Therapeutics - Cassagnol AKI

Question 1

explain what an AKI is – what time period it occurs over

Answer 1

ABRUPT decrease in renal function. occurs over HOURS TO DAYS

Question 2

explain the negative things that are happening to a person with an AKI

Answer 2

nitrogenous wastes accumulating

can’t balance fluid and electrolytes

acid-base imbalance

oliguria/anuria

Question 3

what is the term for the accumulation of nitrogenous wastes?
(occurs in AKI)

Answer 3

azotemia

Question 4

differentiate between oliguria and anuria

Answer 4

oliguria – less than 400mL/ day of urine output

anuria - less than 50mL a day of urine output

Question 5

briefly, what is a CKD

Answer 5

PROGRESSIVE deterioration of kidney function. IRREVERSIBLE structural damage to the nephrons – can be early stage or late stage

lot of times due to HTN or diabetes

Question 6

define end stage renal disease (ESRD)

Answer 6

less than 15mL/min/1.73m OR need dialysis

Question 7

“chronic renal replacement therapy”

Answer 7

same as dialysis

if a pt needs - they have ESRD

Question 8

**macroalbuminuria and microalbuminuria

Answer 8

macroalbuminuria (proteinuria) – MORE THAN 300mg/24 hours of albumin in the urine

microalbuminuria - 30-300mg/24 hours of albumin in the urine

Question 9

Define dialysis

Answer 9

process that removes excess water and toxins from the body – these have accumulated bc of the patient’s renal function and they need to be removed by this “external kidney”

Question 10

true or false

it is normal to have a little bit of protein in the urine

Answer 10

FALSE - should be none

indicates damage to the basement membrane of the glomerulus

Question 11

true or false

only patients with CKD may need dialysis

Answer 11

FALSE

AKI may need it temporarily until their kidneys recover

Question 12

what is the MDRD equation and what is it used for

Answer 12

it’s an estimate of glomerular filtration rate (GFR) – determines baseline kidney function

1 of the things we can use to determine the STAGING of CKD

Question 13

true or false

the MDRD equation is NOT USED to determine kidney function in cases of AKI

Answer 13

TRUE

only used to stage in patients who have CKD. – patients who are validated as stable

Question 14

creatinine clearance is an estimate of….

Answer 14

GFR

Question 15

what equation is used to dose medications for patients with CKD

Answer 15

cockcroft gault equation

Question 16

cockcroft gault equation:

Answer 16

140-age (IBW) / 72 *Scr

multiply by 0.85 if female

Question 17

major limitation of creatinine clearance via cockcroft gault

Answer 17

MUSCLE MASS!! varies greatly, esp with age

therefore, for over 65, if SCr comes back less than 1, just round up to 1. if over 1 tho, just use that number

dont want to overestimate old ppl’s CrCl just bc their SCr is low due to decreased muscle mass

Question 18

2 ways to categorize AKIs

Answer 18

RIFLE

AKIN

Question 19

name all of the RIFLE classes

Answer 19

risk
injury
failure
loss of function
end stage kidney disease

Question 20

differentiate between the AKI RIFLE classes of “loss of function” and “end stage kidney disease”

Answer 20

loss of function - complete loss of function for over 4 weeks

ESRD - complete loss of function for over 3 months – getting to the chronic point

Question 21

when looking at AKI categorizing, the ____ change is more valuable than the ____ change

Answer 21

RELATIVE CHANGE more relative than absolute

-like a 3x decrease in GFR is significant — not just the number it is

Question 22

challenge with using urinary output to stage AKIs with RIFLE

Answer 22

pts may spill – really only way to get accurate value is with an indwelling category

Question 23

differentiate between the SCr bump between the RIF parts of RIFLE AKI staging

Answer 23

R - SCr bump 1.5x over baseline

I - SCr bump 2x over baseline

F - SCr bump 3x over baseline

Question 24

*anuria definition

Answer 24

less than 50 mL a day

Question 25

**which 2 lab values are used the MOST in order to diagnose an AKI

Answer 25

BUN and SCr BUN:SCr ratio should be LESS THAN 20:1 if over -- indicates decreased renal blood flow -- PRERENAL ISSUE!!!!

Question 26

what does FENa mean and what is it used for

Answer 26

fractional excretion of sodium can be used in the diagnosis of an AKI

Question 27

explain what these mean: FENa <1% FENa >2% FENa between 1-2%

Answer 27

if less than 1% -- the reabsorptive capacity of the kidney is INTACT if over 2% -- the reabsorptive capacity of the kidney is IMPAIRED due to the damage between 1-2% is inconclusive. usually due to a diuretic

Question 28

the BUN:SCr ratio is normal, but the kidneys are still failing what could this indicate

Answer 28

intra or post renal cause - not prerenal

Question 29

briefly differentiate between prerenal, function/intrinsic, and postrenal causes of AKI

Answer 29

prerenal - BEFORE KIDNEY issue. there is no structural damage to the kidney, but it is still failing. BUN:SCr ratio would be over 20 function/intrinsic - damage to the kidney itself -- ATN (acute tubular necrosis), AIN, etc postrenal - obstruction AFTER the kidney is causing it to fail. ureter obstruction -- stone, etc

Question 30

an AKI due to radio contrast media is considered to have what etiology

Answer 30

function/intrinsic -- called contrast-induced nephropathy

Question 31

most common functional cause of an AKI

Answer 31

ATN (acute tubular necrosis)

Question 32

*some drugs affect the afferent and efferent arterioles and can thus cause an AKI explain this

Answer 32

NSAIDS constrict the afferent arteriole and ACE's and ARBS dilate the efferent arteriole. this, along with a diuretic causing volume depletion, can lead to a SEVERE AKI due to lack of proper perfusion this is a PRERENAL cause

Question 33

patient develops an AKI due to depleted intravascular volume - also leading to hypotension and shock what is the etiology

Answer 33

prerenal

Question 34

name 3 drugs that can cause an AKI through direct damage to the kidney (function/intrinsic etiology)

Answer 34

quinolones penicillins sulfas

Question 35

true or false bladder obstruction is a postrenal cause of AKI

Answer 35

true

Question 36

crystallizing drugs that cause AKI have what etiology? name some

Answer 36

postrenal sulfonamides triamterene methotrexate acyclovir indinavir

Question 37

**2 MAJOR risk factors for getting an AKI

Answer 37

dehydration nephrotoxin exposure

Question 38

CIN (contrast induced nephropathy) presents within....

Answer 38

48 hours important to watch the patient and that they stay hydrated

Question 39

3 phases of AKI

Answer 39

oliguric phase (less than 400 mL/day) diuretic phase (sign that the kidneys are healing) recovery phase (days-months)

Question 40

***__________ is PARAMOUNT in terms of treating AKIs

Answer 40

finding and reversing the cause!!

Question 41

true or false drugs that have caused an AKI should be discontinued

Answer 41

true may be able to reinitiate depending on how much the patient needs the drug -- but if you do, lower the dose and monitor the patient more frequently

Question 42

pt had AKI .___ are preferred over ____ for analgesia

Answer 42

acetaminophen preferred over NSAIDS (they constrict the afferent arteriole!)

Question 43

treating AKI: -remove offending agent (may possibly restart when AKI resolves) what is the other important thing to do?

Answer 43

CORRECT THE PERFUSION ISSUE may need to add or take away fluid, and optimize meds

Question 44

AKI due to streptococcal glomerulonephritis is considered which category of etiology? what is the treatment?

Answer 44

intrinsic/function supportive care- loop diuretics, sodium/water/protein restriction to manage edema/proteinuria (if present) antibiotics, antihypertensives

Question 45

glomerulonephritis due to autoimmune/vasculitis what is the etiology? treatment?

Answer 45

intrinsic/function supportive treatment is immunosuppressants (bc immune mediated) -- corticosteroids, cyclophosphamide, azathioprine, etc

Question 46

treatment for an AKI caused by acute tubular necrosis

Answer 46

supportive care -- diuretics to help with the fluid and electrolyte imbalance NO DOPAMINE -- INEFFECTIVE (for both prevention AND treatment)

Question 47

how can ATN caused by contrast dye be prevented?

Answer 47

FLUIDS! - normal saline, sodium bicarb fluid, ascorbic acid, NAC

Question 48

dose of NAC for CIN prevention

Answer 48

600mg PO BID for 2 doses (before and after the contrast) AND concomitantly administer sodium bicarb

Question 49

2 drugs that need to be considered when trying to prevent contrast-induced nephropathy

Answer 49

if the pt is on metformin - need to hold before the contrast and for AT LEAST 48 hours afterwards bc risk of lactic acidosis also, avoid diuretics to flush the dye bc this can lead to volume depletion - a prerenal cause on its own!

Question 50

how to prevent ATN caused by aminoglycosides

Answer 50

use extended interval dosing over traditional dosing like BID or TID

Question 51

aminoglycosides cause ATN or AIN

Answer 51

ATN

Question 52

2 things that can cause ATN

Answer 52

contrast dye aminoglycosides

Question 53

AKI due to AIN treatment what category of etiology is this

Answer 53

d/c offending agent, and can consider corticosteroids intrinsic etiology

Question 54

AKI due to post renal etiology treatment

Answer 54

correct the obstruction -- if nephrolithiasis, encourage 2 LITERS OF FLUID A DAY!!! can add a thiazide diuretic and restricted sodium diet, allopurinol can also alkanalize the urine with potassium citrate or potassium-mg-citrate

Question 55

true or false pt got drug-induced AKI due to drug-induced post renal obstruction we need to ensure that we are giving the patient the correct renal dosing for that drug

Answer 55

true

Question 56

*indications for extracorporeal renal replacement therapy (dialysis)

Answer 56

AEIOU acid-base disorders electrolyte disturbances (hyperkalemia) drug Intoxication fluid Overload symptomatic uremia (high levels waste in blood)

Question 57

AKI and drugs

Answer 57

the risk-benefit for that drug needs to be assessed, and temporarily discontinuing (or permanently) also, every med the patient is taking that is eliminated by the kidneys needs to be reassessed and possibly reduced dose -- bc they can accumulate