Week 3

Question 1

definition of AKI?

Answer 1

GFR reduced abruptly (<48 hrs) w/sudden retention of normally cleared endogenous and exogenous metabolites

Question 2

death dt AKI occurs how?

Answer 2

due to acidosis, high K, fluid accumulation

Question 3

groups at increased risk of AKI and KD failure?

Answer 3

DM T2, those w/HTN, geriatrics

Question 4

general presentation of AKI?

Answer 4

Azotemia (N&V, malaise, altered sensorium) Arrythmias from hyperkalemia
Ecchymoses from platelet dysfunction Pericardial effusion, cardiac tamponade
Seizures from electrolyte imbalance Fasciculations and muscle cramps
Perioral paresthesias from hypocalcemia Peripheral edema
Skin/nail pallor Hyper- or hypo volemia

Question 5

general lab findings w/AKI?

Answer 5

increased serum Cr
decreased urine output (<0.5 mL/kg/hr)
BUN rises first

Question 6

MC type of RF?

Answer 6

prerenal failure

Question 7

causes of prerenal failure?

Answer 7

decreased intravascular volume
changes in vascular resistance
low CO

Question 8

ssxs of prerenal failure?

Answer 8

dehydration, thirst, dizziness, mental status changes

poor skin turgor, collapsed neck veins, dry mucous membranes, hypotensive, orthostatic BP changes, tachycardia

Question 9

Oliguria (<400ml/d) (IF<100 mL emergency!)
Dipstick: little protein, SG >1.020
Normal microscopic UA: no cells or casts seen Urine osmolality (>350 mOsm/kg)
Urine sodium < 20 mEq/L
FeNa <1%
HIGHER BUN/creatinine >20:1 (faster inc in BUN–azotemia)

Answer 9

prerenal failure UA findings

Question 10

management and tx of prerenal failure?

Answer 10

tx underlying cause
rapid fluid replacement, IV vol expansion
may need vasopressor drugs (dopamine) to elevate BP and increase renal flow
discont anti-HTN or diuretics
support for reperfusion to KDs: silymarin, garlic

Question 11

prognosis of prerenal failure?

Answer 11

good and reversible if not damage to renal cells persists and renal blood flow doesn’t fall below 20% of normal

Question 12

causes of intrarenal failure?

Answer 12

injury in renal tubules, interstitium and vasculature leading to loss of fxn
ATN
AIN
acute GN
acute PN
vascular diseases

Question 13

presentation of intrinsic renal failure?

Answer 13

salient hx of URI, diarrhea
use of abx or IV drugs
back pain, gross hematuria, fever (PN)
maculopapular rash (possible with AIN)
dehydration and shock

Question 14

UA: SG <1.010 if tubular cz, ≥1.020 if glomerular cz Urine osmolality; <300 mOsm/kg
Urine sodium >30 mEq/L if tubular cz, <20 if glomerular cz
FeNa >2-3%
Casts: Granular=ATN, AIN
WBC casts=PN
RBC casts=PSGN
Eosinophiluria=AIN
CBC: anemia or infection
CMP: Inc BUN and Creatinine levels
BUN/Creatinine ratio is LOWER: 10-15:1 (as Cr rises)
Early in course Cystatin C will rise when creatinine is still normal (more specific marker)
Dec serum complement, circulating immune complexes
Renal BX will show characteristic changes

Answer 14

intrarenal failure

Question 15

postrenal failure is dt what?

Answer 15

urinary flow from BOTH KDs obstructed which leads to increased nephron intraluminal back P and decreased GFR

Question 16

causes of postrenal failure?

Answer 16

obstruction of urine flow dt prostatic enlargement, tumors, urolithiasis, renal V stenosis, neurogenic bladder, post-surgical or trauma, meds

Question 17

ssxs of postrenal failure?

Answer 17

renal pn and tenderness, lower abd pn, post-surgery urine lead, over-hydration, edema, ileus w/abd distention, enlarged prostate on DRE, distended bladder

Question 18

Lab: urine osmolality variable;  
Urine spec gravity >1.010 early, <1.010 late
Urine sodium <20 early, >40 late
high BUN and creatinine, BUN/Cr 10-20 
Microscopic UA: crystals or hematuria
US: may show hydronephrosis
Cystoscopy may show ureteral obstruction
CT or MRI may show mass causing obstruction, hydronephrosis, kinked ureter, Contrast agent-use

Answer 18

postrenal failure

Question 19

management and tx of postrenal failure?

Answer 19

rapidly tx the obstruction with catheterization or stent

Question 20

general pt management for all types of AKI/ARF?

Answer 20

determine and treat cause
assess pts vital force
initiate appropriate referral
assess degree of uremia, electrolyte/mineral imbalance and HTN
assess need for ECG, CXR
cystatin C to monitor KD injury
protein intake decreased
monitor vitals, fluid intake and urine output daily; monitor BUN/Cr, electrolytes until stable and then 2-3x/wk with total protein, albumin, glucose, Hct, Hgb 3x/wk
consider rheum, salvia, cordyceps, urtica
antioxidants and anti-inflammatories: vit C, vit E, CoQ10
remove food allergens
support reperfusion: Renafood, silymarin, garlic

Question 21

criteria for CKD?

Answer 21

GFR < 60 mL/min per 1.73m^2

Question 22

common causes of CKD?

Answer 22

glomerulopathies
tubulointerstitial nephropathies
heredity
obstructive nephropathy
vascular abn

Question 23

general symptoms of CKD?

Answer 23

HTN, edema, osteodystrophy, anemia of chronic dz, uremia

Question 24

symptoms of uremia?
General
Skin
ENT
Eye
Pulmonary
CV
GI
GU
Neuromuscular
Neurologic/ME

Answer 24

Fatigue, weakness
Pruritis, easy bruising
Metallic taste, epistaxis
SOB
Dyspnea on exertion, retrosternal pn on inspiration
Anorexia, N&V, hiccup
Nocturia, impotence
Restless legs, numbness, cramps in legs
Irritability, poor concentration
depression

Question 25

``` signs of uremia? General Skin ENT Eye Pulmonary CV GI GU Neuromuscular Neurologic/ME ```

Answer 25

``` Sallow-appearing Pallor, ecchymosis, edema Urinous breath Pale conjunctiva Crackles, pleural effusion Hypertension, cardiomegaly, friction rub Isosthenuria Stupor, asterixis, myoclonus, peripheral neuropathy ```

Question 26

stages of CKD?

Answer 26

1 GFR >90 - normal or high 2 GFR 60-89 - mildly decreased 3a GFR 45-59 - mildly to moderately decreased 3b GFR 30-44 - moderately to severely decreased 4 GFR 15-29 - severely decreased 5 GFR <15 - kidney failure

Question 27

treatment considerations for CKD

Answer 27

``` monitor BP/temp/pulse/weight optimize nutrition limit protein, Na, Ph; optimize Ca maintain close Ca and Ph balance; keep Ca x Ph below 65 to avoid metastatic calcifications monitor fluid intake and urinary output keep emunctories functioning (charcoal enema, skin brushing, hot mud baths, fever tx, salt bath, mineral bath, wet sheet wrap) support diuresis as needed tx and control: HTN, hypercholesterolemia, hyperglycemia support blood vessel integrity: vaccinium, cratageus, quercetin, bioflavonoids decrease or eradicate renal inflammation: anti-inflam diet, fish oil, ground flax, Salvia, panax, gingko, urtica carnitine replenish tyrosine renal protomorphogen epoetin alfa good quality multivitamin uva ursi, juniper, solidago, eupatorium protective antioxidants - curcumin, coptic, CoQ10, vit C, ALA PUFAs melatonin 3 mg homeopathics diathermy to KDs, COPs gentle resistance exercise manipulation smoking cessation acupuncture/acupressure/ ear seeds mindfulness meditation monitor thyroid fxn, heart fxn, hormones ```

Question 28

major indications for dialysis?

Answer 28

ARF, CRF (Cr clearance <8 mL/min), anuria

Question 29

two forms of dialysis?

Answer 29

peritoneal (intracorporeal) | extracorporal (hemodialysis and hemofiltration)

Question 30

a. Can do at home or in the office b. One year of treatment can cost $53,000. c. Risk of peritoneal infection.

Answer 30

peritoneal dialysis

Question 31

a. Dialysis unit 3-4 hrs/d, 3-4 times per wk (some possibility of home) b. One year of treatment can cost $72,000 c. Requires artificial AV shunt

Answer 31

extracorporeal dialysis

Question 32

3 forms of peritoneal dialysis?

Answer 32

CAPD CCPD IPD

Question 33

indications for peritoneal dialysis?

Answer 33

``` ARF awaiting hemodialysis infxn in CRF pts long-term home care for non-ambulatory pts, elderly, kids preoperatively to transplant ```

Question 34

benefits of peritoneal hemodialysis over extracorporal?

Answer 34

peritoneal reduces protein loss, much better control of K and Ph levels and rarely need water and Na restriction b/c 2 L/d removed in peritoneal fluid

Question 35

SEs of peritoneal hemodialysis

Answer 35

large amount of CHOs --> hyperglycemia, obesity, dyslipidemia, hypotension from sodium depletion, decreased appetite hypokalemia infections and sepsis perforate an abd organ chronic use can cause sclerosis, BO, hypothyroidism, seizures, pneumonia, hypoalbuminemia, arrhythmias

Question 36

protective and replacement herbs and nutrients for pt on peritoneal hemodialysis?

Answer 36

carnitine, fish oil, pantethine, iron citrate or bisglycinate, pyridoxine and cobalamin, biotin, vit E, capsaicin for pruritus EPO to offset anemia anabolic steroid to stimulate EPO and counter sarcopenia

Question 37

extracorporeal hemodialysis requires what concomitant txs? each tx can cause what?

Answer 37

heparin to offset clots | each tx reduces BUN by 50%, relieves hyperK, corrects metabolic acidosis but all are fleeting effects

Question 38

SEs of extracorporal hemodialysis?

Answer 38

``` nutritional deficiencies fever and sepsis seizures hyperhomocysteinemia hypotension muscle cramps/restlessness hyperlipidemia arrhythmias insomnia hypoalbuminemia pruritus dementia ```

Question 39

concomitant therapies with extracorporal hemodialysis?

Answer 39

``` moderate protein restriction sufficient carb to maintain kcal water 400-500 mL plus urine lost/d restrict K, Na EFA supplementation water soluble vitamin supplementation ```

Question 40

advantages and disadvantages of renal transplant?

Answer 40

advantages: reestablishment of nearly normal constant body physiology and chemistry dis: BM suppression, susceptibility to infxn, cushingoid body habitus, psychological uncertainty of homograft's future, later there can be dz in transplanted KD, increased incidence of CA, GU infxn

Question 41

post renal transplant support?

Answer 41

fish oil to decrease thrombosis control HTN, hypercholesterolemia, hyperglycemia support bvs supportive care: CoQ10, centella, rheum, salvia, magnesium protect KD and liver from cyclosporine: gingko, cordyceps, silybum treat cyclosporine induced gout: flaxseed oil, urtica decrease risk of rejection: ginkgo, silybum, fish oil protect from renal re-perfusion injury: ALA, quercetin, curcumin, NAC, coptis, garlic