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acute intrinsic renal failure Flashcards

1
Q

discuss the prognosis for a dog with aztema due to glycol acetate consuption

A

grave

euthanize

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2
Q

this drug damage the kidney and should only be used when necessary

A

aminoglycosides

usg is the best way to monitor

be vigilant for tubular necrosis

check for urinary casts

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3
Q

nephthrotoxic plant in cats

A

easter lilly

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4
Q

cause of AIRF in horses

A

rhabdomyolytis

red maple dz

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5
Q

causes of AIRF in cowas

A

acorns/oak bud

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6
Q

common cause of AIRF in dogs

A

raising /grapes

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7
Q

discuss the pathogenesis of

A

exposure to nephrotoxin/ischemia causes tubular injury

spectrum of injury from degeneration(nephrosis) to acute tubular necrosis

some patients have minimal to no light microscopic lesions but still develop severe renal excretory failure

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8
Q

discuss AIRF due to iscemia

A

renal cortex is very vascular and adrenergic stimulation during renal ischemia can cause potent vasoconstriction

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9
Q

discuss effect of NSAIDs on the kidney

A

doesnt cause AIRF but reduces glococorticoids hence reducing the ability of the kidney to vasodilate

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10
Q

negative effects of NSAIDS

A
  • GI bleeding
  • volume depletion
  • impared vasodilation
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11
Q

discuss mechanism of injury of nephrotoxic AIRF

A
  • delirious effects of true nephrotoxins are direct and occur after binding to the tubular cell membranes
  • decreased energy production and cell death
  • some nephrotoxins causes renal vasocontrictions
  • major effect is direct cell injury rather than ischemia
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12
Q

why are nephrotoxins very toxic to kidney

A

abundant blood supply guarantee tubular cells to toxin

large tubular cell membrane surface area for exposure and attachment

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13
Q

in which stage does the owner recognise AIRF

A

maintainance

they will not see the cs in induction unless they see the animal consuming a chemical

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14
Q

in which stage do most dogs die due to AIRF

A

maintainance stage

the animal has either uligoria or non uloguria

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15
Q

in dogs that progress to CRF,what are the main cs

A

isothenuria

azotemia

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16
Q

discuss urine output in maintainance phase of AIRF

A
  • it can be
  • uligoria
  • normal urine output
  • polyuria
    • presence or absence of uliguria depends on presence of severirity of insult
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17
Q

define maintainance phase of AIRf

A

sudden increase in serum creatine conc. that persists despite the correction of the prerenal factors

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18
Q

why do patients due under maintainance phase

A

because maintainance phase lasts for days to weeks

lasts 1-3 weeks

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19
Q

characteristics maintainance stage of AIRF

A

characterised by severe decrease in renal blood flow

even if rbf returns to normal gfr remains low

conversion from uliguria to polyuria may occur in maintainance phase

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20
Q

discuss recovery phase of AIRF

A

return to normal BUN and creatine=possible

complete recovery may not be possible

partial improvement= chronic renal failure

BUN and creatine may return to normal but GFR may remain low

urinary conc. may remain low

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21
Q

which test is definitive for AIRF

A

no single test is definitive for AIRFhistory is important

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22
Q

discuss body condition in a patient with AIRF

A

no loss of body condition

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23
Q

compare uremia in AIRF and crf

A

signs of uremia in Airf are more than prerenal azotemia but same as crf

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24
Q

signs of uremia in AIRF and crf

A

uremic breath

oral uremic ulcer,tongue tip necrosis

hypothemia(nephrosis) or hyperthemia(nephrosis)

absence of pallor to mucus memberanes

postural changes suggesting back pain (renal pain)

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25
Q

physical exam findings of AIRF

A

dehydration is common before fluids

overhydration may occur after fluids

bradycardia/ arrthymia if marked hyperkalemia

normal to large kidneys

bladder:normal to small ude to less urine

absence of lower urinary obstruction

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26
Q

discuss bladder size in AIRF

A

normal to small

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27
Q

discuss anemia due to AIRF

A

not early on

common in crf

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28
Q

discuss proteinemia in AIRF

A

hyperproteinemia due to dehydration

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29
Q
A
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30
Q

discuss leukogram for AIRF

A

inflamatory stress/leukogram

thrombocytopenia.therefore dx or tx patient for lepto who present with AIRF

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31
Q

discuss usg in AIRF

A
  • usg of 1.007-1.017
  • same as for crf
  • low in both uliguric and non uligoric patients
  • there is also hematuria
  • and proteinuria
  • may see glucosuria with normal glucose levels.this is bcoz they cant reabsorb tubular glucose
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32
Q

discuss sediment in AIRF

A

may be very active bt absence of casts doesnt r/o AIRF

increased # of oxolate crystals supports a dx for ethyl glycol poisoning in a ulogoric AIRF patient

33
Q

discuss sediments in AIRF

A
  • increase in wbc,rbc,tubular epithelial cells= non specific reaction to renal injury
  • increase in wbc an bacteria =suspected pylonephritis
34
Q

for increased wbc and bacteria in AIRf what should u suspect

A

pyelonephritis

35
Q

if a patient has azotemia,should u consider euthanasia

A

u cant use the magnitude of azotemia to determine AIRF and crf

u cant use the magnitude of azotemia to determine prerenal,renal and post renal

36
Q

discuss hyperkalemia in AIRF

A

remember that K is higher in acute renal failure than in chronic.this is because with acute renal failure,there is rapid decrease in blood flow and less k is going to be cleared while with chronic renal failure,the kidneys are able to adapt
some of the cats with chronic renal failure may be hypokalemic

normal or lower serum k is expected in crf

37
Q

discuss blood gases in AIRF

A

moderate/sevewre metabolic acidosis during maintainance phase of AIRF

more severe than the one in compensated crf

38
Q

discuss the size of kidneys in both AIRF and crf

A

AIRF:normal to large

CRF:normal to small

no specific cause of AIRF may be infered from ultrasound findings with possible exception of glycol poisoning

normal us findings do not exclude AIRF

39
Q

severe renal hyperchogenesity in US suggests

A

ethyl glycol intoxication

40
Q

discuss the US of hyperthyroid imanging in AIRF

A

may be helpful to differentiate AIRF vs CRF

dogs with crf may hav an enlarged parathyroid hormone

dogs with AIRF have normal size hyperthyroidism

it requires substantial skill

41
Q

discuss serology in AIRf

A

acute/convolescent serum samples for leptosporosis if nephritis= possible cause AIRF

submit samples of borellia if a rapidly progressive glomerular nephritis=suspected cause of AIRF

42
Q

advantages of renal biopsy

A

Confirm primary renal origin of azotemia
Differentiate AIRF from CRF
Assess potential for healing / prognosis(e.g. basement membranes intact)
Differentiate nephritis (Lepto) from nephrosis

43
Q

prgnosis for AIRF with Ethylene Glycol

A

poor to grave

44
Q

prognosis for lepto in AIRF

A

fair to good with adequate tx

45
Q

prognosis for bacterial pyelonephritis in AIRF

A

fair

46
Q

prognosis for aminoglocosides

A

poor to grave

47
Q

prognosis of AIRF due to NSAIDS

A

guarde to poor

48
Q

prognosis for AIRF with easterlilly

A

poor to grave

49
Q

discuss prognosis for patients with severe azotemia in maintainence stage of AIRF

A

Patients with severe baseline azotemiaduring the maintenance phase often are NOTsuccessfully managed without dialysis

50
Q

new ways of improving prognosis for AIRF

A
  • Early hemodialysis = increased survival of AIRF patients (UC Davis)
  • Dialysis may be needed for several months with severe AIRF
  • peritonial dialysis-New catheters now available (T-Fluted)
  • Mayincrease survival time (no data yet)
51
Q

Prognosis of AIRF without Dialysis

A

Over 80% of patients with AIRF & high level azotemia will either die or be euthanized

52
Q

Why do Animals with AIRF Die, or are Euthanized

A

Hyperkalemia
Metabolic acidosis
Severe azotemia

Overhydration and pulmonary edema next major cause of death during vigorous fluid therapy

53
Q

Treatment Goals for AIRF During the Maintenance Phase

A
  • Provide adequate supportive care and sufficient time for renal healing
  • No “quick fix” (may require several weeks)
  • No treatment can change lesions already present in kidneys
  • Avoid any nephrotoxic drugs
  • Avoid periods of hypotension (e.g. anesthesia, surgery)
54
Q

discuss fluid therapy in AIRF therapy

A
  • Place IV catheter
  • Meticulous attention to fluid therapy
  • Measurement of urine output is critical initially to avoid overhydration
  • “Flushing the kidneys”……NOTalways a good idea!!
55
Q

Treatment of AIRF –“Ins & Outs

A
  • Normal urine output = 1-2 ml/kg/hr
  • < 1 ml/kg/hr = oliguria
  • Over each 4-hour period, give a volume of IV fluids equal to the insensible needs for that time period plus a volume equal to the urine output of the preceding 4 hours:
  • (20 ml/kg)/6 + measured urine output of preceding 4 hrs
  • Will avoid overhydration but may underestimate actual fluid needs
56
Q

tx for hyperkalemia in AIRF

A
  • Sodium bicarbonate (2 mEq/kg)
  • Regular insulin (0.25-0.5 U/kg) and glucose (1-2 ml/kg 50% dextrose) IV
  • Calcium gluconate (2-10 ml of a 10% solution)
  • Polystyrene sulfonate (each g binds 1 mEq K+and releases 1-3 mEq Na+) mixed with sorbitol and given by retention enema
  • IF hyperkalemia persists must proceed to dialysis
57
Q

discuss tx of oliguria in AIRF

A
  • Diuretics
  • Probably of limited value once oliguria is established …
  • AIRF prophylaxis?
  • Furosemide (2-4 mg/kg IV followed by 1 mg/kg/hr)
  • Dopamine (2-4 μg/kg/min)
  • Mannitol (0.25-0.50 g/kg IV over 3-5 min)
58
Q

discuss severity of glycol

A
  • May cause illness
  • Usually NOTfatal
59
Q

in ethlyn glycol metabolism, which step/product signify a point of return

A

Glycolate

60
Q

which enzyme converts ethelyn glycol to glucolate

A

alcohol dehydrogenase

61
Q

list the final byproducts of ethelyn glycol

A
  • hippurate
  • calcium oxylate
  • formate and co2
62
Q

discuss effectsEthylene Glycol Poisoning after 30 mins to 12 hrs

A

neurologic

Ataxia, stupor, seizures, coma

63
Q

discuss the effects of ethelyn glycol after 12-24 hrs

A
  • Cardiopulmonary -12 to 24 hrs
    • Tachycardia, tachypnea
64
Q

discuss effect of Ethylene Glycol Poisoning after 24-72 hrs

A
  • renal
    • Initial PD/PU
    • Progresses to profound oligo-anuric AIRF (almost always fatal once established)
65
Q

discuss Ethylene Glycol Nephrotoxicity:Pathophysiology

A
  • Cytotoxicity from metabolites (most important)
  • Calcium oxalate crystals
    • Intraluminal
    • Intracellular
  • Tubular backleak?
  • Compression of RBF by interstitial edema
66
Q

Ethylene Glycol Measurement

A
  • Colorimetric test for ethylene glycol (EGT Kit® from PRN Laboratories)
  • Whole blood or serum

KEY POINT:
Ethylene glycol is
rapidly absorbed from the GI
tract of dogs and is undetectable
in plasma 48 hrs after ingestion

67
Q

when can u have false -ve measurements in Ethylene Glycol Measurement

A
  • Samples obtained < 30 minutes after ingestion
  • Samples obtained > 12 hours after ingestion
68
Q

potential for false positive in Ethylene Glycol Measurement

A
  • Propylene glycol
  • Glycerol
  • Metaldehyde
69
Q

Presumptive EG Poisoning

A
  • Alcohol-like intoxication
  • Initial pu/pd to oliguria
  • Renal / muscle pain
  • Progression to coma
  • ask the client if the patient had excess to radiator fluid
70
Q

dx for ethylene glycol poisoning

A
  • Dilute urine
  • Oxalate crystalluria
  • ↑ Anion gap metabolic acidosis (up to 24 hrs)
  • ↑ Osmolal gap (up to 12-24 hrs)
  • Progressive azotemia
  • Hypocalcemia (formation of calcium oxalate crystals
71
Q

Treatment of EG Poisoning

A
  • Timing is everything!
    • For best outcome treat within 4 hours of ingestion
  • Do NOT wait for “definitive” test results
    • Induce vomiting
    • Gastric lavage with activated charcoal
  • Attempts to stimulate urine production with furosemide usually futile
72
Q

discuss drugs used for treating ethelyn glycol

A
  • Definitive treatment with ethanol or 4-methyl pyrazole to prevent metabolism of ethylene glycol
  • Calcium gluconate if symptomatic hypocalcemia
  • Sodium bicarbonate for metabolic acidosis
  • they complete with ethelyn glycol and ethelyn glycol gets excreted unchanged
73
Q

discuss how ethanol can be used to tx ethelyn glycol poisoning

A
  • Has greater affinity for alcohol dehydrogenase than ethylene glycol does
  • Saves dogs and cats if used within 2-4 hours of ingestion
    • Dilute to 20% solution for IV use
    • Dogs: 5.5 ml/kg q 4h X 5 then q 6h X 4
    • Cats: 5 ml/kg q 6h X 5 then q 8h X 4
74
Q

discuss tx of ethelyn glycol with fomipizole

A
  • No CNS depression
  • Dogs:
    • Treat within 8 hrs of EG ingestion
    • 20 mg/kg followed by 15 mg/kg at 12 and 24 hrs and 5 mg/kg at 36 hrs
  • Cats:
    • Require MUCHhigher doses
    • Treated within 3 hrs of EG ingestion125 mg/kg followed by 31 mg/k
75
Q

discuss prognosis for ethelyn glycol poisoning in dogs

A
  • < 3 hr … Excellent
  • 3-5 hrs … Good
  • 5-8 hrs … Good to Guarded
  • > 8 hrs … Guarded
  • > 12 hrs … Guarded to Grave
76
Q

discuss prognosis for ethelyn glycol in cats

A

< 3 hrs … Good
> 3 hrs … Guarded to GraveTIMING

77
Q

teristics that define crf

A
  • When compensatory mechanisms of the diseased kidneys are no longer able to maintain:
    • EXCRETORYfunctions of the kidneys
    • REGULATORYfunctions of the kidneys
    • ENDOCRINEfunctions of the kidneys
  • Results in:
    • Retention of nitrogenous solutes
    • Derangements of fluid
    • Alterations in electrolyte and acid-base balance
    • Failure of hormone production
78
Q
A

small animal medicine (3 decks)

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