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302 Renal > 2. Acute Kidney Injury > Flashcards

2. Acute Kidney Injury Flashcards

1
Q

AKI definition

A

a rapid (hours-days) fall in glomerular filtration rate (GFR) which impedes kidney’s normal functions

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2
Q

AKI stage 1 - serum creatinine criteria

A

increase in serum creatinine of 25 umol/litre or more within 48 hours
OR
1.5-2 fold increase from baseline

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3
Q

AKI stage 1 - urine output criteria

A

less than 0.5ml/kg/hour for more than 6 hours

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4
Q

AKI stage 2 - serum creatinine criteria

A

increase in serum creatinine to more than 2-3 fold from baseline

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5
Q

AKI stage 2 - urine output criteria

A

less than 0.5 ml/kg/hour for more than 12 hours

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6
Q

AKI stage 3 - serum creatinine criteria

A

increase in serum creatinine to more than 3-fold from baseline
OR
serum creatinine more than 354 umol/L with acute increase of at least 44 umol/L

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7
Q

AKI stage 3 - urine output criteria

A

less than 0.3ml/kg/hour for 24 hours
OR
anuria for 12 hours

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8
Q

what is creatinine?

A

normal product of muscle turnover
non-toxic
transported by blood and excreted ONLY by kidneys
used as surrogate marker for glomerular filtration
used for eGFR

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9
Q

normal creatinine range in Brighton

A

~ 60-110 micromol/L

what is normal for one patient may not be for another

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10
Q

define oliguria

A

<0.5 ml/kg/hour urine output

usually <500ml/24hr in adults

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11
Q

define anuria

A

officially would be mean no output

softly defined as <100ml/24 hr

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12
Q

4 phases of AKI

A

onset phase
oliguric/anuric phase
polyuric/diuretic phase
recovery phase

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13
Q

onset phase features and duration

A

features:

  • triggering events - signif blood loss, burns, fluid loss, diabetes insipidus
  • renal blood flow 25% fo normal
  • tissue oxygenation 25% of normal
  • urine output below 0.5ml/kg/hour
    duration: hours to days
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14
Q

oliguric / anuric phase features and duration

A

features:

  • urine output below 400ml/day (may be <100ml/day)
  • increases in blood urea nitrogen (BUN) and creatinine levels
  • electrolyte disturbances, acidosis, fluid overload (kidneys unable to excrete water)
    duration: 8-14 days or longer
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15
Q

diuretic / polyuric phase features and duration

A 
features:
- occurs when AKI is corrected 
- renal tubule scarring and oedema 
- increased eGFR
daily urine output above 400ml 
- possible electrolyte depletion from excretion of more water and osmotic effects of high BUN 
duration: 7-14 days
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16
Q

recovery phase features and duration

A

features:

  • decreased oedema
  • normalisation of fluid and electrolyte balance
  • return of GFR to 70% or 80% of normal
    duration: several months - 1 year
17
Q

kidney functions

A 
excretion of toxins, eg urea
electrolyte balance, eg. 
Na+/K+
acid base balance 
fluid balance
BP control 
control of bone metabolism, vit D activation, phosphate excretion 
production of EPO
18
Q

hyperkalaemia ECG changes

A

K+ > 6.5 is medical emergency
progressive changes:
- tented T wave
- reduced P wave with widened QRS complex
- ‘sine wave’ pattern (precardiac arrest)

19
Q

fluid overload symptoms

A

breathlessness
orthopnoea
limb swelling
danger = pulmonary oedema, severe tissue hypoxia

20
Q

4 main indications for dialysis in oliguric / anuric AKI

A

refractory hyperkalaemia
pulmonary oedema
refractory acid/base disturbance
uraemic complications (coma, pericarditis)

21
Q

types of causes of AKI

A

pre-renal
renal
post-renal

22
Q

pre-renal causes of AKI

A 
decrease in perfusion, resulting in ischaemia or infarction 
common 
- bleeding
- septic shock 
- dehydration 
- myocardial infarction
- renal artery stenosis 
- iatrogenic?
23
Q

renal causes of AKI

A 
uncommon
direct toxic effects 
- drugs 
- calcium and other metals 
overproduction leading to blockage of tubules 
- rhabdomyolysis 
- myeloma 
inflammation in kidney 
- glomerulonephritis 
- interstitial nephritis -
- acute tubular necrosis (ATN)
24
Q

post renal causes of AKI

A 
plumbing problem/outflow obstruction 
less likely than pre-renal 
- stones 
- ureteric/urethral strictures 
- BPH
- prostate cancer 
- urinary retention, eg.g. neurogenic, constipation
25
Q

who is at risk of AKI? chronic

A 
elderly
CKD 
cardiac failure 
liver disease 
diabetes
vascular disease 
background nephrotoxic mediations
26
Q

who is at risk of AKI? acute

A 
STOP
s - sepsis and hypoperfusion 
t - toxins 
o - obstruction 
p - parenchyma
27
Q

how to predict/prevent AKI

A

4 ‘Ms’

  • monitor: obs/NEWS, regular bloods, fluid balance
  • maintain circulation: hydration, resuscitation, oxygenation
  • minimise kidney insults: nephrotoxic meds, surgery, contrast, hospital acquired infection
  • manage acute illness - sepsis, heart failure, liver failure
28
Q

what to do when AKI identified

A 
make patient safe 
- aBCDE 
- K+
- volume status
if hypovolaemic, give 250/500ml bolus saline 
consider cathetre for fluid monitor 
- check VBG for acid-base status
investigate cause once stable 
- urine dip 
- bladder scan/KUB ultrasound 
- detailed history and exam
29
Q

fluid assessment

A 
is patient thirsty 
cap refill 
mucous membranes
skin turgor 
pulse rate 
BP - relative and postural 
resp rate 
central vs peripheral temp 
JVP
lung auscultation 
oedema - peripheral and sacral 
CXR - pulmonary oedema, infiltrates 
fluid balance charte, urine output 
invasive methods - catheter, arterial line, central line
30
Q

drugs to hold in AKI

A 
ACE inhibitors 
angiotensin receptor blockers 
NSAIDs: ibuprofen, diclofenac, naproxen 
any diuretics
metformin
31
Q

causes of polyuria

A 
known and common phase of AKI 
post relief of obstruction 
diabetes mellitus
psychogenic 
beer potomania 
rare endocrine causes (eg diabetes insipidus)
32
Q

how to manage polyuria

A

encourage patient to drink
depending on assessment of fluid balance
- iv fluids to match output
reduce to 75% urine output when renal function improve

33
Q

red flags in history - worry about cause

A 
haemoptysis 
rashes 
joint pain/swelling
ENT-- crusting of nose/acute hearing impairment 
significant acute limb swelling 
noticeable urine frothiness

302 Renal (3 decks)

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