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Clin Med 3 > AKI - Exam 2 > Flashcards

AKI - Exam 2 Flashcards

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1
Q

what is AKI?

A

Abrupt decline in renal function manifesting as reversible acute increase in nitrogenous wastes over hours to weeks

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2
Q

AKI is a precursor to what?

A

renal failure

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3
Q

BUN, Cr, and GFR in AKI?

A

BUN and Cr increase

GFR decreases

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4
Q

what is the RIFLE criteria?

A

” Classification system for the degree of insult to the kidney

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5
Q

are acute renal failure (ARF) and AKI the same?

A

NO!!!

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6
Q

3 graded levels of injury in RIFLE Criteria

A

risk, injury, failure

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7
Q

2 outcome measures of RIFLE Criteria

A

Loss of function
-total loss of kidney function (GFR < 15 for >4weeks) -> need dialysis for >4 weeks

End stage renal disease
-GFR < 15 for >3 months -> need dialysis for >3 months

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8
Q

RIFLE Criteria based on what?

A

Based on either degree of serum creatinine elevation or decrease in urine output

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9
Q

what conditions are at a higher risk for developing AKI?

A

HTN, DM (2 M/C)

CHF (chronic low flow to the kidneys = greater risk for AKI)

MM (have underlying kidney injury at baseline)

Chronic infection

Myeloproliferative disorder

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10
Q

3 etiologies of AKI?

A

pre-renal causes, intrinsic causes, post-renal causes

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11
Q

what are pre-renal causes of AKI?

A

low flow problem into kidney

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12
Q

what are intrinsic causes of AKI?

A

problem with kidney itself
-Problem with glomerulus, interstitial nephritis, tubules

-tubular problems are the M/C

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13
Q

what is the most common cause of intrinsic causes to the kidney? what is it due to?

A

tubular problems

-d/t vascular problems, ischemic problems, toxic problems, obstructive problems

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14
Q

what are post-renal causes of AKI?

A

anything that blocks off both ureters

ex: large bladder cancer, clot in bladder if someone on Coumadin and starts bleeding, problems with prostate

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15
Q

MAP and AKI

A

MAP < 80mmHg causes AKI to occur quickly

pre-renal cause of AKI

can occur in septic pts, cariogenic shock pts

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16
Q

examples of pre-renal causes of AKI?

A

pre-renal azotemia (increase in BUN/Cr w/out sx’s associated with it)

MAP <80mmHg then steep decline in GFR

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17
Q

most common cause of ARF?

A

renal blood flow problems (pre-renal causes)

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18
Q

intrinsic renal diseases affect what?

A

affecting small vessels, interstitial, glomeruli, or tubules

-most common is obstructive (acute tubular necrosis)

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19
Q

most common cause of tubular problems for AKI?

A

acute tubular necrosis - causes obstruction

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20
Q

post-renal processes of AKI

A

Obstruction or urine flow in ureters, bladder, or urethra

REVERSIBLE

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21
Q

how do NSAIDs affect the kidney?

A

NSAIDs are bad for kidneys (not toxic to kidney itself), but b/c they prevent the afferent arteriole from dilating to increase flow to kidney -> thus decreases flow to kidney -> increases likelihood of developing AKI

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22
Q

what is TTP-HUS-DIC?

A

all are coagulopathy disorders which can cause clots in the vessels and blockage of the vessels -> causing an ischemic kidney

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23
Q

pre-renal AKI etiology

A

Hypovolemia, decreased cardiac output, decreased effective circulating volume (CHF, liver failure/hepatorenal syndrome, sepsis, pancreatitis, nephrotic syndrome) -> all cause low flow through glomerulus

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24
Q

what is the most common cause of renal failure?

A

pre-renal injury

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25
how is pre-renal injury reversed?
with restoration of renal perfusion/glomerular pressure (ex: with IVF, blood, vasopressors -> all improve volume thru kidneys)
26
BUN/Cr ratio for pre-renal injury
>20:1 (dehydration ratio)
27
what do you see a decrease of in pre-renal injury?
fractional excretion of sodium (FeNa) | -activating RAAS -> holding onto fluid and sodium, so see decrease in FeNa
28
what does urinalysis for pre-renal injury reveal?
hyaline casts
29
FeNa <1% is suggestive of what?
pre-renal azotemia -Kidney is working well, it's trying to hold onto sodium with aldosterone and also water, so have less Na being secreted, so < 1% FeNa
30
FeNa >1% is suggestive of what?
intrinsic renal failure -kidney is losing Na, it can't hold onto it
31
FeNa >4% is suggestive of what?
post-renal failure -Early on the FeNa will be lower than 4%, but later on it will rise b/c later on you don't make as much urine, so have a lot of Na just sitting around in the little bit of urine that you do make (urine is super concentrated with Na)
32
when is FeNa not accurate?
when pt is on diuretics - can't do FeNa if have taken diuretics w/in past 24hrs
33
can have increase in FeNa and be pre-renal if ___
on diuretics, have CKD and baseline FeNa is already baseline high
34
what is an alternative to FeNa?
FeUrea or FeUA
35
FeUrea/FeUA is not influenced by what?
not influenced by diuretics like FeNa is
36
FeUrea < 35% or an FeUA < 9-10% suggests?
a prerenal etiology of ARF
37
FeUrea > 50% or an FeUA > 10-12% suggests?
ATN (intrinsic cause) - acute tubular necrosis
38
pre-renal labs
elevated H/H, albumin, Ca (b/c pts are dry) elevated Na, BUN, Cr Decreased CO/effective arterial volume -> have edema Urine output - oliguria (<500ml/day) or anuria (<100ml/day); low urine Na (<20 mEq/L)
39
what is the urine output like in pre-renal AKI?
OLIGURIA (< 500ml/day) or anuria (<100ml/day) Low urine Na (<20 mEq/L)
40
if a male has anuria, what is the first thing to think about?
their prostate
41
if not making any urine, then what is usually the cause?
an obstruction of some kind
42
pre-renal tx
volume depletion -NS and titrate decreased CO/effective circulating volume -diuretics (high dose IV), nitrates, dobutamine all meds cleared by renal excretion should be avoided or doses adjusted if pt volume depleted -> do not give diuretics
43
what meds are never given to a person that anuric?
diuretics
44
why give high dose IV diuretics for pre-renal tx?
to get the volume off, so give something nephrotoxic treating like severe CHF pts with low volume
45
what is acute interstitial nephritis?
ALLERGIC reaction to medication (usually a new drug) | intrinsic renal cause
46
classic presentation of acute interstitial nephritis?
after recent new drug exposure peripheral eosinophilia ***More commonly, pts are found incidentally to having rising serum creatinine after initiation of new med
47
most common meds associated with causing acute interstitial nephritis?
antibiotics | -Beta-lactams, sulfonamides, vancomycin, erythromycin, rifampin
48
what does urinalysis in acute interstitial nephritis show?
WBC casts (PATHOGNOMONIC)
49
treatment of acute interstitial nephritis?
D/C offending agent -> leads to reversal of renal injury Glucocorticoids (can accelerate renal recovery) - 6wk taper prednisone or IV methylprednisolone x 3 days
50
can damage be permanent in acute interstitial nephritis?
yes, if long duration of exposure
51
is acute tubular necrosis reversible?
yes, unless severe/prolonged injury to tubular cells
52
causes of acute tubular necrosis?
1. Ischemia (protracted pre-renal condition like AAA and have to clamp aorta -> causing low flow to both kidneys) 2. Sepsis 3. Toxins (sepsis and toxins b/c of poor renal perfusion)
53
toxins that cause acute tubular necrosis
exogenous nephrotoxins (meds, poison) endogenous nephrotoxins
54
what are some endogenous nephrotoxins that cause acute tubular necrosis?
myoglobinuria (rhabdo) severe transfusion rx (get hemolysis) -> hemoglobinuria uric acid (tumor lysis syndrome) light chains (multiple myeloma)
55
exogenous nephrotoxins that cause acute tubular necrosis
NSAIDs, chemotherapeutic agents, ahminoglycosides (GN's), amphotericin (anti-fungal), Vancomycin, radio contrast dye, poison (ethylene glycol -> alcoholics)
56
what is seen on urinalysis for acute tubular necrosis?
pigmented granular casts (muddle-brown casts) - PATHOGNOMONIC
57
what is the first thing to do when treating pt with acute tubular necrosis?
aggressive volume replacement (hydrate!!!) (esp if nephrotoxic agent, volume depletion)
58
what can you consider giving a pt with acute tubular necrosis?
high dose loop diuretics (100-200mg Lasix) to improve urine output if oliguria is present and extracellular-volume normalized
59
restrict what fr any pt with renal disease and for acute tubular necrosis?
Protein restriction
60
what examples of glomerular diseases?
Infectious Disease associated Syndromes -Post-streptococcal glomerulonephritis - M/C (group strep A) Nephrotic syndrome -Minimal change disease (pediatric version of nephrotic syndrome) Membranous glomerulonephritis IgA nephropathy Henoch-Schonlein Purpura Goodpasture syndrome Diabetic nephropathy Hypertensive nephropathy Progressive Glomerulonephritis Polycystic kidney disease
61
which glomerular diseases are d/t chronic renal failure?
Goodpasture syndrome, Diabetic nephropathy, Hypertensive nephropathy, Progressive Glomerulonephritis, Polycystic kidney disease
62
what is post-strep glomerulonephritis?
immune-mediated disease -Immune complex containing strep Ag deposited in affected glomeruli -> body keeps attacking the antigen and thus causes inflammation -> causes glomerular nephritis
63
post-strep glomerulonephritis caused by what and occurs when?
Caused by the infection, but occurs 7-12 days following the infection/sore throat/impetigo (usually untreated infection)
64
color of urine in post-strep glomerulonephritis?
cola colored urine (blood degraded/hematuria/RBC casts)
65
classic sign of post-strep glomerulonephritis?
HTN (salt and fluid retention) in the child
66
post-strep glomerulonephritis is the M/C of what? occurs where?
AKI in children globally M/C in developing countries
67
post-strep glomerulonephritis highest risk at what age?
children 5-12 y/o
68
what does urinalysis show for post-strep glomerulonephritis?
RBC casts - PATHOGNOMONIC -also have proteinuria, hematuria, pyuria (all b/c glomerulus is leaking everything)
69
if see a lot of sediment on urinalysis and maybe no infection, but child has HTN what should you think?
PSGN
70
what will pts with post-strep glomerulonephritis have elevated?
elevated titers of antibodies to strep ELEVATED anti-streptolysin (ASO)
71
post-strep glomerulonephritis tx
PCNs if there is infection symptomatic tx if no infection (anti-HTNs, Na restriction, diuretics) children usually recover, adults can progress to permanent kidney damage
72
what is IgA Nephropathy?
IgA deposition in glomerulus (like PSGN), but NOT INFECTIOUS
73
IgA nephropathy often following?
URI
74
color of urine in IgA nephropathy?
red or Coca Cola 1-2 days s/p onset
75
IgA nephropathy dx?
renal bx
76
IgA nephropathy tx?
ACEI/ARB steroids renal transplant (will need this eventually)
77
what is Henoch Schonlein Purpura?
small vessel vasculitis w/IgA complex deposition (related to IgA) PEDIATRIC VERSION OF IgA Nephropathy Same IgA complex deposited at glomerulus and in small vessels -> so causes vasculitis/inflammation of vessels -> causes ischemic state
78
who is affected in Henoch Schonlein Purpura?
children about 6 y/o
79
Classic presentation of Henoch Schonlein Purpura?
Rash - esp LE's and buttocks Severe abdominal pain/vomiting (can also have arthralgia in knees, ankles)
80
Henoch Schonlein Purpura tx?
Mostly supportive (immunosuppressants and/or plasmapheresis for worsening disease) Excellent prognosis Recover spontaneously in weeks (if not then use immunosuppressants)
81
nephrotic syndrome can be problem with what?
primary (problem with kidney) or secondary
82
type of nephrotic syndrome?
minimal change disease (pets version of nephrotic syndrome)
83
what is seen in nephrotic syndrome?
***Heavy proteinuria (> 3.5g/24hrs) -> foamy urine ***Hypoalbuminemia (< 3 g/dL) ***Peripheral edema Hypercoag state (DVT, PE may be first presentation) Bland urinary sediments (not many cells or casts)
84
what is minimal change disease?
nephrotic syndrome in children
85
what is the characteristic histologic finding for minimal change disease?
diffuse effacement of the epithelial cell foot processes on electron microscopy
86
abrupt onset what for minimal change disease?
edema & nephrotic syndrome
87
Minimal change disease tx
all children treated with PREDNISONE (steroids) for 8-16 weeks (most have complete remission after 8 weeks of steroids) PREDNISONE!!! (up to 16 weeks of therapy)
88
urine sediment in nephrotic syndrome?
heavy proteinuria
89
what is vascular AKI?
intrinsic use of AKI d/t: - renal artery obstruction from thrombus, embolus, dissection, vasculitis - renal vein obstruction - microangiopathy (TTP, HUS, DIC) - scleroderma renal crisis
90
vascular AKI sx's?
LE rash, lived reticularis, urine eosinophils
91
tx for vascular AKI?
no tx just BP control and symptomatic management
92
common cause of post-renal failure?
bladder outlet obstruction -check with bedside U/S -> see no urine output d/t: -prostatic obstruction, bladder Ca, stone, clots
93
treatment for bladder outlet obstruction/post-renal failure (d/t obstruction)?
relief of obstruction -> bladder catheterization
94
what is polycystic kidney disease?
Multisystem and progressive genetic d/o w/cyst formation and enlargement of the kidney (and other organs i.e. Pancreas, liver, spleen)
95
where are cysts predominantly in polycystic kidney disease?
in the kidney (but can be in other organs like pancreas, liver, spleen)
96
pt with polycystic kidney disease may come in with what and at 2x the risk of what?
May come in with worst headache of their life | -at 2x the risk of intracranial aneurysm
97
polycystic kidney disease significant association with?
ESRD
98
polycystic kidney disease signs and sx's?
Pain (M/C) - abd, flank, back d/t enlargement of cysts, bleeding of cysts, kidney stones, infections Hypertension
99
need to image polycystic kidney disease pts for what?
for bleeding from the cysts
100
polycystic kidney disease are on a lot of what for their pain?
narcotics -> need chronic pain management
101
diagnostic for polycystic kidney disease?
U/S - see multiple cysts in the kidney Urinalysis - hematuria (d/t bleeding cysts)
102
polycystic kidney disease tx
BP management (ACEI/ARB - slows progression of disease) Pain control -> use narcotics - AVOID NSAIDs b/c promote bleeding and suppress auto-regulation - AVOID Tylenol b/c of liver cysts - surgical cyst decompression (done by IR) - Nephrectomy = LAST LINE Hematuria - hydrate and if a lot then transfuse - can bleed a lot
103
when to dialyze?
``` Acidosis Electrolytes (can't fix them) -***hyperkalemia***, hyperphosphatemia, hypocalcemia ``` Ingestions: OD Overload: -severe volume overload, esp on many IVs + anuria (on diuretics, but not peeing -> dialysis) Uremia -many sx's: CNS (asterixis, seizures, coma), platelet dysfxn (gi bleed, diathesis, coagulopathies), infectious risk, pleuritis/pericarditis (friction rub), pericardial effusion

Clin Med 3 (21 decks)

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