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CPR M2T1E3 > #12 Press - Acute Kidney Injury > Flashcards

#12 Press - Acute Kidney Injury Flashcards

1
Q

What constitutes acute kidney injury?

A
  • Increase in serum creatinine of = or > 0.5 mg per deciliter over the baseline value
  • hours to days
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2
Q

Patient comes in with orthostatic hypertension with presence of edema. Upon examination you hear a pericardial rub. What type of offending agents might have induced the acute kidney injury?

A
  • IV contrast
  • antibiotics
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3
Q

What labs would you order to investigate AKI?

A

BUN/creatinine ratio (>20:1 is consitent with pre-renal azotemia)

Chem7 - electrolytes and acid/base status

UA - look for WBC/RBC/granular casts

US - exclude obstruction

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4
Q

Is all elevated creatinine AKI?

A

NO Factitious ARF also has elevated creatinine.

Bactrim can interfere with creatinine levels, showing increased creatinine.

Opposite is also true. Elderly, malnutrition and liver disease patients may have AKI without elevated creatinine.

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5
Q

You look at the patient’s file at the hospital and their creatinine is at 6. Is this acute or chronic kidney disease?

A

You would need their history to determine. If their baseline has been 6 for years then chronic. If their baseline was 1 a year ago –> acute.

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6
Q

Is all elevated BUN AKI?

A

No.

Steroids

Increased catabolic rate (febriile, bed-bound, septic ICU)

Tetracycline

Parenteral nutrition

GI bleed

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7
Q

Patient’s labs show a FeNa less than 1%. What type of AKI is most likely?

A

Pre-renal azotemia

[FeNa >2% is likely ATN]

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8
Q

What are the ddx for a FeNa less than 1%?

A

Renal Artery Stenosis

Acute GN

Non-oliguric ATN

ATN when pigment or contrast nephropathy

Early urinary tract obstruction

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9
Q

FeNa is over 1%. What pre-renal ddx might it be?

A

Elderly

CKD

Diuretic use

Poor nutritional intake

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10
Q

What are the most common causes of pre-renal azotemia?

A

Decreased intravascular volume

  • hemorrhage
  • renal losses (osmotic diuresis, DI, salt wasting nephritis)
  • GI losses (V/D)
  • Insensible losses (fever, mechanical respiration)
  • 3rd spacing (burns, pancreatitis, peritonitis, Ileus)
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11
Q

How will low BP affect kidneys?

A

Low perfusion

No BP, no pee pee

Decrease cardiac output can lead to pre-renal azotemia

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12
Q

In what scenarios might you find decreased cardiac output leading to pre-renal azotemia?

A

Acute MI

CHF

Pulmonary embolus

Cardiac tamponade

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13
Q

Patient in the hospital with peripheral vasodilation could be due to?

A

BP meds

Gram-negative shock

Anaphylactic reaction

Hepato-renal syndrome

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14
Q

Which drugs are the biggest offenders of increased vascular resistance causing pre-renal azotemia?

A

NSAIDS

Calcineurin inhibitors (cyclosporine)

Radiocontrast dye

ACE/AT II inhibitors

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15
Q

Patient has a fast rise in creatinine and granular casts are seen in urinalyssis. FeNa is above 2%. What type of AKI is the patient likely to have?

A

ATN

Most severe in the early proximal tubule

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16
Q

What are the two major histological changes in ATN?

A

Loss of intact or necrotic tubular changes

Occlusion of the tubular lumen by cellular debris

17
Q

Identify

A

ATN

Muddy brown casts

Cola casts

18
Q

Identify

A

ATN

Loss of nuclei

19
Q

Labs return and the patient’s BUN:Cr is 12:1 and FeNa is > than 2%. Specific gravity is isosthenuric 1.010. What do you suspect?

A

ATN

Tx: Dopamine may be HARMFUL

Minimize hypotension

Remove offending agents

Diuretics to convert oliguric ATN to non-oliguric ATN*

*DOES NOT Decrease mortality

20
Q

What are indications for dialysis?

A

AEIOU (**Digoxin is not dialyzable)

Acidosis

Electrolytes

Intoxicants (LISA MET BARB)

[LIthium, SAlicylates, Methanol, Ethylene glycol, Theophylline, BARBituates]

Overload

Uremia

21
Q

65 year old man with diabetes and a creatinine of 4 mg/dL comes in complaining of chest pain but is worried about having to go on dialysis from contrast nephropathy. What imaging would you use that would not need radiocontrast agents?

A

US

MRI

CT w/o contrast

Withhold certain offending medication (NSAIDS, DM-metformin)

Avoid volume depletion

22
Q

What pre-procedure prophylaxis would be used IV?

A

Isotonic IVF

0.9 NS

1 ml/kg/hour x 12 hours prior and 6-12 hours after procedure

23
Q

You have an elderly patient who was given gentamyacin by a local urgent clinic. What toxicity may result?

A

Aminoglycoside nephrotoxicity

Susceptible groups:

Volume depletion

Sepsis

Preexisting renal disease

Hypokalemia

Elderly

24
Q

A patient comes in with suspected ethylene glycol ingestion. What examination of the urine would you order and how would you treat it?

A

Wood’s light (ultraviolet)

Calcium oxalate crystals

Tx: alcohol or fomepizole +dialysis

Fomepizole - prevents metabolism of ethylene glycol

If suicide attempt, refer after treatment

25
Q

Patient comes in with livedo retularis from a cardiovascular cath procedure. Dx?

A

Atheroembolic Renal disease (rare but looks like contrast induced nephropathy [CIN])

-small artery occlusion leading to organ ischemia

*blood thinners may also be causative

26
Q

Patient comes in after labs indicated decrease in GFR and on renal biopsy crescent formations were found. Dx?

A

Rapidsly Progressive GN (RPGN)

27
Q

RPGN has three main classes. Type I, II, III. Classification is based on immunofluorescent. What pattern is seen in each?

A

Type I (Goodpastures)- IF –>linear deposition

Type II (PSGN, Lupus, IgA, HS, MPGN)- IF–> granular deposition

Type III (Wegener’s, MicroPolyangitis, Idiopathic crescenteric) - IF –> Pauci immune deposition, ANCA

28
Q

A patient comes in with a rash, fever and eosinophilia. You go through the history and find he is currently on ibuprofen. After asking more questions you find he had an injury 13 months ago after cycling. You immediately think?

A

Allergic Interstitial Nephritis

(May take weeks after initial exposure. NSAIDS can take up to 18 months!)

29
Q

You send your cyclist patient in for labs upon suspicion of allergic interstitial nephritis. If he has AIN, what will be on the report?

A

Bland sediment or WBCs, RBCs, non-nephrotic proteinuria

WBC casts

Normal or mildley increased protein excretion

Urine eosinophils on Wright’s or Hansel’s stain

30
Q

Your cyclist patient comes back with WBC casts and eos. Based on labs and clinical findings, how would you treat his allergic interstitial nephritis?

A

Remove the offending agent.

If severe, he should undergo a renal biopsy to confirm.

If poor candidate for renal biopsy, then prednisone.

2-3 month therapy

CPR M2T1E3 (20 decks)

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