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Week 227 - Acute Renal Injury Flashcards

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1
Q

Week 227 - Acute Renal Injury: What are the pre-renal causes of Acute Renal Failure?

A

• Due to disturbance in renal blood supply.

- E.g. Hypotension/Hypovolaemia, Cirrhosis, renal artery stenosis.

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2
Q

Week 227 - Acute Renal Injury: What are the renal/intrinsic causes of Acute Renal Failure?

A

• Damage to the parenchyma of the kidney itself.

- E.g. glomerulonephritis, acute tubular necrosis, acute interstitial nephritis.

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3
Q

Week 227 - Acute Renal Injury: What are the post-renal causes of Acute Renal Failure?

A

• Usually a consequence of urinary tract obstruction.

- E.g. BPH, renal stones, obstructed urinary catheter, bladder stones or malignancy.

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4
Q

Week 227 - Acute Renal Injury: What is Rhabdomyolysis?

A
  • Skeletal muscle breakdown secondary to injury.
  • For example following strenuous exercise, trauma or infection.
  • Leading to the leakage of potentially toxic intracellular contents into the blood stream,
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5
Q

Week 227 - Acute Renal Injury: What is the ‘triad’ of Rhabdomyolysis?

A

1) Myalgia
2) Generalized weakness
3) Tea-coloured urine.

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6
Q

Week 227 - Acute Renal Injury: How can rhabdomyolysis cause acute renal failure?

A
  • Obstruction with haem pigment casts.
  • Proximal tubular injury by haem iron.
  • Volume depletion (Damaged muscles can accumulate fluid over time, causing a reduction in circulating volume).
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7
Q

Week 227 - Acute Renal Injury: What are some of the non-traumatic causes of rhabdomyolysis?

A
  • Marathon runners
  • Hot weather
  • Hypokalaemia
  • Prolonged convulsions
  • Metabolic myopathy
  • Malignant hyperthermia
  • Hypothermia
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8
Q

Week 227 - Acute Renal Injury: Which drugs can cause rhabdomyolysis?

A

• Alcohol, opiates, statins, colchicine, cyclosporin.

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9
Q

Week 227 - Acute Renal Injury: How is rhabdomyolysis induced AKI diagnosed?

A
  • History
  • Red to brown urine
  • Elevated serum enzyme level - CK, LDH
  • Electrolyte abnormalities.
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10
Q

Week 227 - Acute Renal Injury: Which electrolyte abnormalities do you get with rhabdomyolysis induced AKI?

A
  • Hyperkalaemia
  • Hyperphosphatamia
  • Hyperuricaemia
  • Hypocalcaemia (However, you will get hypercalcaemia in the recovery phase)
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11
Q

Week 227 - Acute Renal Injury: What are the preventative options for stopping rhabdomyolysis causing AKI?

A
  • Fluid repletion - Improve renal perfusion, washout obstructing casts.
  • Forced alkaline diuresis - Using Sodium Bicarbonate - Reduces myoglobin precipitation.
  • Forced diuresis - Using Mannitol.
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12
Q

Week 227 - Acute Renal Injury: What is Mannitol used for and what are the complications of its use?

A
  • Osmotic diuretic - Forced diuresis - Free radical scavenger.
  • Can cause hypernatraemia.
  • And can cause increased plasma osmolality and volume expansion in those with poor renal function.
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13
Q

Week 227 - Acute Renal Injury: What are urinary casts?

A
  • They are cylindrical structures formed in the distal convoluted tubules.
  • They are primarily made from tubular mucoprotein (Tamm-Horsfall protein).
  • The presence of the them in urine microscopy can signify a number of disease states.
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14
Q

Week 227 - Acute Renal Injury: The presence of a red blood cell cast can indicate which disease state?

A

• Patients with glomerular haematuria.

- E.g. glomerulonephritis.

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15
Q

Week 227 - Acute Renal Injury: The presence of a white blood cell cast indicates which disease state?

A

• Acute pyelonephritis or interstitial nephritis.

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16
Q

Week 227 - Acute Renal Injury: The presence of a fatty cast indicates the presence of which disease state?

A

• Lipiduria

- E.g. nephrotic syndrome.

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17
Q

Week 227 - Acute Renal Injury: What is nephrotic syndrome?

A

• This is where the permeability of the walls of the glomerulus is increased resulting in proteinuria.

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18
Q

Week 227 - Acute Renal Injury: The presence of a pigmented cast indicates the presence of which disease states?

A
  • Haemoglobinuria

* Myoglobinuria

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19
Q

Week 227 - Acute Renal Injury: What is the shape of calcium oxalate crystals?

A

Square, enveloped shapes.

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20
Q

Week 227 - Acute Renal Injury: What is the shape of a triple phosphate crystal? What does it indicate?

A
  • Coffin lid shape.
  • Alkaline urine
  • Proteus UTI
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21
Q

Week 227 - Acute Renal Injury: What shape are uric acid crystals? What does their presence indicate?

A
  • Diamond shaped.

* Hyperuricaemia.

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22
Q

Week 227 - Acute Renal Injury: What is the definition of clearance (In terms of measuring renal function)?

A
  • Volume of plasma cleared of substance in unit time.

* Measured as the volume of indicator removed from plasma divided by average plasma concentration during a given time.

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23
Q

Week 227 - Acute Renal Injury: What are the limitations of using creatinine clearance to measure renal function?

A
  • Difficult, time consuming.
  • Inaccurate urine collections.
  • Diurnal and day-to-day variations in creatinine clearance.
  • Not adjusted for age,gender,race etc.
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24
Q

Week 227 - Acute Renal Injury: What is the eGFR, clinical findings and treatment of stage one of CKD?

A
  • Normal kidney function but urine findings or structural abnormalities point to kidney disease.
  • eGFR 90+
  • Observation, control of BP.
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25
Week 227 - Acute Renal Injury: What is the eGFR, clinical findings and treatment of stage two of CKD?
* Mildly reduced kidney function and urine/structural/genetic findings point to kidney disease. * eGFR 60-89 * Observation, control of BP, Control of risk factors.
26
Week 227 - Acute Renal Injury: What is the eGFR, clinical findings and treatment of stage three of CKD?
* Moderately reduced kidney functions. * eGFR 30-59 * Observation, control of BP, Control of risk factors.
27
Week 227 - Acute Renal Injury: What is the eGFR, clinical findings and treatment of stage four of CKD?
* Severely reduced kidney function. * eGFR 15-29 * Planning for end stage renal failure.
28
Week 227 - Acute Renal Injury: What is the eGFR, clinical findings and treatment of stage five of CKD?
* Very severe, or end stage renal failure. | * eGFR
29
Week 227 - Acute Renal Injury: What is the RIFLE criteria?
• Categorizes the degree of renal failure into, - Risk - Injury - Failure - Loss - End stage kidney disease
30
Week 227 - Acute Renal Injury: What are the pulmonary complications of acute kidney injury?
* Fluid overload > Pulmonary oedema * Increased pulmonary vascular permeability. * Leucocyte migration * Pulmonary haemorrhage * Infection * ARDS
31
Week 227 - Acute Renal Injury: What are the CNS complications of acute kidney injury?
* Inflammatory reaction * Acidosis * Electrolyte imbalance * Confusion * Convulsions * Altered conscious levels * Coma
32
Week 227 - Acute Renal Injury: What are the cardiac complications of acute kidney injury?
* Acidosis * Sympathetic overactivity * Hypertension * Pericarditis * Arrhythmia * Cardiac hypertrophy * Heart Failure * MI
33
Week 227 - Acute Renal Injury: What characterises pre-renal acute renal failure?
``` • Intravascular volume depletion. • Decreased effective blood volume. • Altered intrarenal haemodynamics - Afferent vasoconstriction - Efferent vasodilation ```
34
Week 227 - Acute Renal Injury: What are the characteristics of intrinsic acute renal failure?
* Acute tubular necrosis * Acute interstitial nephritis * Acute glomerulonephritis * Acute vascular syndromes
35
Week 227 - Acute Renal Injury: What is third space sequestration?
* Accumulation of fluid in the third space - i.e. the transcellular compartment. * Can be a result of bowel obstruction, peritonitis, pancreatitis, ascites. * Can result in hypovolaemia resulting in acute renal injury.
36
Week 227 - Acute Renal Injury: How can third space sequestration clinically manifest?
* Respiratory compromise. * Decreased cardiac output. * Intestinal ischaemia. * Hepatic dysfunction. * Oliguric renal failure - Oliguria occurs when intra-abdominal pressure exceeds 15mmHg, with anuria developing when the pressure exceeds >30mmHg.
37
Week 227 - Acute Renal Injury: How is third space sequestration treated?
• Abdominal decompression. - Paracentesis - Surgical decompression
38
Week 227 - Acute Renal Injury: What is the normal GFR?
120 ml/min, >7L/hr
39
Week 227 - Acute Renal Injury: In cases of partial post-renal obstruction, what dysfunction does the distal tubule experience in terms of concentration and acid/base balance?
* Reduced concentration - Polyuria | * Loss of acidification resulting in a metabolic acidosis.
40
Week 227 - Acute Renal Injury: In terms of history and examination, what may indicate post-renal failure?
* History - Colic, stone disease, polyuria, nocturia, Haematuria, DM, Neurological condition. * Examination - Palpable bladder, bladder scan, post-micturition residual urine, KUB ultrasound scan.
41
Week 227 - Acute Renal Injury: What type of acute kidney injury is acute tubular necrosis?
Intrinsic
42
Week 227 - Acute Renal Injury: What are some of the causes of acute tubular necrosis?
• Ischaemic - e.g. Hypotension, Sepsis. • Nephrotoxic - Drug-induced e.g. Aminoglycosides, cisplatinum, paracetamol. - Pigment nephropathy - Intravascular haemolysis, rhabdomyolysis.
43
Week 227 - Acute Renal Injury: What is the most common form of intrinsic acute renal failure?
• Acute Tubular Necrosis (ATN)
44
Week 227 - Acute Renal Injury: What is the mortality rate of uncomplicated ATN?
7%-23%
45
Week 227 - Acute Renal Injury: 50% of radiocontrast nephropathies develop after which procedures?
• Cardiac diagnostic and interventional procedures.
46
Week 227 - Acute Renal Injury: What are the risk factors for developing radiocontrast nephropathy?
* Pre-existing renal disease. * DM * Hypertension * ACEI, NSAIDs * Volume depletion * Large volume of contrast
47
Week 227 - Acute Renal Injury: How can the risk of developing radiocontrast nephropathy be reduced?
* Low-osmolality contrast media. * IV fluid (Antioxidants, N acetyl cysteine, diuretics, IV sodium bicarbonate)
48
Week 227 - Acute Renal Injury: What are the causes of Acute tubulo-interstitial nephritis?
* Drug-induced - Penicillins, cephalosporins, sulfonamides, rifampicin, frusemide, NSAIDs. * Infection - Bacterial, viral, rickettsial disease, tuberculosis.
49
Week 227 - Acute Renal Injury: What (from history, signs, examination, investigations) would lead you to consider acute tubulo-interstitial necrosis?
* History - Exposure, drug/infection. * Fever * Rash * Arthralgia * Oesinophilia * Biopsy - cellular infiltrate.
50
Week 227 - Acute Renal Injury: How do you treat acute tubulo-interstitial necrosis?
* Withdraw the offending agent/ treat infection. * Steroids. • Has a very good outcome.
51
Week 227 - Acute Renal Injury: What are the three life-threatening complications of acute kidney injury?
* Metabolic Acidosis * Hyperkalaemia * Acute pulmonary oedema
52
Week 227 - Acute Renal Injury: How is the serum anion gap calculated?
``` AG = Cations - Anions AG= Na + K - Cl - HCO3 ```
53
Week 227 - Acute Renal Injury: What occurs during normal anion gap metabolic acidosis? What causes it?
* Acidosis is due to loss of bicarbonate, this is replaced by chloride resulting in a normal anion gap. * Can be caused by diarrhoea, renal tubular acidosis.
54
Week 227 - Acute Renal Injury: What occurs to give an increased anion gap metabolic acidosis? What can cause it?
* Increased acid production with anion other than Cl. | * Can be caused by lactic acidosis, DKA, Renal failure, Methanol, Ethylene Glycol.
55
Week 227 - Acute Renal Injury: What is the clinical effect of a metabolic acidosis?
* Muscle weakness * Altered mental state * Kussmaul breathing * Hyperkalaemia * Hypotension
56
Week 227 - Acute Renal Injury: What is Kussmaul breathing?
* Deep and labored breathing. | * Associated with severe metabolic acidosis.
57
Week 227 - Acute Renal Injury: What is the treatment of metabolic acidosis?
* Treat the cause! * Volume expansion * IV sodium bicarbonate (Only in severe acidosis
58
Week 227 - Acute Renal Injury: What are the effects of hyperkalaemia?
* Muscle weakness * Constipation * Cardiac effects * ECG changes - loss of P wave, AV block, bradycardia, V tachycardia, asystole.
59
Week 227 - Acute Renal Injury: What are the ECG changes associated with hyperkalaemia?
* Loss of p waves. * AV block * Bradycardia * V tachycardia * Asystole
60
Week 227 - Acute Renal Injury: What are the treatment options for hyperkalaemia?
* Treatment of the cause! * IV fluid * Bicarbonate therapy * IV dextrose insulin - shifts K into intracellular.
61
Week 227 - Acute Renal Injury: What are the four main mechanisms for maintaining blood pressure?
1) Sympathetic stimulation. 2) Stimulation of renin-angiotensin system. 3) Mechanisms to retain fluid - Thirst + ADH 4) Retaining sodium
62
Week 227 - Acute Renal Injury: How does sympathetic activation maintain blood pressure?
1) Tachycardia and increased cardiac contractility | 2) Peripheral vasoconstriction > Diverting blood to vital organs.
63
Week 227 - Acute Renal Injury: What are the key steps in the renin-angiotensin pathway? Pro-Renin > Aldosterone
Pro-renin > Renin converts Angiotensinogen > Angiotensin I > Angiotensin II (Angiotensin II has a number of effects)
64
Week 227 - Acute Renal Injury: ACE is responsible for what step in the renin-angiotensin system?
Conversion of angiotensin I into angiotensin II.
65
Week 227 - Acute Renal Injury: What are the 5 effects of angiotensin II?
1) Increases sympathetic activity. 2) Tubular Na, Cl reabsorption and K excretion, H20 retention. 3) Stimulates adrenal cortex to release aldosterone. 4) Arteriolar constriction. 5) Stimulates posterior pituitary gland to increase ADH secretion.
66
Week 227 - Acute Renal Injury: Where are the juxtaglomerular cells?
Afferent arterioles.
67
Week 227 - Acute Renal Injury: Where is the macula densa?
Distal tubular cells.
68
Week 227 - Acute Renal Injury: What occurs in the kidney in response to a low GFR?
* You will get decreased tubular flow rate. Results in, * Decreased Cl delivery to macular densa. The Macula densa then, * Decreases afferent arteriolar resistance, which, * Increases renal blood flow, which * Increases glomerular pressure, causing an * Increase in tubular flow.
69
Week 227 - Acute Renal Injury: How does the kidney respond to high BP?
Afferent arteriolar constriction in order to protect the glomeruli.
70
Week 227 - Acute Renal Injury: How does the kidney respond to low BP?
• Barostretch receptors are triggered causing afferent dilation and an increase in angiotensin II causing efferent constriction and an increase in glomerular pressure.
71
Week 227 - Acute Renal Injury: How does a high GFR affect the kidney?
• Rise in tubular flow, causing an increased delivery of Na and Cl to the macula densa, there is then afferent constriction to reduce glomerular pressure.
72
Week 227 - Acute Renal Injury: What effect does angiotensin II have on the afferent/efferent arterioles?
Constricts both. However efferent is already narrower, so has the net effect of increasing glomerular pressure.
73
Week 227 - Acute Renal Injury: What can cause the dilation of the afferent arterioles?
* Prostaglandins * Ca channel blockers * Decreased tubular flow rate.
74
Week 227 - Acute Renal Injury: What can cause constriction of the afferent arterioles?
* Increased barostretch * Increased tubular flow rate * Increased sympathertic activity * NSAIDs * Angiotensin II
75
Week 227 - Acute Renal Injury: What is the effect of volume depletion in the kidney?
* Decreased barostretch > Afferent dilation. * Increased sympathetic tone > Increased renin. * Increase in Renin and ATII > Rise in GFR * Increase of Na absorption in proximal convoluted tubules due to ATII. * Decreased delivery of NaCl to macula densa which also decreases afferent resistance.
76
Week 227 - Acute Renal Injury: What does losartan do?
• Angiotensin receptor blocker.
77
Week 227 - Acute Renal Injury: What blood flow is required for effective dialysis?
200ml/min
78
Week 227 - Acute Renal Injury: What is a Scribner shunt?
An external AV shunt used to dialysis. Goes from the radial artery into a vein in the arm (Ulna side). Or ankle.
79
Week 227 - Acute Renal Injury: What is hyponatraemia?
• Low sodium (
80
Week 227 - Acute Renal Injury: What can cause the pituitary to release more ADH?
* Angiotensin II * Sympathetic stimulation * Hyperosmolarity * Hypovolaemia * Hypotension
81
Week 227 - Acute Renal Injury: How does Vasopressin/ADH increase arterial pressure?
* V1 receptors - Causes vasoconstriction | * V2 receptors - Renal fluid reabsorption
82
Week 227 - Acute Renal Injury: What are the causes of high plasma osmolality, than can in turn cause hyponatraemia?
* Hyperglycaemia, DKA * Mannitol * Hyperlipidaemia * Glycine solutions
83
Week 227 - Acute Renal Injury: How is serum osmolality calculated?
(2x serum Na) + serum glucose + plasma urea
84
Week 227 - Acute Renal Injury: What are the causes of hyponatraemia with a normal/high serum osmolality?
* Renal failure - Uraemic solutes compensate for low osmolality. * Marked hypoglycaemia, DKA * Mannitol therapy - Osmotic diuresis.
85
Week 227 - Acute Renal Injury: What is pseudohyponatraemia?
Hyponatraemia caused by severe hyperlipidaemia or hyperproteinaemia.
86
Week 227 - Acute Renal Injury: Hyponatraemia can result from which three main mechanisms?
* High ADH * Low ADH * high plasma osmolality.
87
Week 227 - Acute Renal Injury: How can excessive exercise cause hyponatraemia?
* Increased water intake | * Exercise stimulates ADH secretion
88
Week 227 - Acute Renal Injury: How does MDMA cause life threatening hyponatraemia?
* Increased CNS level of serotonin, norepinephrine and dopamine. * Increased plasma level of ADH, prolactin, cortisol, ACTH. * Have a direct effect on water retention and thirst centre.
89
Week 227 - Acute Renal Injury: How does hyponatraemia occur when there is appropriate suppression of ADH?
* Renal failure - Impairment in water excretion. | * Primary polydipsia (thirst) - May be due to antipsychotic drugs, hypothalamic lesions, beer drinkers.
90
Week 227 - Acute Renal Injury: How does hyponatraemia clinically manifest?
• The severity of the symptoms reflect the severity of cerebral oedema. - Nausea, confusion. - Headache, lethargy. - Convulsions, coma.
91
Week 227 - Acute Renal Injury: What investigations should be performed for suspected hyponatraemia?
* Serum osmolality * Urine osmolality * Urinary Na concentration
92
Week 227 - Acute Renal Injury: What investigation results would suggest SIADH?
* Low serum osmolality * Low serum Na * Low blood urea * High urine osmolality * High urinary Na * Normal acid/base balance * Normal adrenal and thyroid function.
93
Week 227 - Acute Renal Injury: What is the management of hyponatraemia?
* Treat underlying cause! * Fluid restriction * Salt replacement * Loop diuretics * ADH receptor antagonist
94
Week 227 - Acute Renal Injury: What should the rate of correction be in both acute and chronic hyponatraemia?
* Acute - safe to correct rapidly. * Chronic - Risk of osmotic demyelination - Increase by 10 in 1st 24hrs - Increase by 18 in next 24 hrs.
95
Week 227 - Acute Renal Injury: Which drugs can cause hypokalaemia?
* Thiazide diuretics | * Loop diuretics
96
Week 227 - Acute Renal Injury: Which drugs can cause hyperkalaemia?
* ACE inhibitors * Angiotensin receptor blockers * Spironolactone
97
Week 227 - Acute Renal Injury: The long term use of which drugs may cause irreversible renal damage?
* Aminoglycosides (gentamicin) | * NSAIDs
98
Week 227 - Acute Renal Injury: Which drugs can cause rhabdomyolysis / High CK?
* Statins | * Calcineuin inhibitors : Cyclosporin / tacrolimus
99
Week 227 - Acute Renal Injury: What is the most appropriate investigation? A patient presented with ARF, chest symptoms, urine dipstock showed blood +++ and protein +++.
Renal Biopsy
100
Week 227 - Acute Renal Injury: What is the most appropriate investigation? Patient presented with ARF, fever, night sweats, dysuria and loin pain.
Urine microscopy looking for cell casts, urine culture.
101
Week 227 - Acute Renal Injury: What is the most appropriate investigation? An elderly patient developing ARF 4 days after knee replacement.
Urinary Na
102
Week 227 - Acute Renal Injury: What is the most appropriate investigation? Patient with symptoms of poor stream, dribbling hesitancy and nocturia developing a gradual rise of serum urea and creatinine.
Physical examination and bladder scan.
103
Week 227 - Acute Renal Injury: Choose the electrolyte abnormality. ARF after a marathon run.
Hypocalcaemia
104
Week 227 - Acute Renal Injury: Choose the electrolyte abnormality. Recovery phase of ARF due to rhabdomyolysis.
Hypercalcaemia
105
Week 227 - Acute Renal Injury: Choose the electrolyte abnormality. ARF after introduction of ACE inhibitor in a patient with chronic heart failure.
Hyperkalaemia
106
Week 227 - Acute Renal Injury: Choose the electrolyte abnormality. Chronic use of thiazide diuretics.
Hypokalaemia
107
Week 227 - Acute Renal Injury: Match the following urinary casts to the pathological conditions. RBC cast.
Glomerulonephritis
108
Week 227 - Acute Renal Injury: Match the following urinary casts to the pathological conditions. WBC cast.
Pyelonephritis
109
Week 227 - Acute Renal Injury: Match the following urinary casts to the pathological conditions. Fatty casts.
Nephrotic syndrome
110
Week 227 - Acute Renal Injury: Match the following urinary casts to the pathological conditions. Pigmented casts.
Rhabdomyolysis

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