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AKI Flashcards

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1
Q

What are some common definitions of AKI?

A 
Solute clearance (urea, creatinine) 
Urine output (oliguria) 
Distinguish patients with pre-existing renal impairment
Some defined by requirement for dialysis (AKI3)
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2
Q

What is the definitive definition of AKI?

A

An abrupt (<48hours) reduction in kidney function:
Absolute increase in serum creatinine by >26.4
OR
Increase in baseline creatinine by >50% (1.5 times baseline)
OR
Reduction in UO (harder to measure)

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3
Q

What is stage 1 AKI?

A

Increase >26 in creatinine or increase in 1.5-1.9x the reference Cr
<0.5ml/kg/hr urine for more than 6 hours

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4
Q

What is stage 2 AKI?

A

Increase in more than 2-2.9x reference SCr

More than <0.5ml/kg/hr of urine for more than 12 hours

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5
Q

What is stage 3 AKI?

A

More than 3x reference SCr OR increase to >354 OR need for RRT
Less than 0.3 ml/kg/hr for more than 24 hours or 12 hours of anuria

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6
Q

What are risk factors for AKI?

A 
Older age
CKD
Diabetes
Cardiac failure
Liver disease
PVD
Previous AKI
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7
Q

What exposure risk factors can cause an AKI?

A 
Hypotension
Hypovolemia
Sepsis
Deteriorating NEWS
Recent contrast
Exposure to certain medications: gentamicin for example
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8
Q

What are the 3 different causes of AKI?

A 
Pre-renal (functional) 
Renal (structural) 
Post renal (obstruction)
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9
Q

What causes hypovolemia related pre-renal AKI?

A

Hemorrhage

Volume depletion - diarrhoea, vomiting, burns

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10
Q

What causes hypotensive related pre-renal AKI?

A

Cardiogenic shock

Distributive shock - sepsis, anaphylaxis

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11
Q

What can cause renal hypoperfusion?

A

NSAIDs/ COX-2
ACEi/ ARBs
Hepatorenal syndrome

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12
Q

What is the definition of pre-renal AKI?

A

Reversible volume depletion leading to oliguria and increase in creatinine

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13
Q

What is normal urine output and therefore what is oliguria?

A

Normal: 0.5 ml/kg/hr, e.g. 30mls/hr in a 60 kg patient
Oliguria: <0.5 mls/kg/hr

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14
Q

Describe normal renal perfusion?

A

Decreased renal perfusion causes the release of renin which in turn causes vasoconstriction of the efferent arteriole via angiotensin 2, maintaining GFR

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15
Q

Why does ACEI increase the risk of AKI?

A

Reduce angiotensin 2, therefore in decreased renal perfusion the kidneys cannot respond normally and the efferent arterioles will stay vasodilated resulting in a decreased GFR

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16
Q

What will untreated pre-renal AKI lead to?

A

Acute tubular necrosis

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17
Q

What will cause acute tubular necrosis?

A

Combo of factors leading to decreased renal perfusion

Common causes are sepsis and severe dehydration

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18
Q

How is hydration assessed?

A

Clinical observations (BP, HR, UO)
JVP, CRT, oedema
Pulmonary oedema

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19
Q

How is pre-renal AKI treated?

A

Fluid challegnge for hypovolaemia:
Crystalloid (0.9% NaCl) or colloid (gelofusin)
Do NOT use 5% dextrose
Give 250 ml bolus at a time and repeat
Get senior help when 1000ml is used with no affect - needs vasopression

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20
Q

Why is hartmann’s not used in treatment of pre-renal AKI?

A

Contains potassium

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21
Q

Why is 5% dextrose not used for treatment of pre-renal AKI?

A

It will not stay in the capillaries so wont increase the circulating volume

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22
Q

What is renal AKI?

A

Disease causing inflammation or damage to cells causing AKI

Split by structure: blood vessels, glomerular disease, interstitial disease, tubular injury

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23
Q

What are the vascular causes of renal AKI?

A

Vasculitis - GPA, MPA, goodpasture’s

Renovascular disease

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24
Q

What is the glomerular cause of renal AKI?

Study These Flashcards
A

Glomerulonephritis

25
What are the interstitial nephritis causes of renal AKI?
Drugs - penicillins, trimethoprim, NSAIDs, PPI Infection - TB Systemic - sarcoidosis
26
What are the tubular injury causes of renal AKI?
Ischaemia - prolonged renal hypoperfusion Drugs - gentamicin Contrast Rhabdomyolysis
27
What are the symptoms of AKI?
Constitutional: anorexia, wt loss, fatigue, lethargy Nausea and vomiting Itch Fluid overload - SOb, oedema
28
What are the signs of AKI?
Fluid overload including HTN, oedema, pulmonary oedema, effusions Uraemia - itch, pericarditis Oliguria
29
What clues in the history can point to a renal cause?
``` Sore throat (step pyogenes; rheumatic fever) Rash (vasculitis or lupus) Joint pains (lupus and vasculitis) Diarrhoea and vomiting Haemoptysis (TB, GPA, goodpastures) ```
30
What can be seen on urinalysis of renal AKI?
Protein and blood - this will NOT be seen in pre-renal
31
What drugs are important to look out for in renal AKI?
``` ACEi PPI NSAIDs Gent and vanc Recent contrast ```
32
What blood tests can aid in the diagnosis of renal AKI?
``` Eosinophilia (eGPA, intestitial nephritis; reaction to a drug) Cholesterol microemboli (renal failure and trash foot) CK for rhabdomyolysis ```
33
What are you looking for in U&Es?
Marker of renal function (Na, K, Ur, Cr) | Is potassium high - MEDICAL EMERGENCY
34
Why is an FBC and coagulation screen done in AKI?
Abnormal clotting - DIC in sepsis | Anaemia - lack of erythropoietin
35
What can urinalysis show in AKI?
Haematoproteinuria in renal AKI
36
Why is an USS doone in suspected AKI?
Obstruction (postrenal) | Size - hydronephrosis
37
What immunological markers are done in suspected AKI?
``` ANA - lupus ANCA - GPA, eGPA, MPA GMB - goodpastures Immunoglobulins C3/4 - lupus ```
38
What is protein electrophoresis and BJP done for?
Myeloma | Patient over 50 with hypercalcaemia and anaemia = DO THESE TESTS AND SUSPECT MYELOMA
39
What will RAS show on ultrasound?
One large kidney
40
How is a good perfusion pressure established in AKI?
Fluid resuscitate | If still not achieving adequate BP - inotropes/vasopressors
41
What is the further treatment of AKI?
Treat underlying cause e.g. antibiotics in sepsis Stop nephrotoxins Dialysis if remains anuria and uraemia
42
What are the life-threatening complications of AKI?
``` Hyperkalemia Fluid overload - pulmonary oedema Severe acidosis (pH <7.15) Uraemic pericardial effusion Severe uraemia (Ur >40) ```
43
What is post-renal AKI?
AKI due to obstruction of urine flow leading to back pressure (hydronephrosis) and thus loss of concentrating ability
44
What can cause post-renal AKI?
Stones Cancers Strictures Extrinsic pressure
45
What will obstruction look like on USS?
Dilated renal pelvis
46
How is post-renal AKI treated?
Catheterisation Nephrostomy Refer to urology for ureteric stenting
47
How is hyperkalemia assessed?
ECG - predisposes to VT, VF and bradycardia | Muscle weakness
48
What level of potassium is considered life-threatening?
More than 6.5
49
What are the ECG changes of hyperkalemia?
``` Peaked T waves Prolonged PR interval Depressed ST segment Prolonged QRS Sine-wave pattern (this is peri arrest) ```
50
What is the 1st line treatment in hyperkalemia?
Stabilise myocardium | 10 ml 10% calcium gluconate over 2/3 mins
51
What is performed after treatment with calcium gluconate in hyperkalemia?
Need to move K+ back into cells: 10 units actrapid with 50mls 50% dextrose over 30 mins Salbutamol nebs over 90mins
52
What is the treatment for chronic hyperkalemia but NOT used in the acute setting?
Calcium resonium
53
What should you do if someone is severely acidotic with a very low bicarb?
Give sodium bicarbonate
54
What are the urgent indications of haemodialysis?
Hyperkalemia over 7 Severe acidosis - pH <7.15 Fluid overload - diuretics will NOT work Urea >40, pericardial rub/effusion
55
What medicines should you stop on sick days (D+V OR fevers, shakes and sweats)?
``` ACEi ARB NSAIDs Diuretics Metformin Empagliflozin ```
56
Does furosemide cause hyper or hypokalemia?
Hypokalemia
57
What drugs commonly cause hyperkalemia?
``` Spironolactone ACEi Amiloride Beta-blockers CCB ```
58
What drugs should be avoided in those with AKI?
``` NSAIDs ACEi/ARB Diuretics Gentamicin IV Contrast for CT Trimethoprim/co-trimoxazole as will cause hyperkalemia and cause increased creatinine Potassium sparing diuretics ```

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