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CDM 1 Exam 2 > Renal: Lecture 2 > Flashcards

Renal: Lecture 2 Flashcards

1
Q

What to look for in drug induced kidney disease?

A

Still looking for doubling in SCr due to medications

Depends on predisposing factors, not everyone will develop

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2
Q

Combo of drugs that can cause kidney issues

A

“Triple Whammy” = ACEi + Diuretic + NSAID

“Nephrotoxic quartet” = ACEi, NSAID, Aminoglycosides, radio contrast media

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3
Q

“Triple Whammy”

A

due to each drug affecting kidney function through different mechanisms

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4
Q

Diuretic will lead to….

A

decreased fluid volume

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5
Q

ACEi/ARBs will lead to….

A

Efferent dilation

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6
Q

NSAIDs will lead to….

A

afferent constriction

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7
Q

What increase Kidney susceptibility to injury

A

Drug-related factors = what drug does to kidney
Kidney-related factors = what happens in kidney
Host-related factors

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8
Q

Angiotensin II is responsible for ….. of the efferent arteriole

A

Constriction

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9
Q

Prostaglandins are responsible for ….. of the afferent arteriole

A

Dilation

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10
Q

Common medications causing Prerenal AKI

A

NSAIDs
ACE/ARBs
Calcineurin inhib

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11
Q

Renal modulators of Hemodynamic autoregulation

A

Angiotensin II
Prostaglandins
Endothelin and Norepi

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12
Q

Pre-disposing factors for DI pre renal AKI

A

Reduced renal blood flow state
Reduced perfusion pressure due to low volume state

Those who relay on renal modulators to keep normal eGFR, these meds will “tip the balance”

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13
Q

How can diuretics/ hyperosmolar radio contrast dyes tip the balance?

A

decrease blood volume

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14
Q

How can NSAIDs tip the balance?

A

decrease renal prostaglandins

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15
Q

How can ACEi/ARBs tip the balance?

A

alter AT2

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16
Q

Which agents alter calcium and endothelin

A

Radiocontrast agents, Cyclosporine

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17
Q

Which agents cause histamine release with Hypotension

A

Radiocontrast agents

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18
Q

Risk for NSAIDs is primarily in patients with…

A

preexisting low flow/volume states or conditions

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19
Q

Prerenal AKI NSAIDs clinical presentation

A 
Low FeNA <1%
Low urine Na
Urine osm >500
Normal urinalysis
BUN:SCr > 20:1
Oliguric (dark, tea-colored pee)

onset 1-5 days of start/dose increase NSAID
time to recovery ~2-7day, based on mechanism of drug
All NSAIDs should be suspect, indomethacin greatest risk

20
Q

Which NSAID has greatest risk for Prerenal AKI

A

Indomethacin, most potent

21
Q

Prevention and Treatment NSAIDs Prerenal AKI

A

Use analgesics with less PG effect

Use lowest dose of NSAID in high-pt

Avoid potent agents

Discontinue drug, usually reversible state

22
Q

Prerenal AKI - ACEi/ARBs pathogenesis

A

Lower the tone of efferent arteriole, which may be maintaining perfusion pressure in select patients

Reduce intraglomerular hydrostatic pressure leading to reduced filtration in select patient

23
Q

Patients who develop Prerenal AKI from ACEi and ARBs usually have….

A

Severe renal artery stenosis
CHF
CKD

24
Q

Pathogenesis of impaired auto regulation with ACEi/ARBs

A

Blocks AT2 = dilation of efferent arteriole = reduction in back pressure/intraglomerular pressure = decreased perfusion pressure and filtration

25
Prerenal AKI - ACEi/ARBs Risk factors
``` CHF CKD (Scr >1.6) Severe renal artery stenosis Concomitant diuretic use concomitant NSAID use Salt restricted diet/hypoantremia ```
26
Prevention and Treatment ACEi/ARB pre renal AKI
start low, titrate upward slowly (start sort acting agent) reduce diuretic dose "diuretic holiday" Counsel patients what to monitor Monitor SCr and Serum K Monitor for more than predictable rise in SCr
27
How does radiocontrast media cause pre renal AKI?
enhance effects of endothelin (vasoconstriction of afferent), caution in patients with similar predisposing causes Need to hydrate w/ NaCL prior to dye study
28
How can loop diuretics and metolazone cause prerenal AKI
Cause dehydration, monitor body weight daily to assess fluid loss monitor urine color and frequency
29
Most common drug-induced AKI in inpatient setting?
Drug induced ATN
30
Most common medications in drug induce ATN
Radiocontrast media | Aminoglycosides
31
Radiocontrast media associated with...
dialysis 3rd leading cause of inpatient AKI and 34% inpatient mortality
32
risk factors for ATN w/ Radiocontrast media
``` underlying diabetic nephropathy or CKD Age >75 CHF Volume depletion Aggressive diuresis ```
33
radiocontrast pathogenic mechanism
cause transient pre renal azotemia (via endotelio) and progressive non-oliguric or oliguric ATN mechanism complex and not fully understood
34
Which radio contrast media are we generally concerned with?
Ionic monomers and dimers
35
Contrast induced nephropathy (CIN)
**Defined as increase in SCr by 0.5 mg/dL or 25% from baseline **Usually begins 24-48hrs after procedure, peak in 3-5 days, returns to baseline in 7-10 days can extend hospital stay + costs usually transient and nonoliguric severe form presents as ATN
36
CIN Pathogenesis
1st Renal Hemodynamic changes which can progress into direct tubular toxicity, acute tubular necrosis
37
CIN Risk factors
occurs in <2% pop Highest Risk: DM w/ SCr >1.5, CrCl <60 Other: Age >75, HF, Hypotension, Volume depletion, anemia, high dose of radiocontrast (>140ml) and repeated doses,
38
CIN Risk assessment
Chart used to calculate risk of CIN and Risk of Dialysis. Each risk gets a score and its all added together
39
CIN preventative Strategies
Avoidance when possible, consider alternative imaging techniques If pt req contrast: DC metformin and NSAIDs 48hr prior Gold standard: pre/post hydration start 12hr before/12hr after for high risk patients 1ml/kg/hr NaCL
40
Has any medical or mechanical treatment been proved to be efficacious in reducing risk of CIN?
No
41
Crystal Nephropathy mechanism
Precipitation of crystals in distal tubular lumen = obstruct urine flow/create back pressure = illicit interstitial reaction
42
Common meds causing Crystal Nephropathy
Antibiotics: Ampicillin, cipro, sulfonamides Antivirals: acyclovir, foscarnet, indinavir Methotrexate Triamterene
43
Risk factors for Crystal Nephropathy
Volume Depletion CKD Excessive Dose IV admin
44
Preventing postrenal drug induced AKI
DC or reduce dose of drug ensure adequate hydration Establish high urine flow Admin orally when possible
45
General management of Drug induced KD
short term: stop progression of kidney damage Long term: restore normal kidney function ``` General: Stop offending agent avoid concomitant nephrotoxin maintain hydration RRT if needed ```

CDM 1 Exam 2 (16 decks)

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