AKI + congenital/stricture disorders

Question 1

Increased BP, failure of fluid homeostasis, accumulation of waste productions → N/V, malaise, AMS, pericarditis/pericardial effusion
Symptoms due to underlying problem

Severe = arrhythmias (hyperkalemia), platelet dysfunction, neuro changes

Answer 1

AKI

Question 2

failure of excretion, acid/base disturbance, electrolyte imbalance

Answer 2

renal/tubular problem

Question 3

patient unable to pee, pain

Answer 3

postrenal

Question 4

what are RF for AKI?

Answer 4

NSAID use, diuretics

Question 5

Rapid increase in serum Cr → rapid loss of kidney function

Answer 5

AKI

Question 6

normal Cr

Answer 6

Men .7-1.3
Women .6-1.1

Question 7

Initiation → anuric/oliguric (kidneys working to concentrate urine) → diuretic (urine no longer concentrated, body is losing water) → recovery

Answer 7

AKI

Question 8

MC: hypoperfusion, dehydration, shock, clot, liver, meds, heart (cardiorenal syndrome, often from sepsis), vasoconstriction, HOTN

Answer 8

prerenal AKI

Question 9

glomerulus (nephritic, nephrotic), tubule (ATN), interstitium (AIN) from prolonged prerenal azotemia, radiocontrast dye, AGs, vancomycin

Answer 9

renal AKI

Question 10

obstruction (prostate, neurogenic bladder, retroperitoneal fibrosis, kidney stone, tumors, urinary retention meds)

Answer 10

postrenal AKI

Question 11

What are the three diagnostic tools you could use with AKI?

Answer 11

Cr increase of >/= .3 mg/dL in 48 hours
Cr 1.5x baseline in 7 days
UO <.5 ml/kg/6 hours

Question 12

Elevated Cr, metabolic acidosis, hyperkalemia, hypocalcemia, hyperphosphatemia, anemia, prolonged bleeding time

Answer 12

AKI

Question 13

low sodium, increased osmolality, increased specific gravity, FeNA <1% (if on diuretics, FeUrea <35%)
BUN:Cr = >20:1 (BUN has risen)

Answer 13

prerenal AKI

Question 14

rule out pre/post renal – urine abnormalities with Cr increase, urine osmo lower than normal, same as plasma, increased sodium, muddy brown casts
BUN:Cr = <20:1 (Cr has risen as well, with ratio normal, but both elevated)

Answer 14

renal AKI

Question 15

US → distended bladder, kidneys, ureter
BUN:Cr not helpful
>Cr = bilateral kidney involvement
US most beneficial for this type

Answer 15

postrenal AKI

Question 16

stages of AKI

Answer 16

Stage I: 1.5-1.9 fold increase in Cr or decline in UO to <.5 ml/kg/hr over 6-12 hours
Stage II: 2-2.9 increase in Cr or decline to <.5 ml/kg/hour over 12 hours or longer
Stage III: 3x greater Cr or increase to >/= 4 or decline in UO <.3 for 24+ hours or anuria for 12+ hours or initiation of kidney replacement therapy

Question 17

How do you treat AKI?

Answer 17

Prerenal: Volume repletion to restore volume + renal perfusion
– return of Cr to previous baseline w/n 24-72 hours is considered correction

Renal: remove offending agent/s and IV fluids first line

Postrenal: remove obstruction

Question 18

Asymptomatic and often found incidentally
May have: UTIs, vesicoureteral reflux (retro flow of urine from bladder into upper urinary tract often in children which can cause lots of complications), ureteropelvic junction obstruction is most common, nephrolithiasis, malignancies, trauma

→ increased risk for pyelonephritis and kidney stone formation, renal carcinoma

Answer 18

horseshoe kidney

Question 19

Lower poles of kidneys fused together (connected = isthmus)

Embryological abnormality – IMA hooks over isthmus and they do not ascend properly

Higher incidence with other congenital syndromes, teratogenic drugs (thalidomide), alcohol consumption, poor glycemic control

Answer 19

horseshoe kidney

Question 20

Can be diagnosed on routine fetal US – suspect in those with hydronephrosis in infancy, abdominal mass, any complications indicating renal abnormality
* US or CT
CT and MRI best for anatomy + structures
CT urogram for stones and urinary blockages, UPJ
MRI for diminished renal function

Answer 20

horseshoe kidney

Question 21

voiding cystourethrogram and radionuclide cystogram is best to diagnose

Answer 21

Vesicoureteral reflux

Question 22

How do you treat horseshoe kidney?

Answer 22

Mostly no treatment needed

Vesicoureteral reflux = prophylactic antibiotics to prevent UTI

Treat obstruction, stones, infection as needed

Question 23

Pain in side and back/flank, abdomen, groin, painful urination, increased/decreased urinary frequency, incomplete urination, incontinence

Acute renal failure + anuria = bilateral

Answer 23

hydronephrosis

Question 24

Enlargement of renal pelvis due to build-up of urine (generally to UTO), dilation of collecting system
MCC = BPH
Cancer, stones
Unilateral = blockage occurs above the bladder
Bilateral = blockage at or below the bladder
Can also be from congenital abnormalities, blood clot, scarring, pregnancy, UTI

Answer 24

hydronephrosis

Question 25

* US Confirm diagnosis with XR, CT, MRI Increased Cr with bilateral obstruction or unilateral obstruction with underlying kidney disease Hematuria and pyuria Chronic obstruction = hyperkalemic renal tubular acidosis

Answer 25

hydronephrosis

Question 26

how do you treat hydronephrosis?

Answer 26

Address underlying cause (stone, infection) Catheter or nephrostomy tube to drain urine

Question 27

Abdominal or flank pain, hematuria History of UTIs and nephrolithiasis First symptom commonly HTN, may have “berry” aneurysms, MVP, colonic diverticula

Answer 27

polycystic kidney disease

Question 28

Family history Autosomal recessive – can cause death in first month of life (lung immaturity b/c of insufficient amniotic fluid) – formation of cysts on kidney More at risk for cerebral aneurysms and other vascular problems

Answer 28

polycystic kidney disease

Question 29

PE: large kidneys may be palpable on exam, renal impairment (microscopic/gross hematuria) *US (if unclear, CT scan) Brain MRA if family history is +, employed in high risk profession, or undergoing elective surgery with high risk for post op HT

Answer 29

polycystic kidney disease

Question 30

how do you treat polycystic kidney disease?

Answer 30

Lifestyle modifications – healthy diet, decreased sodium intake, weight management, exercise, don’t smoke, drink water, avoid caffeine BP meds – statins, tolvaptan, bed rest and analgesics for pain Chronic pain = cyst decompression Hematuria = bed rest + hydration – recurrent bleeding = renal cell cancer (esp. in men >50) Renal infection = antibiotics (fluoroquinolones, bactrim)

Question 31

Refractory HTN New onset HTN in older patients Pulmonary edema with poorly controlled BP AKI with ACEI or ARB Audible abdominal bruit Unexplained HTN in woman <40 (consider fibromuscular dysplasia), <20 or >50

Answer 31

renal vascular disease

Question 32

What are RF for renal vascular disease?

Answer 32

HTN >45 CKD Diabetes Tobacco use

Question 33

Atherosclerosis causing renal artery stenosis → MCC of secondary HTN! Fibromuscular dysplasia is MCC in women <50 years

Answer 33

renal vascular disease

Question 34

Abdominal US – asymmetric kidney size, small hyperechoic kidneys if bilateral Hypokalemia If corrective procedure considered, screen with: Dopper US (sensitive + specific) but poor for obese, supine, bowel issues CT angio MRA $$ Renal angiography – performed after a positive screening test String of beads = fibromuscular dysplasia

Answer 34

renal vascular disease

Question 35

how do you treat renal vascular disease?

Answer 35

Medical management: BP control, lipid management, glucose control, tobacco cessation → ACEI or ARBs, except in those with bilateral stenosis or solitary kidney Angioplasty w/ or w/o stenting Surgical bypass

Question 36

how do you treat fibromuscular dysplasia?

Answer 36

percutaneous transluminal angioplasty is curative