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Scientific Basis of Medicine > The Case Of The Injured Kidneys > Flashcards

The Case Of The Injured Kidneys Flashcards

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1
Q

Intravenous Contrast Media - Used in … (3)

A
  • Contrast enhanced plain films –IVU
  • CT scanning
  • Angiography / interventional procedures
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2
Q

Intravenous Contrast Media - What is it, what does it do and how is it given?

A
  • Iodinated hydrocarbon ring
  • Iodine atomic number 53
  • Increases absorption of x-rays
  • Injected intravenously
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3
Q

Side effects of iodinated contrast (5)

A
  • Warmth / Flushing
  • Headache
  • Nausea
  • Itching / rash
  • Metallic taste
  • These do NOT indicate allergy to contrast
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4
Q

Reactions to contrast (Allergy)

A
  • Urticaria
  • Bronchospasm
  • Laryngeal oedema
  • Hypotension
  • Generalised anaphylaxis
    • Incidence of severe reactions: 0.04%
    • Incidence of major anaphylaxis: 0.004%
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5
Q

Reactions to contrast (Allergy)

  • Incidence of severe reactions: …%
  • Incidence of major anaphylaxis: …%
A
  • Urticaria
  • Bronchospasm
  • Laryngeal oedema
  • Hypotension
  • Generalised anaphylaxis
    • Incidence of severe reactions: 0.04%
    • Incidence of major anaphylaxis: 0.004%
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6
Q

Patients at risk of contrast reaction

A
  • Previous contrast reaction
  • Asthma (6 times increase risk of reaction)
    • NOT shellfish allergy or topical Iodine reaction
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7
Q

Contrast reaction - what do we give?

A
  • Oxygen and IV fluids,
  • Anti-hystamine – chlorphenamine 10mg
  • Hydrocortisone – 200mg
  • Adrenaline(IM) – 1:1000 (500mcg initially)
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8
Q

RCR recommendations - contrast

A
  • Doctor available whenever IV contrast is injected
  • If risk factors – decision to inject contrast is taken by radiologist only.
  • Patient never left alone in first 5 mins after injection
  • Facilities / drugs for treating reaction readily available
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9
Q

Contrast-Mediated Nephrotoxicity

  • Nephrotoxicity:
    • defined as …% increase in serum creatinine 48-72hrs following contrast injection
    • A leading cause of hospital acquired …, with increased in-hospital/1yr mortality
  • Direct cytotoxic effect on proximal renal tubules (and exacerbate renal vasoconstriction)
A
  • Nephrotoxicity:
  • defined as 25% increase in serum creatinine 48-72hrs following contrast injection
  • A leading cause of hospital acquired AKI, with increased in-hospital/1yr mortality
  • Direct cytotoxic effect on proximal renal tubules (and exacerbate renal vasoconstriction)
  • Risk of Nephrotoxicity if:
  • renal impairment (raised creatinine)
  • Diabetes
  • Metformin therapy
  • Caution if dehydration, high dose of contrast, CCF
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10
Q

Risk of Nephrotoxicity if:

  • …. impairment (raised …)
  • D…
  • … therapy
  • Caution if …, … dose of contrast, CCF
A

Risk of Nephrotoxicity if:

  • renal impairment (raised creatinine)
  • Diabetes
  • Metformin therapy
  • Caution if dehydration, high dose of contrast, CCF
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11
Q

Preventing contrast induced AKI

  • Stop …. (48hrs post contrast injection)
  • Pre- and post-hydration (oral/IV) – intra-vascular volume expansion maintains renal perfusion
  • Use of contrast is on a risk Vs benefits basis
    • e.g. Trauma or cancer imaging.
  • …. mandated if:
    • History of renal disease or DM
    • …. dose of CM than average
    • If using IA route that will directly expose the kidneys to a larger/more concentrated dose
A
  • Stop Metformin (48hrs post contrast injection)
  • Pre- and post-hydration (oral/IV) – intra-vascular volume expansion maintains renal perfusion
  • Use of contrast is on a risk Vs benefits basis
    • e.g. Trauma or cancer imaging.
  • eGFR mandated if:
    • History of renal disease or DM
    • Larger dose of CM than average
    • If using IA route that will directly expose the kidneys to a larger/more concentrated dose
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12
Q

Preventing contrast induced AKI

  • Stop Metformin (… post contrast injection)
  • Pre- and post-hydration (oral/IV) – intra-vascular volume expansion maintains renal …
  • Use of contrast is on a risk Vs benefits basis
    • e.g. Trauma or cancer imaging.
  • eGFR mandated if:
    • History of renal disease or ….
    • Larger dose of CM than average
    • If using IA route that will directly expose the kidneys to a larger/more … dose
A
  • Stop Metformin (48hrs post contrast injection)
  • Pre- and post-hydration (oral/IV) – intra-vascular volume expansion maintains renal perfusion
  • Use of contrast is on a risk Vs benefits basis
    • e.g. Trauma or cancer imaging.
  • eGFR mandated if:
    • History of renal disease or DM
    • Larger dose of CM than average
    • If using IA route that will directly expose the kidneys to a larger/more concentrated dose
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13
Q

Imaging in AKI

  • Exclude …. – i.e. is obstruction the cause of the AKI
  • s…
  • …: TCC, prostate, gynae
  • 1st Investigation – renal …
A
  • Exclude hydronephrosis – i.e. is obstruction the cause of the AKI
  • Stones
  • Tumour: TCC, prostate, gynae
  • 1st Investigation – renal U/S
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14
Q

CT Imaging- Kidneys

  • Left image shows - Right … – normal size kidneys (preserved …. thickness)
  • Right image shows - Left …. –
A
  • Right hydronephrosis – normal size kidneys (preserved cortical thickness)
  • Left hydronephrosis – 5mm stone dependent in renal pelvis ? Further stone in ureter?
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15
Q

Nephrostomy Insertion

A
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16
Q

Renal sepsis:

  • ….:
    • U/S is usually normal in acute ….
    • CT often normal. May be oedema, debris, gas or perinephric stranding
A
  • Pyelonephritis:
    • U/S is usually normal in acute pyelonephritis
    • CT often normal. May be oedema, debris, gas or perinephric stranding
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17
Q

Peri-nephric abscess

  • Left - Large … within the perinephric fat posterior to the kidney
  • Right - … from …. obstruction. Perinephric abscess extening into … muscle
  • Both of these abscesses can be drained under…guidance (exactly the same technie as the nephrostomy)
A
  • Left - Large abscess within the perinephric fat posterior to the kidney
  • Right - Pyelonephritis from stone obstruction. Perinephric abscess extening into psoas muscle
  • Both of these abscesses can be drained under U/S guidance (exactly the same technie as the nephrostomy.
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18
Q

Reminder of key functions - Kidneys

  • Fill in the blanks
A
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19
Q

Reminder of key functions - Kidneys

  • Fill in the blanks
A
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20
Q

What is kidney failure?

  • Loss of … …
    • –Irreversible, slow, progressive….CKD
      • Urine output …
    • –Potentially reversible, rapid onset…AKI
      • Oliguria (low urine output)
      • Anuria (no urine output)
  • Degrees of failure
    • Stages 1-… in CKD
    • Stages 1-… in AKI
A
  • Loss of functioning nephrons
      • –Irreversible, slow, progressive….CKD
        * Urine output preserved
        • –Potentially reversible, rapid onset…AKI
          • Oliguria (low urine output)
          • Anuria (no urine output)
  • Degrees of failure
    • Stages 1-5 in CKD
    • Stages 1-3 in AKI
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21
Q

What is kidney failure?

  • Loss of functioning nephrons
    • –Irreversible, slow, progressive……..
      • Urine output preserved
    • –Potentially reversible, rapid onset…….
      • … (low urine output)
      • …. (no urine output)
  • Degrees of failure
    • Stages 1-5 in ….
    • Stages 1-3 in ….
Study These Flashcards
A
  • Loss of functioning nephrons
    • –Irreversible, slow, progressive….CKD
    • Urine output preserved
      • –Potentially reversible, rapid onset…AKI
    • Oliguria (low urine output)
    • Anuria (no urine output)
  • Degrees of failure
    • Stages 1-5 in CKD
    • Stages 1-3 in AKI
22
Q

Degrees of failure - Kidneys

23
Q

What can go wrong? - Kidney tubules

24
Q

What can go wrong? - Kidney Glomeruli

25
What can go wrong? - Kidney Blood Vessels
26
What can go wrong? - Kidney Interstitium
27
_Effects of diabetes on the glomerulus_
28
_Pathogenesis of diabetic kidney disease_ 1. Podocyte damage leading to ... 2. High glucose environment— - \> reactive oxygen species-\>vascular endothelial cell damage 3. Tubulo-interstital and glomerular ...
1. Podocyte damage leading to albuminuria 2. High glucose environment— - \> reactive oxygen species-àvascular endothelial cell damage 3. Tubulo-interstital and glomerular fibrosis
29
_Who gets diabetic kidney disease?_
30
_Tubules_
31
What is ATN?
Acute tubular necrosis (ATN) is a kidney disorder involving damage to the tubule cells of the kidneys, which can lead to acute kidney failure.
32
Types of injury in ATN - Ischaemic (8)
* Diarrhoea, vomiting * Bleeding * Dehydration * Burns * Renal losses via diuretics or osmotic diuresis * Third fluid sequestration (e.g nephrotic syndrome) * Oedematous states such as heart failure and cirrhosis cause reduced kidney perfusion. * Coagulopathy, such as disseminated intravascular coagulation
33
Types of injury in ATN - Toxic (9)
* Aminoglycosides * Amphotericin B * Acyclovir * Cisplatin * Cidofovir * Uric acid (gout) * Light chain accumulation (myeloma) * Myoglobin (rhabdomyolysis) * Ethylene glycol
34
Types of injury in ATN - Sepsis (3)
* Systemic hypoperfusion * Endotoxins leading to vasoconstriction * Inflammatory cytokines-àROS-àinjury
35
_AKI: What works? Goals of therapy are to prevent AKI or need for RRT_ * Effective……….. Once AKI is present * ... (...% saline) * Prevent ... * Avoid ... * Treat ... * Specific treatment (mostly ...)
* Effective……….. Once AKI is present * Hydration (0.9% saline) * Prevent hypotension * Avoid nephrotoxins * Treat obstruction * Specific treatment (mostly immunosuppression)
36
The ... compartment is affected in all the forms of renal disease.
The tubulointerstitial compartment is affected in all the forms of renal disease.
37
AKI - drug causes
* Gentamicin * Vancomycin * NSAIDS * Ethlyene glycol
38
AKI - UTI causes
* Leptospirosis * CMV
39
Renal Blood Vessels
40
_Renal vascular disease_
41
Final common pathway
42
_Treatments in CKD_ * Each condition might have specific treatment. * e.g. Diabetes-good ... control * e.g. ....-iv fluids including iv bicarbonate * .../... (like ramipril) * ... inhibitors (like dapagliflozin)
* Each condition might have specific treatment. * e.g. Diabetes-good glycaemic control * e.g. Rhabdomyolysis-iv fluids including iv bicarbonate * ACEi/ARB (like ramipril) * SGLT2 inhibitors (like dapagliflozin)
43
Renal replacement therapy comprises either .... or ....
Renal replacement therapy comprises either transplantation or dialysis
44
Renal Function: responsible for ... (4)
* Excretion of waste * Maintenance of extracellular fluid(ECF) volume and composition * Hormone synthesis(erythropoeitin, vitamin D, Renin/Aldo) * Also contribute to gluconeogenesis
45
Kidneys receiving ...% of cardiac output
46
* Kidneys receiving 25% of cardiac output * Blood → glomerular capillary tuft → glomerular filtrate * Glomerular filtrate is ultrafiltrate of ... * Glomerular filtrate has similar composition to ... except ... * Total filtration rate of the kidneys depends on ... pressure, osmotic pressure and integrity of ... membrane
* Kidneys receiving 25% of cardiac output * Blood → glomerular capillary tuft → glomerular filtrate * Glomerular filtrate is ultrafiltrate of plasma * Glomerular filtrate has similar composition to plasma except protein * Total filtration rate of the kidneys depends on hydrostatic pressure, osmotic pressure and integrity of basement membrane
47
* Normal Glomerular filtration rate (GFR) is approximately ... ml/min ˷ 170L/24h much of it is reabsorbed in proximal convoluted tubules(PCT) * Estimated GFR (eGFR) is used in clinical practice
* Normal Glomerular filtration rate (GFR) is approximately 120 ml/min ˷ 170L/24h much of it is reabsorbed in proximal convoluted tubules(PCT) * Estimated GFR (eGFR) is used in clinical practice
48
_Biochemical investigation of kidney function Creatinine_
Creatinine origin
49
_Biochemical investigation of kidney function Creatinine - limitations (5)_
* Creatinine starts to rise only when there is a significant decline in glomerular filtration (~50% glomeruli lost) * Serum levels can increase with ingestion of large amounts of meat * Patient with fluid overload has a lower serum creatinine due to dilution of blood * Malnutrition and inactivity decreases muscle mass, thus decrease serum creatinine * Sensitivity of serum creatinine in mild to moderate renal impairment is poor.
50
*GFR vs serum creatinine Levey et al Ann Int Med 1999*
51
``` _Biochemical investigation of kidney function Creatinine Clearance (Ccr) - GFR_ ``` * To assess GFR(clearance test) : measuring the urinary excretion of a substance that is completely ..., not secreted, reabsorbed or metabolised * - Inulin, iohexol– meet the criteria but not suitable in routine clinical use, rarely used as rarely required to accurately measure GFR (kidney donor assessment) * -The most widely used clearance test is Ccr, (Cr is secreted by renal tubules but negligible when GFR is normal) * Cr Clearance = U x V/P (ml/min) * U= Urinary Cr concentration -µmol/L * V= Urine flow rate -ml/min * P= Plasma Cr concentration - µmol/L
* To assess GFR(clearance test) : measuring the urinary excretion of a substance that is completely filtered, not secreted, reabsorbed or metabolised * - Inulin, iohexol– meet the criteria but not suitable in routine clinical use, rarely used as rarely required to accurately measure GFR (kidney donor assessment) * -The most widely used clearance test is Ccr, (Cr is secreted by renal tubules but negligible when GFR is normal) * Cr Clearance = U x V/P (ml/min) * U= Urinary Cr concentration -µmol/L * V= Urine flow rate -ml/min * P= Plasma Cr concentration - µmol/L
52

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