L isotonic fluids for hypovolemia

diuretics for hypervolemia

Question 7

causes of ATN

Answer 7

ischemia
nephrotoxins (contrast, meds)

most common type of hospital acquired AKI

Question 8

causes of AIN

Answer 8

infection
drugs - antibiotics (allergic interstitial nephritis)!!!!!! #!
immune disorders

Question 9

causes of glomerulonephritis

Answer 9

damage to filtering mechanisms (immune complex-mediated)

other causes

Question 10

vascular AKI causes

Answer 10

large vessels - renal vein thrombosis, renal artery stenosis

small vessels - vasculitis, atheroembolic, malignancy hypotension, thrombotic microangiopathies (HUS, TTP)

Question 11

ATN diagnostics

Answer 11

BUN:Crt ratio - PRESERVED (10-20:1)
FENa: >1 (when oliguric)
UA - negative protein, negative blood, POSITIVE GRANULAR CASTS (dirty brown), RENAL TUBULAR EPITHELIAL CELLS

Question 12

RF for contrast-induced AKI

Answer 12

(type of ATN)
renal insufficiency
diabetes

multiple myeloma
high osmolar (ionic) contrast media
contrast medium volume
age

Question 13

contrast-induced AKI characterstics

Answer 13

onset 24-48 h after exposure
duration 5-7 d
non-oliguric
tx w fluids & prevention! (500-1000 ml of NS before procedure, during, and after)

hold other nephrotoxic agents 2 days before if high risk

Question 14

ATN treatment

Answer 14

remove offending agent
treat offending cause
maintain renal perfusion
avoid nephrotoxins
diuretics for fluid removal

Question 15

acute interstitial nephritis

Answer 15

renal lesion that causes a decline in renal function

characterized by an inflammatory infiltrate in the kidney interstitial

think inflammatory, hematuria, blood

Question 16

classic presentation of AIN

Answer 16

fever , rash, arthralgias, eosinophilia

(ask about new meds)

Question 17

AIN diagnostics

Answer 17

BUN:Crt <20:1
microscopic hematuria
gallium 67 scan, renal ultrasound
renal biopsy - gold standard
white casts, white cell casts, eosinophils

Question 18

AIN treatment

Answer 18

supportive tx
dx offending agents
manage underlying condition

consider corticosteroids

Question 19

nephritic vs nephrotic

Answer 19

nephritic - think blood
(think inflammation, hematuria)

nephrotic - think protein
(severe proteinuria, edema, hyperlipidemia, hypoalbuminemia)

Question 20

in what syndrome do you see glomerular crescent formation

Answer 20

rapidly progressive glomerulonephritis (RPGN)

rapid decline of GFR in 3 month period

Question 21

nephrotic syndrome tx

Answer 21

treat underlying cause

reduce BP and cholesterol!

manage edema

Question 22

nephrotic syndrome s/s

Answer 22

severe proteinuria (>3g) d/t kidney damage, HLD, edema

dyspnea, abd fullness, edema, pleural effusions

Question 23

glomerulonephritis diagnostics

Answer 23

previous infection????

UA - protein, blood RBCs, RBC casts

BUN:Crt ratio preserved

kidney biopsy diagnostic

Question 24

glomerulonephritis treatment

Answer 24

treat underlying cause - manage BP?

treat infection

immunosuppression if severe

Question 25

IgA nephropathy

Answer 25

berger's disease most common cause of primary glomerulonephritis classic presentation - gross hematuria after URI

Question 26

IgA nephropathy diagnostics

Answer 26

gross hematuria within 12-72 hours of infection (viral URI) proteinuria kidney biopsy - positive IgA deposits

Question 27

IgA nephropathy tx

Answer 27

reduce proteinuria control HTN consider prednisone or immunosuppression may require transplant if severe

Question 28

post renal causes of AKI

Answer 28

mechanical (BPH, strictures, tumors, etc) functional (spinal cord disease, neurogenic bladder, diabetic neuropathy)

Question 29

indications for renal biopsy

Answer 29

unexplained AKI/CKD, acute nephritis syndrome, proteinuria/hematuria, previously identified lesion, systemic disease, suspected transplant rejection, help guide treatment CI : bleeding, uncontrolled HTN

Question 30

FeNa

Answer 30

used to differentiate between prerenal and intrinsic pre renal <1% ATN >2

Question 31

lab findings for AKI

Answer 31

rising creatinine and urea rising K decreasing hgb acidosis hyponatremia hypocalcemia

Question 32

indications for acute dialysis

Answer 32

AEIOU anuria oliguria pulmonary edema hyper K >6.5 severe academies <7.2 uremic encephalopathy uremic pericarditis

Question 33

when to consult/admit for AKI

Answer 33

consult - AKI not reversed after 1/2 weeks (neph), s/s/ of persistent UTI (urologist) admit - sudden loss of kidney function that cannot be handled op, need for acute intervention

Question 34

acute pyelonephritis

Answer 34

acute inflammatory disease that involves renal parenchyma and renal pelvis E. coli most common bacteria

Question 35

acute pyelonephritis tx

Answer 35

fluids IV abx 48-72 h, then oral abx depends on pathogen CTX fluoroquinolones zosyn

Question 36

nephrolithiasis s/s

Answer 36

renal colic - intermittent back/flank pain with radiation dysuria, chills, fever, N/V, hematuria uncomfortable, tachycardia, fever, diaphoresis, CVA tenderness

Question 37

nephrolithiasis management

Answer 37

<5 mm will usually pass spontaneously FLUIDS if obstruction or accompanying infection - need removal (extra-corporal shock wave lithotripsy, percutaneous access and removal, ureteroscopy) pain mgmt - NSAIDs alpha blockers/calcium channel blockers x4 weeks to help stone pass prevent future stones - diet changes (dec protein)

Question 38

nephrolithiasis

Answer 38

kidney stones calcium oxalate most common can cause AKI

Question 39

first line dx for nephrolithiasis

Answer 39

non contrast spinal CT hematuria

Question 40

renal artery stenosis

Answer 40

renal artery and its branches are potential sites for plaque formation, which can lead to ischemic renal disease and HTN caused by atherosclerosis if you can't get their BP under control - think renal artery stenosis

Question 41

fibromuscular dysplasia

Answer 41

unexplained HTN can lead to renal artery stenosis

Question 42

renal artery stenosis s/s

Answer 42

refractory HTN AKI w initiation of ACE pulmonary edema audible abdominal bruit

Question 43

renal artery stenosis diagnostics

Answer 43

renal angiography screening via ultrasound or CT

Question 44

renal artery stenosis mgmt

Answer 44

consider revascularization control HTN, lipids, DM! ACE, ARB, CCB, statin

Question 45

postrenal diagnostics

Answer 45

elevated BUN:creatinine ratio unremarkable UA consider renal US/CT for hydronephrosis