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Stage 3 > Nephrology: AKI > Flashcards

Nephrology: AKI Flashcards

1
Q

What are the defining features of AKI?

A

1) Rapid (within 7 days)
2) Sustained (lasting > 24h)
3) Reduction in renal function
4) Resulting in oliguria + rise in serum urea and creatinine

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2
Q

Is AKI usually reversible?

A

Yes, unlike CKD

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3
Q

Which classification system is used to risk stratify AKI?

A

KDIGO

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4
Q

How many stages of AKI are there?

A

3

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5
Q

What are the features of stage 1 AKI?

A

1) Creatinine rise of 1.5x compared to baseline OR
2) Urine output < 0.5 ml/kg/hour for 6 hours

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6
Q

What are the features of stage 2 AKI?

A

1) Creatinine rise of 2x compared to baseline OR
2) Urine output < 0.5 ml/kg/hour for 12 hours

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7
Q

What are the features of stage 1 AKI?

A

1) Creatinine rise of 3x compared to baseline OR
2) Serum creatinine > 354 umol/d OR
2) Urine output < 0.3 ml/kg/hour for 24 hours OR
3) Anuria for 12 hours

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8
Q

How high does serum creatinine need to be for AKI to be classified as stage 3?

A

354

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9
Q

How long does anuria need to be present for AKI to be classified as stage 3?

A

12 hours

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10
Q

What are the risk factors for AKI?

A

1) CKD
2) Diabetes with CKD
3) Heart failure
4) Renal transplant
5) Age > 75
6) Hypovolaemia
7) Contrast administration

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11
Q

What are the 3 different categories for causes of AKI?

A

1) Pre-renal (55%)
2) Renal (35%)
3) Post-renal (20%)

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12
Q

What are pre-renal causes of AKI?

A

1) Shock - hypovolaemic, cardiogenic or distributive
2) Renovascular disease e.g. renal artery stenosis

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13
Q

What are renal causes of AKI?

A

1) Acute glomerulonephritis (dysfunction in the glomeruli)
2) Acute tubular necrosis (tubules)
3) Acute interstitial nephritis (interstitial)
4) Haemolytic uraemic syndrome or vasculitis (renal vessels)

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14
Q

What are the post-renal causes of AKI?

A

Caused by obstruction to urinary outflow
1) Kidney stones - luminal
2) Tumour of urinary tract - mural
3) Benign prostatic hypertrophy - external compression

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15
Q

What investigations do you do in AKI?

A

1) Bloods - FBC, U&E, LFT, glucose, clotting, calcium, ESR
2) ABG
3) Urine dip, MC&S, chemistry (U&E, CRP, osmolality, BJP/light chain)
4) ECG
5) CXR
6) Renal US
7) Glomerulonephritis screen - if cause is unclear

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16
Q

What might you see on ABG in AKI?

A

1) Hypoxia - due to oedema
2) Acidosis
3) Hyperkalaemia

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17
Q

What might you see on ECG in AKI?

A

Hyperkalaemia - tall, tented T waves

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18
Q

What might you see on a CXR in AKI?

A

Pulmonary oedema

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19
Q

How do you acutely assess/manage AKI?

A

1) A - is the airway compromised
2) B - AKI may be associated with critical illness and can result in pulmonary oedema
3) C - assess fluid status, if patient is hypovolaemic they will require IV fluid resuscitation
4) Any life-threatening complications should then be identified and treated e.g. hyperkalaemia, sepsis, pulmonary oedema
5) Identify and treat cause appropriately
6) Patient should be monitored carefully with regular observations, fluid status, and measurement of urine output (usually with a catheter) and U&Es

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20
Q

How do you acutely manage pulmonary oedema in AKI?

A

1) Sit the patient up
2) Give high flow oxygen
3) IV furosemide with diamorphine

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21
Q

How do you treat pre-renal AKI?

A

1) Give fluids if the patient is hypovolaemic
2) Give IV abx if the patient is septic
3) Stop nephrotoxic drugs

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22
Q

How do you treat renal AKI?

A

Nephrology review often required to identify less common causes of AKI

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23
Q

How do you treat post-renal AKI?

A

Catheterisation + urology review

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24
Q

What is important to remember to do in a patient with AKI?

A

Medication review - review the drug chart

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25
Q

How do you carry out a medication review for a patient with AKI?

A

1) Suspend nephrotoxic drugs - NSAIDs, aminoglycosides e.g. gentamicin, ACEi/ARBs and diuretics
2) Suspend renally excreted drugs e.g. metformin, lithium, digoxin
3) Adjust renally excreted drugs e.g. opioids

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26
Q

Which nephrotoxic drugs would you suspend in AKI?

A

1) NSAIDs
2) Aminoglycosides e.g. gentamicin
3) ACEi/ARBs
4) Diuretics

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27
Q

Which renally excreted drugs would you suspend in AKI?

A

1) Metformin - accumulates in renal failure, should be suspended when eGFR < 30
2) Lithium
3) Digoxin
4) LMWH - in severe AKI

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28
Q

What are indications for acute dialysis in AKI?

A

AEIOU
1) Acidosis - severe metabolic acidosis with pH < 7.2
2) Electrolyte imbalance - persistent hyperkalaemia > 7
3) Intoxication - poisoning
4) Oedema - refractory pulmonary oedema
5) Uraemia - encephalopathy or pericarditis

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29
Q

What are you checking for on renal US in AKI?

A

Checking for renal size, hydronephrosis

30
Q

Which contrast can cause AKI and how soon after contrast administration can AKI occur?

A

Gadolinium - nephrotoxicity characteristically causes an AKI within 72h of administration

31
Q

Which anticoagulant is safe in renal dysfunction?

A

Unfractionated heparin

32
Q

Which medication used in severe viral meningitis is protective against renal failure in patients with increased ICP?

A

IV mannitol

33
Q

What is CKD?

A

A gradual, irreversible decline in kidney function

34
Q

What are the KDIGO criteria for the presence of CKD?

A

Present for > 3 months:
1) Decreased GFR < 60 (on two blood tests three months apart) OR
2) Markers of kidney damage - albuminuria, electrolyte abnormalities, structural or histological renal abnormalities

35
Q

How many stages of CKD are there?

A

5 (1-5)

36
Q

Until which stage are patients with CKD typically asymptomatic?

A

Stage 4 or 5

37
Q

How is stage 1 CKD defined?

A

eGFR > 90 with demonstrable kidney damage e.g. haematuria or proteinuria

38
Q

How is stage 2 CKD defined?

A

eGFR 60-89 with demonstrable kidney damage e.g. haematuria, proteinuria or raised urine albumin/creatinine ratio

39
Q

How is stage 3 CKD defined?

A

eGFR 30-59

40
Q

How is stage 4 CKD defined?

A

eGFR 15-30

41
Q

How is stage 5 CKD defined?

A

eGFR < 15

42
Q

How long to changes in the eGFR have to be present to diagnose CKD?

A

3 months

43
Q

Which measure is used to diagnose CKD?

A

eGFR (± albumin:creatinine ratio) - NOT serum creatinine or urine output

44
Q

Which measures are used to diagnose AKI?

A

Creatinine + urine output

45
Q

What are the classifications of causes of CKD?

A

1) Glomerular
2) Vascular
3) Tubulointerstitial
4) Congenital
5) Systemic
6) Developmental

46
Q

Give one example each of a primary and secondary glomerular cause of CKD

A

1) Primary - IgA nephropathy
2) Secondary - SLE

47
Q

Give two examples of vascular causes of CKD

A

1) Vasculitis
2) Renal artery stenosis

48
Q

Give two examples of tubulointerstitial causes of CKD

A

1) Amyloidosis
2) Myeloma

49
Q

Give two examples of congenital causes of CKD

A

1) Polycystic kidney disease
2) Alport syndrome

50
Q

Give two examples of systemic causes of CKD

A

1) Diabetes
2) Hypertension

51
Q

Give one example of a developmental causes of CKD

A

Vesico-ureteric reflux causing chronic pyelonephritis

52
Q

What are the four most common causes of CKD?

A

1) Diabetes
2) Hypertension
3) Chronic glomerulonephritis
4) Polycystic kidney disease

53
Q

What are the complications of CKD?

A

CRF HEALS
1) Cardiovascular disease
2) Renal osteodystrophy
3) Fluid (oedema)
4) Hypertension
5) Electrolyte disturbance - hyperkalaemia, acidosis, uraemia, hyperphosphataemia, low calcium
6) Anaemia
7) Leg restlessness
8) Sensory neuropathy

54
Q

What are the U&Es results in CKD?

A

1) High urea and phosphate and potassium
2) Low calcium

55
Q

Why does CKD cause uraemia and hyperphosphataemia?

A

Bc of the kidney’s role of waste excretion

56
Q

Why does CKD cause hypertension and peripheral/pulmonary oedema?

A

Bc of the kidney’s role in regulation of fluid balance

57
Q

Why does CKD cause metabolic acidosis?

A

Bc of the kidney’s role in acid-base balance

58
Q

Why does CKD cause anaemia?

A

Bc of the kidney’s role in erythropoietin production

59
Q

Why does CKD cause hypocalcaemia?

A

Bc of the kidney’s role in activation of vitamin D

60
Q

What is the most common cause of death in CKD?

A

Cardiovascular disease

61
Q

What are the clinical features of renal osteodystrophy?

A

1) Osteoporosis - reduced bone density
2) Osteomalacia - reduced bone mineralisation
3) Secondary/tertiary hyperparathyroidism
4) Spinal osteosclerosis - Rugger Jersey spine

62
Q

What finding in the urine can diabetic nephropathy cause and what can this lead to?

A

Microalbuminuria - progression can lead to overt nephropathy and CKD

63
Q

How should microalbuminuria in diabetic nephropathy be assessed and managed?

A

1) All patients with diabetes > age of 12 should undergo regular urinary albumin:creatinine ratio to screen for microalbuminuria
2) If microalbuminuria is detected patients should be started on an ACEi

64
Q

What levels of albumin:creatinine ratio are the definitions for microalbuminuria?

A

1) Men > 2.5 mg/mmol
2) Women > 3.5 mg/mmol

65
Q

How do you manage oedema as a result of CKD?

A

1) Conservative measures incl. fluid and salt restriction
2) Medical management - use of diuretics e.g. furosemide

66
Q

How do you manage anaemia as a result of CKD?

A

Administer monthly subcutaneous erythropoietin with target Hb of 100-120

67
Q

How do you manage hypocalcaemia and hyperphosphataemia as a result of CKD?

A

1) Advise patients to restrict dietary potassium - found in dairy products and eggs
2) Sevelamer (a phosphate binder)
3) Alfacalcidol (a 1-hydroxylated vitamin D analogue)
4) Parathyroidectomy - option for patients with tertiary hyperparathyroidism

68
Q

How is tertiary hyperparathyroidism defined?

A

PTH > 28 mmol/L

69
Q

What are causes of a raised urea:creatinine ratio (i.e. raised urea)

A

1) Dehydration - although both urea and creatinine can be elevated in more severe cases
2) Upper GI bleed - due to gut bacteria breaking down blood proteins
3) ‘Protein meal’/high protein diet - urea is a major nitrogenous waste product of protein metabolism within the liver - patient who is muscular and using protein supplements

70
Q

What are causes of a decreased urea:creatinine ratio?

A

1) Occult hepatic dysfunction
2) Rhabdomyolysis - elevated creatinine kinase

71
Q

What level of albumin:creatinine ratio can help diagnose CKD?

A

> 3 mg/mmol

72
Q

What level of albumin:creatinine ratio can help diagnose CKD?

A

> 3 mg/mmol

Stage 3 (61 decks)

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