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Pharm II Liza > Acute Kidney Dz > Flashcards

Acute Kidney Dz Flashcards

0
Q

RIFLE (Risk Inj Failure Loss EndStage Renal Dz=ESRD)

A

Can dx spectrum of kid impairment/injury
Based on changes in serum CREATININE and UO
Severity classes; Risk, Inj, Failure (FIF)
Outcome classes: Loss, ESRD

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1
Q

Acute Kidney Injury AKI

A

Sudden decline in rx , GFR -> to go hospital

  • failure ot excrete metabolic waster
  • inability to maint fluid and electrolytes balance
  • impaired acid-base regulation
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2
Q

Dx criteria: AKIN: Acute Kid Inj Network

A

Modification of RIFLE
Risk category: addition of 0.3 mg or higher increase in serum CREAT
Missed Dx of Inj and Failuer in RIFLE

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3
Q

Dx Limitations

A

Concordance btw serum CREAT and UP not established
Poor correlation betw AKI stage and GFR
Relies on relative changes in serum Creat
Independent of cause of AKI

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4
Q

RIFLE

A

Risk: Incr Cr x1.5 or GFR decrby >25% UO50% UO 75% OR Cr>4.0 (with acute rise of 0.5)
UO 4wk
E: ESRD = end stage renal dz

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5
Q

AKIN

A

stage 1: inc Cr x 1.5 UO < 0.5 x 6 hr
stage 2: inc Cr x 2 UP 4 (with acute rise of .5) UO < .3 x 24 hr or ———————————————————anuria x 12 hr
Stage 3 = dialysis

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6
Q

Nonoliguric
Oliguric
Anuric

A

nonoliguric > 400 mL/24 hr
Oliguric < 400 / 24 hrs
Anuric < 100 / 24 hrs

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7
Q

3 sources of injury

A

Prerenal
Intrarenal
Postrenal

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8
Q

Prerenal injury

A 
Inadequate perfusion to kidney:
Vascular deplesion (decreased volume):
---------true: Hemmorhage, GI: V/D, NG tube, pancreatitis; Renal (DKA, Addison's dz (dicr Aldo: decr volume); Cutaneous (burns, sweating)
---------effective: decr. Effective Circulating Volume: normovolemic, hypervolemic; vasoDILATION (sepsis=dilate, cirrhosis causes Ascites, anaphylactic shock decr TPR); decr CO (aortic stenosis); renal vasoCONSTRICTION (renal artery stenosis, FMD=familial muscular dz)
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9
Q

NSAIDS and ACE-I/ARB affect which arteriole in the glomerulus

A

NSAIDS: Afferent arteriole
ACE ARB: Efferent
A doesn’t equal Afferent

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10
Q

Intrarenal injury

A

glomerular
interstitial
vascular
TUBULAR (most)

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11
Q

Tubular Intrarenal Injury

A

1) Ishemic due to HTN, Sepsis = Acute Tubular Necrosis
2) Nephrotoxic due to
- —- meds: aminoglycosides, Amphotericin B, Cisplatin, CONTRAST
- —- CAST nephropathy (pathology in nephrons): Mult Meyloma (rare)
- —- Rhabdomyolysis (often): 92 yo fell, ironman (inc myoglobin)

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12
Q

CONTRAST nephropathy

A

renal TUBULAR epithilial cell toxicity and renal ischemia of medulla

  • # 2 cause of acute kid injury in hosp pts
  • Risks: age, dehydration, PRE-EXIST RENAL DZ, REPEATED CONTRAST, comorbid DM, CHF
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13
Q

prevention of contrast nephropathy

A

HYDRATION is key
Acetylcysteine - antidote to tylenol
NaHCO3- sodium bicard - still controvercial

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14
Q

Postrenal Injury

A 
OBSTRUCTION (most) due to :
retroperitoneal fibrosis
bladder outlet obstruction
stones
tumors (press on ureter, urethra, bladder, kidney)
clots
BPH (older men)
Can have any or all
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15
Q

hypotension (decreased vol) would lead to

A

Acute Tubular necrosis (part of Intrarenal)

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16
Q

Increased BUN and Cr may bd due to

A

Effective Volume depletion (dehydration?) = type of prerenal inj

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17
Q

Matastasis can lead to

A

Obstruction (Postrenal injury)

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18
Q

Prerenal vascular (vol) depletion can be 2 types

A

True: GI, burn, sweating
Effective vol depletion: decr Effect circ vol
vasoDILATION (sepsis, cirrhosis, anaphylactic shock)
decr CO
renal vasoCONSTRICTION (renal artery stenosis, FMD)

19
Q

Acute Interstitial Dz is going to be which: prerenal intra or post

A

intrarenal

20
Q

primary blood exams performed in AKI

A 
BUN
ELECTROLYTES (high K, high Ca)
CBC with diff: EOSINOPHILS to ro infection (interstitial nephritis)
Phosphorus, high
Uric Acidd (in ppl with gout)
21
Q

2nd blood exams

A

Albumin, ANA, Anti DS DNA Ab, complement (low bc fighting), ANCA, ANti GMB, antistreptolysin O titler, Hep B and C - bc need to ro if want dialysis

22
Q

UA sediment

A

Muddy brown CASTS: PATHOGNOMIC OF TUBULAR INJURY
Can get random electrolytes
Eosinophils (in Acute Interstitial Nephritis)

23
Q

Urine prot/urine creat ration < 30 can be done by

A

24 hr or spot as effective

must be early morning sample

24
Q

FENa Fractional Excretion of Na

A

3 % suggests intrarenal (ATN acute tubular necrosis)

25
Q

BUN/creat ration is >20.1 and FENa is 3% in

<20.1 and FENa is 1-3 in

A

PRErenal
Intrinsic/intrarenal (Acute tubular necrosis)
POSTrenal

26
Q

When to use radiology (CT and MRI)

A

little value in CR and MRI

CT may be used if retroperitoneas FIBROSIS (WHY?)

27
Q

When can you use gadolinium with GFR

A

> 30

28
Q

Which is the go to scan

A

CT (do after labs) - no contrast, bed side, non-invasive -> see obstruction right away (necrosis, stone, tumor), infection (pyelonephritis)

29
Q

Biopsy in Acute Kid Dz

A

Not needed to dx AKI
Use if unexplained Chronic Kid Dz, unexp worsening Acute KInj, Nephrotic syndrome, Acute nephritic symdrome.
DON”T if: solitary native kid, bellding diathesis (anticoag dz), hydronephrosis, pyelonephritis (bc can spread infection), renal tumor can spread

30
Q

Biopsy is CI in

A

solitary native kid, bellding diathesis (anticoag dz), hydronephrosis, pyelonephritis (bc can spread infection), renal tumor can spread

31
Q

In captain Ohagan: takes thiazide, hx bladder CA and BCG?, UTI one week ago tx with Bactrim:
present to ED with fever, dysuria, BP low, HR high, H/H low, BUN high, Cr 1.9 then 2.2, WBC high, UA: large leukocytes, WBC, TooNumerousToCount (TNTC), few RBC

A

Dx: sepsis due to UTI but Cr goes up to 2.2 on day 3;
First tx with vol resuscitation to improve BP and HRvc hypoThyroid???
Order: Phosphorus, Uric Acid, LDH (hemolytic anemia) WNL (within normal limits)
Urinary sediment: muddy brown granular casts = intrinsic/tubular
FEna 4% > 3 so intrarenal
US neg for pyelonephritis

32
Q

Brown muddy casts are a sign of which type of renal injury

A

Tubular injury (intrarenal)

33
Q

Which type of renal injury would be corrected with fluid resuscitation

A

Prerenal

34
Q

Mngt of acute Kid injury

A

Volume/hydration
Avoid nephrotoxins: NSIADS, Lasix decreases K, RENAL DOSING OF ACE
Has decreased albumin so feed then
If uremia - kid failure and dialysis or kid replacement

35
Q

Meds concerns

A 
Vancomycin Getamycin (aminoglycoside?), ACE i, K+ supplements (want to decrease K?)
OTC NSAIDS, supplements
(DVT prophylaxic meds have to be renally dosed)
36
Q

Meds that cause false + rise in Cr?

A

Trimethoprim (Bactrim)

Cefoitin (pepsid)

37
Q

Nutrition

A 
Protein restriction is controversial bc AKI have protein deficit
RESTRICT FLUID (could have fluid overload bc of kid dysfx)
LOW K (due to vomiting and diahrrehia?)
38
Q

Complication mngt

A

-volume depletion
-volume overload
-Electrolytes:
HYPERK+ is number 1, most impt
HYPOCa and Hyperphosphate
-metabolic acidosis
-uremia leads to bleeding disorders

39
Q

When to tx HyperK

A
  • makes BP go up
  • peaked T waved
  • tx based on clin presentation/findings
  • EKG finding determine urgency (get baseline EKG)
40
Q

3 principles of HyperK mngt

A

-stabilize cardio if EKG changes (for ppl with K >5.5): IV Calcium fast (shot) or Ca Gluconate if can wait
-Chasers: Drive extracellular K into cells with insuline and sugar D50W, Beta 2 Agonist (albuterol), NaHCO3- sod bicard (controversial)
-Remove excess K with
diuretics - Lasix if produce urine,
Cation exchange resins (KYEXALATE (bind to K and poop out)),
dialysis

41
Q

If Hyper K >5.5 and peaked T wave

A

actively tx,

if flat P wave, then what ?

42
Q

K uptake by cells is increased by

A

Beta 2 agonists - albuterol
insulin plus sugar d50W
poss sod bicarb

43
Q

Kayexalate does what?

A

cation exchange resin - binds K and poop out

44
Q

Albuterol, beta 2 agonist does what?

A

moves K into cells to tx HyperK

45
Q

Incidations for Dialysis

AEIOU

A

Acid-base disturbance (met acidosis)
Electrolyte abnormalities (HyperK with EKG changes)
Ingested toxins
Overload (fluid) refractory to diuretics (common)- bc not responding
Uremia (not just BUN) : with AMS (altered mental status), Seizures, Pericarditis

46
Q

Most likely cause of death in AKI

A

INFECTION is 1

  1. Cardiovascular events
  2. GI, pulm, neuro complication
  3. HyperK or dialysis related

Pharm II Liza (9 decks)

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