HYHO AKI Flashcards
(57 cards)
1
Q
Acute kidney injury is defined as what?
A
- Increase in serum creatine of >0.3 mg/dL within 48 hours or within 7 days
OR
- Urine output is less than 0.5mL/kg/hour for > 6hours
2
Q
What is cardiorenal syndrome?
A
a condition in which therapy to relieve congestive symptoms of HF is limited by a decline in renal funtion, manifested by reduced GFR.
3
Q
How is GFR calculated?
Give an example of how this can underestimate the degree of dysfunction.
A
- Calculated using creatnine, but this can underestimate the degree of dysfunction.
- For example, frail elderly person has lower muscle mass. Thus, if they have renal insuffiency, they may have NL or mild elevation of creatinine.
4
Q
Prerenal azotemia (BUN/Cr _____) is more common in ____.
A
BUN/Cr more than 20
HF
5
Q
How many patients with HF will develop moderate-severe kidney impairment?
A
30-60%
6
Q
What can cause pre-renal AKI?
A
- Hypovolemia
- Decreased CO
- Decreased effective circulating volume seen in CHF or liver failure.
- Impaired renal autoregulation due to NSAIDS, ACE-I or ARB, cyclosporine
7
Q
What can cause intrinsic AKI?
A
- Damage to glomerulus
- Damage to tubules and interstitium (ischemia, sepsis or infection or nephrotoxins)
- Vascular pathologies (vasculitis, malignant HTN or HUS-TTP)
8
Q
What causes post-renal AKI?
A
Obstruction distal to the kidney
9
Q
What can eliminate obstructive causes of kidney injury?
A
Lack of hydronephrosis on ultrasound
10
Q
On ultrasound, what will see in a patient with chronic kidney disease?
A
- Smaller kidneys
- Cortical thinning
- Cystic kidneys
11
Q
Exposure to IV contrast causes what effects in patients?
A
↑ in serum Creatinine within 48 hours.
12
Q
Urine Na+ _____ is expected with HF. What is this due to?
A
- Less than 25mEq/L
- Reduced renal perfusion, which causes [+ of RAAS and sympathetic NS].
13
Q
Urine Na+ is _____ in HF patients undergoing diuretic therapy.
A
Higher
14
Q
On PE, what can the following indicate:
- Blue toes
- Drug rash
A
- Blue toes: cholesterol emboli
- Drug rash: Acute intersitial nephritis (ANI)
15
Q
On PE, the following can indicate:
- - Signs of volume contraction (tachycardia, skin tenting, dry oral mucosa)
- - Jaundice or ascites
A
- - Signs of volume contraction (tachycardia, skin tenting, dry oral mucosa): dehydration
- - Jaundice or ascites: liver disease with portal HTN
16
Q
What are signs of volume contraction (_____)?
A
Dehydration
Tachycardia, skin tenting, dry oral mucosa.
17
Q
A patient with cardiorenal syndrome will have what 2 symptoms?
A
[Signs of volume overload + signs of HF]
18
Q
What can we perform on PE to see if a patient is dehydrated?
A
Skin tenting: pinch skin on forehead.
If dehydrated, skin will remain elevated.
19
Q
What are symptoms of AKI? (6)
A
- ↓ urine output
- Worsening dyspnea, including at rest, orthopnea and PND
- Worsening edema that bcomes ansarca or ascites
- Tachycardia (S3)
- Hypotension
- JVD
20
Q
What are signs of respiratory distress
A
1. Tachypnea
2. Hypoxia
3. Increased work of breathing
21
Q
Sudden dyspnea and orthopnea that awakens patient from sleep, causing the patient to sit or stand. Wheezing or coughing may be present.
A
Paroxysmal nocturnal dyspnea
22
Q
PND can be mimicked by what?
A
nocturnal asthma attacks
23
Q
Ansarca is severe generalized edema that extends from __________.
A
Lower extremity, proximally.
24
Q
Ansarca can cause _____ and is associated with what?
A
ascites and subcutaneous edema
HF, cirrhosis, severe malnutrition and renal failure
25
\_\_\_\_\_\_\_\_ detects large volumes of **free intrabdominal fluid.**
* **(+) finding:**
* **(-) finding:**
**Fluid wave**
* **(+) finding:** highly specific for ascites
* **(-) finding:** only 50% sensitive, so does NOT exclude ascites.
26
How is a **fluid wave** conducted?
* 1. Patient places ulnar surface of hand only midline of abdomen
* 2. Doc places one hand on one flank and taps the opposite flank
* 3. (+) sign: doc feels moderate to strong fluid wave on opposite side.
27
How is a **puddle sign,** a _______ sign, conducted?
**_Auscultory percussion sign_**
1. Patient is on all 4s for 5 minutes
2. Doc listens with diaphragm of stethoscope while flicking a flinger over flank, starting at lowest point and moving to opposite flank.
3. (+) sign: 40-50% sensitive in testing _ascites_
1. sudden increase in intensity and clarity of sound, signaling that the stethoscope and passed the edge of peritoneal fluid.
28
Sympathetic region of the:
* **Kidney**
* **Ureters (upper)**
* **Ureters (lower)**
* **Bladder**
* Kidney: T10-11
* Ureters (upper): T10-T11
* Ureters (lower): T12-L2
* Bladder: T12-L2
29
What **parasympathetic nerve** supplies:
* Kidney
* Ureters (upper)
* Ureters (lower)
* Bladder
* Kidney: **vagus nerve**
* Ureters (upper): **vagus nerve**
* Ureters (lower): **pelvic splanchnic nerve**
* Bladder: **pelvic splanchnic nerve**
30
What are the anterior and posterior **chapmans points** of the **kidney**?
**Anterior**: 1 inch lateral and 1 inch superior to belly button
**Posterior**: between TP of T12-L1 on ipsilateral side
31
What is the **Five Osteopathic Treatment Model** to hollistically treat a patient?
* **1. Biomechanical**
* **2. Respiratory/Circulatory**
* **3. Neurologic**
* **4. Metabolic/Energetic/ Immune**
* **5. Behavioral**
32
**Biomechanical approach:** Optimize structure and function of the musculoskeletal system to affect the body’s homeostatic mechanisms
**_What can be done to improve biochemical function of a AKI patient?_**
Examine
1. **SD of OA/AA**
2. **SD of T10-T11**
3. **SD of the psoas muscle**
33
What can be done to improve **respiratory/circulatory function** of a AKI patient?
1. **O2 via mask/nasal canula**
2. **Lymphatics**
1. Thoracic inlet MFR
2. Diaphragm
3. Thoracic area: pectoral traction, dome diaphramg, thoracic pump
4. Abdominal area: pump, sacral rocking, pelvic diapragm
5. Extremeties: effleurage, petrissage, pedal pump
6. Rib rasing
34
What **thoracic** and **abdominal lymphatic treatments** can be done on a patient with AKI?
**Thoracic**:
* pectoral traction
* dome diaphragm
* thoracic pump
**Abdominal diaphram:**
* pump
* sacral rocking
* pelvic diaphram
35
What lymphatic treatments can be done on **extremeties** in a patient with **AKI**?
* **effleurage/petrissage**
* **pedal pump**
36
what can be done to improve **neurlogic function** in patients with AKI?
* 1. **Examine parasympathetics/sympathetic** function of kidneys, ureters and bladder
* 2**. Chapmans points** of the kidney
* 3. **Rib raising**
37
How do we **alter metabolic/energic immune function** in patients with **AKI**? (4)
* 1. Give **loop diuretics**
* 2. **Restrict fluid** & **remove NSAIDS and PPI**
* 3**. Adjust meds** based on kidney fx
* 4. **Monitor** patients **intake/outtake** and **weight**
38
How can we alter **behavioral function** in a patient with AKI?
* 1. **Excercise**
* 2. **Diet** (restrict fluids)
* 3. **Avoid offending agents**
* 4. **Manage CHF better**, which is what caused AKI
*
39
What are the possible mechanisms to cause **AKI** in a patient with **AHF**?
* 1. Hemodynamic changes =\> + sympathetic NS =\> + RAAS, ↑ vasopression (ADH) and endothelin release =\> ↑ Na+ and H20 retention =\> **↑ systemic vasoconstriction**
* ↑ cardiac afterload =\> ↓ CO =\> ↓ renal perfusion
* 2. **↓ renal perfusion**
* 3. **↑ renal vein pressure,** caused by ↑ intra-abdominal/central venous pressure =\> **↓ GFR**
* 4. **Associations with** **HF with preserved EF**
* Renal dysfunction can lead to metabolic derangements, causing systemic inflammation and microvascular dysfunction=\> cardiomyocyte stiffening, hypertrophy and interstitial fibropsis .
40
**Central venous pressure** and **GFR** are \_\_\_\_\_\_\_-related.
**Inversely**
41
What 2 other effects does systemic vasoconstriction caused by HF cause?
1. **Disproportional reasborption** of **urea**, compared to **creatinine**
2. **Overwhelm** vasodilator/natriuretic effects of NPs, NO, prostaglandins and bradykinin.
42
The first thing to do in the face of **AKI (low GFR)** is to do what?
1. **Remove offending agents (**NSAIDS, PPIs, ACE-I/ARBS, IV contrast).
43
If there is no offending agent causing the low GFR, a \_\_\_\_\_\_\_should be given next
**Loop diuretic (furosemide),** adjusting the dose based on renal function.
44
When is **dialysis (aka \_\_\_\_\_)** initiated?
When must it end?
**Dialysis (renal replacement therapy)**
* Patient progresses to **oliguira** or **anuria**, causing changes in fluid, electrolye and acid-base balance.
* Continue until renal function is reovered or if renal support is not goal of tx anymore.
45
What other treatments should be done in a patient with AKI? (6)
* 1. Supportive care (O2)
* 2. Monitor weight/ intake and outatake
* 3. Fluid restriction (oral and IV)
* 4. Monitor electrolytes
* 5. Assign a case manager
* 6. Diet consult
46
What should patients with **AKI** avoid using?
**K+ sparing diuretics (spironolactone),** because they can make it harder to manage K+.
47
Why is it important to monitor electrolytes, Mg, Phosphate, BUN/Cr?
electrolyte abnormalities can cause **arrhythmias**
48
When should **case managers** be involved?
**Early in care**, especially if there are new complications or signs of worsening.
49
When must advanced directives, code status, DPAHC be addressed?
**Early in hospitalization**
50
Long-term management of AKI includes what?
* 1. Discuss dialysis and end of life matterns (will and DPAHC)
* 2. Avoid nephrotic drugs, like OTC NSAIDS and PPIs
* 3. Monitor electrolytes, weight and fluid status regularly.
51
What is the difference between a **living will** and a **DPAHC**?
* **Living will:** summarizes choices about future medical care (resuscitation, life support, feeding tube, dialysis, intubitation and ventilator)
* **DPAHC (durable power of attorney for healthcare):** gives another person right to make decision about patients healthcare
52
Advanced care planning allows what?
how quickly is it done and using what approach?
what is the doctors role
* - patients to talk to docs and family about end-of life issues.
* - takes many visits
* - team approach (interprofessional -- case manager and nurse staff)
* - give information about prognosis and treatment options to help the pt make decision based on cost/risk and values.
53
If the patient has elected some restriction (do not resuscitate, intubate) in living will, **what must the doctor do?**
**DOCUMENT THE ORDER APPROPRIATLEY,** because the prescence of the LW alone will NOT prevent resusictation.
54
**Stage 1** of **KDIGO** is defined as
## Footnote
- Creatine criteria
- UO criteria
* 1. ↑ in serum Cr of \>0.3 or 50-99%
OR
* 2. Urine output \<0.5mL/kg/hr for 6 - 12 hrs
55
**Stage 2 of KDIGO** is defined as an...
## Footnote
- Creatine criteria
- UO criteria
1. ↑ in serum Cr **100-199%**
OR
2. Urine output **\<0.5mL/kg/hr** for **12 - 24 hrs**
56
**Stage 3 of KDIGO** is defined as..
- Creatine criteria
- UO criteria
1. ↑ in serum Cr more than 200%
OR
2. ↑ in serum Cr of 0.3 mg/dL to \>4.0 mg/dL
OR
3. Urine output \<0.5mL/kg/hr for more than 24 hours or anuria for 12 or more hours
OR
4. Initiation of dialysis
57
in patients **less than 18 YO,** _stage 3 AKI_ is defeined as what
**GFR less than 35mL/min**
