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Acute kidney injury Flashcards

1
Q

What is classified as acute kidney injury

A

<48 hours reduction in kidney function = increase in serum creatinine by >26.4 µm/l or by >50% or reduction in urine output

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2
Q

What are the types of causes of AKI

A

Prerenal
Intrinsic (renal)
Post-renal

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3
Q

What is the pre renal cause of AKI

A

Impaired blood flow to the kidney = reduction in perfusion

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4
Q

What conditions can cause pre renal AKI

A

Hypovolaemia - haemorrhage / burns / vomiting / diarrhoea
Hypotension
Drugs - ACEi, ARB, NSAID, COX-2
Renal artery stenosis

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5
Q

What conditions can cause hypotension

A

Sepsis
Anaphylaxis
Cardiogenic shock

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6
Q

What are the drugs that can cause pre renal AKI

A

NSAID
COX-2
ACEi
ARB

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7
Q

How does ACEi cause pre-renal AKI

A

Because ACEi causes vasodilation of the efferent arteriole hence prevents vasoconstriction as a compensatory mechanism for low perfusion pressure (which leads to low perfusion)

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8
Q

How does NSAID cause pre-renal AKI

A

It causes vasoconstriction of the afferent arteriole = reduction in perfusion

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9
Q

What is the renal cause of AKI

A

Diseases that causes inflammation or damage to cells of the kidney structures - glomeruli, tubules, interstitium of kidneys

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10
Q

What causes intrinsic (renal) AKI

A

Glomerulonephritis
Acute tubular necrosis
Acute interstitial nephritis
Drugs (damage tubules and interstitium)
Contrast exposure (from imaging)
Rhabdomyolysis (damage tubules)

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11
Q

What can be damaged through contrast exposure

A

Tubules

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12
Q

What causes acute tubular necrosis

A

Sepsis
Severe dehydration -> shock
Rhabdomyolysis
Drug toxicity
Contrast exposure

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13
Q

Which drug can cause acute tubular necrosis

A

Gentamicin

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14
Q

What conditions can cause interstitial nephritis

A

TB infection
Sarcoidosis

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15
Q

What is the post renal cause of AKI

A

due to obstruction of urine flow leading to back pressure and thus loss of concentrating ability

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16
Q

What conditions causes post renal AKI

A

Ureteric stone
Urinary retention caused by benign prostatic hyperplasia / malignancy
External compression of the ureter

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17
Q

Which type of causes of AKI is the most common

A

Pre-renal

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18
Q

Which condition is the most common cause of AKI

A

Acute tubular necrosis

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19
Q

Risk factors of AKI

A

Other organ failure - HF, liver disease
History of AKI
Chronic kidney disease
>65 years old
Use of nephrotoxic drugs
Contrast exposure within the past week

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20
Q

What are the nephrotoxic drugs

A

NSAID
ACEi / ARB
Aminoglycosides (gentamicin, streptomycin)
Diuretics

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21
Q

Symptoms of AKI

A

May experience no symptoms
Reduced urine output
Pulmonary and peripheral oedema
Arrhythmias
Uraemia symptoms (itch, pericarditis, encephalopathy)

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22
Q

What are the uraemia symptoms

A

Itch
Pericarditis
Encephalopathy

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23
Q

What is the diagnostic criteria of AKI

A

Rise in creatinine of 26 µmol/L or more in 48 hours
OR
> 50 % rise in creatinine over 7 days
OR
Fall in urine output to <0.5 ml/kg/hour for more than 6 hours in adults (8 hours in children)
OR
> 25% fall in eGFR in children or young adults in 7 days

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24
Q

What is the staging criteria used for AKI

A

KDIGO (Kidney Disease: Improving Global Outcomes)

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25
Describe stage 1 AKI
Increase in creatinine to 1.5-1.9 times baseline OR Increase in creatinine by ≥26.5 µmol/L OR Reduction in urine output to <0.5 mL/kg/hour for ≥ 6 hours
26
Describe stage 2 AKI
Increase in creatinine to 2.0 to 2.9 times baseline OR Reduction in urine output to <0.5 mL/kg/hour for ≥12 hours
27
Describe stage 3 AKI
Increase in creatinine to ≥ 3.0 times baseline OR Increase in creatinine to ≥353.6 µmol/L OR Reduction in urine output to <0.3 mL/kg/hour for ≥24 hours OR The initiation of kidney replacement therapy OR In patients <18 years, decrease in eGFR to <35 mL/min/1.73 m2
28
Investigations for AKI
Bloods - U+E, serum creatinine Arterial blood gas Urinalysis Renal ultrasound if suspect urinary tract obstruction / no other identifiable cause Autoantibodies ECG CXR
29
What may arterial blood gas show in AKI
Hypoxia if there is pulmonary oedema
30
What may ECG show in AKI
Hyperkalaemia - tall T waves - wide QRS - Flattening of P waves
31
What electrolyte imbalance does AKI cause
Hyperkalaemia Hyperphosphataemia Acidosis
32
Management of AKI
ABCDE - correct hypoxia / hyperkalaemia / hypovolaemia / sepsis Identify which type of AKI it is and treat
33
Management of pre-renal AKI
give fluids if the patient is hypovolaemic - 0.9% NaCl give IV antibiotics if the patient is septic Correct hyperkalaemia Stop nephrotoxic drugs.
34
What are the nephrotoxic drugs that should be stopped in AKI
NSAID (except aspirin at cardiac protective dose 75mg) Aminoglycosides ACEi ARB Diuretics
35
What are the drugs that may be required to be stopped in AKI because it increases risk of toxicity (it is not nephrotoxic)
Metformin Lithium Digoxin
36
How do you correct hyperkalaemia
1. IV calcium gluconate 2. IV insulin + dextrose / Nebulised salbutamol 3. Calcium resonium / loop diuretics / dialysis
37
How is calcium resonium adminsitered in treating hyperkalaemia
Enema / orally Enema is more effective
38
What is the function of IV calcium gluconate in correcting hyperkalaemia
Stabilisation of cardiac membrane It DOES NOT lower potassium level
39
What are the agents used to remove potassium from the body to treat hyperkalaemia
Calcium resonium Loop diuretics Dialysis - for AKI with persistent hyperkalaemia
40
What is the effect of IV insulin and nebulised salbutamol in treating hyperkalaemia
Short term shift in potassium to intracellular fluid compartment It lowers K+ for a short time. K+ will still come out of the ICF eventually so removal of K+ is needed by other agents
41
Management of renal AKI
give fluids if the patient is hypovolaemic - 0.9% NaCl give IV antibiotics if the patient is septic Correct hyperkalaemia Stop nephrotoxic drugs. Nephrology review to identify uncommon causes of renal AKI
42
Management of post-renal AKI
catheterisation and urologist review
43
What are the indications for haemodialysis (AEIOU)
Acidosis (severe metabolic acidosis with pH < 7.20) Electrolyte imbalance (persistent hyperkalaemia > 7 mmol) Intoxication (poisoning) Oedema (refractory pulmonary oedema) Uraemia (encephalopathy or pericarditis)
44
What is classified as chronic kidney disease
Reduction in kidney function or structural damage or both, present for more than 3 months
45
Causes of chronic kidney disease
diabetic nephropathy hypertension chronic glomerulonephritis chronic pyelonephritis polycystic kidney disease Alport syndrome SLE Vasculitis - GPA, EGPA, MPA
46
What is pyelonephritis
infection of one or both kidneys
47
What are the most common causes of CKD
Hypertension Diabetic nephropathy
48
Symptoms of CKD
Usually asymptomatic May be symptomatic with pruritus, nausea, oedema, muscle cramps at severe late stage (stage 4 or 5)
49
What is used to stage CKD
eGFR
50
What are the variables in eGFR calculation
Serum creatinine Age Gender Ethnicity
51
Why is serum creatinine used in AKI rather than eGFR
Because eGFR calculations assume that the level of creatinine in blood is stable over days hence eGFR is not used in a unsteady state such as AKI
52
What factors may affect the eGFR calculation
Severely malnourished Severely overweight Bodybuilder Past organ transplant / amputees Eating red meat 12 hours prior to sample being taken
53
Describe Stage 1 CKD
>/ 90 eGFR with some sign of kidney damage No sign of damage = not CKD
54
Describe Stage 2 CKD
eGFR 60-90 ml/min with some sign of kidney damage No sign of damage = not CKD
55
What tests are used to indicate kidney damage for CKD classification
Urinary ACR Renal ultrasound Urinalysis - Haematuria/proteinuria
56
Describe stage 3a and 3b CKD
3a: eGFR 45-59 ml/min with moderate reduction in kidney function 3b: eGFR 30-44 ml/min with moderate reduction in kidney function
57
Describe stage 4 CKD
eGFR 15-29 ml/min with severe reduction in kidney function
58
Describe stage 5 CKD
eGFR < 15ml/min = kidney failure
59
Investigations for CKD
U+E Urinalysis Renal ultrasound
60
What are the complications of CKD (CRF HEALS)
Cardiovascular disease Renal osteodystrophy Fluid (oedema) Hypertension Electrolyte disturbance Anaemia Leg restlessness Sensory neuropathy (parasthesia)
61
What is the main cause of death in patients with CKD
Cardiovascular disease
62
Management of CVD risk in CKD
Smoking cessation, weight loss Control hypertension Correct hyperlipidaemia
63
What are the electrolyte disturbances in CKD
Hyperkalaemia Hyperphosphataemia Low vitamin D Hypocalcaemia
64
What causes low vitamin D in CKD
because the conversion of vitamin D to its active form occurs in the kidneys
65
What is renal osteodystrophy
Skeletal complications of CKD - osteomalacia - Osteoporosis - secondary / tertiary hyperparathyroidism - spinal osteosclerosis (due to hyperparathyroidism)
66
What is the other name for spinal osteosclerosis
Rugger jersey spine - due to hyperparathyroidism
67
What causes osteomalacia in CKD
low vitamin D high phosphate level
68
Why is there hyperphosphataemia in CKD
Because the kidneys normally excrete phosphate
69
How does hyperphosphataemia cause osteomalacia
high phosphate level drags calcium from bones
70
Management of electrolyte imbalance and parathyroid hormone levels for CKD
Reduce diet intake of phosphate Phosphate binders Vitamin D tablets
71
Example of phosphate binders
sevelamer
72
Function of sevelamer (phosphate binder)
Binds to dietary phosphate and prevent its absorption has benefits in reducing uric acid and lipids
73
What are the vitamin D tablets used for CKD
Alfacalcidol Calcitriol
74
What is the most common cause of anaemia in CKD
Reduced erythropoietin levels
75
Management of anaemia in CKD
Check iron status before administration 1. Oral iron 2. IV iron if oral iron is insufficient 3. ESA (erythropoiesis-stimulating agents) + IV iron
76
Management of hypertension in CKD
ACEi / ARB Aim for 140/90
77
Management of dyslipidaemia in CKD
Atorvastatin Increase dose if 40% reduction in non-HDL cholesterol is not achieved and eGFR is 30 ml/min/1.73 m2 or more
78
Why is it important to control hypertension and hyperlipidaemia
Because it can contribute to accelerated CKD progression And it can increase risk of CVD
79
CKD increases the risk of which type of malignancies
Renal tract cancer Thyroid gland cancer
80
Causes of hyperkalaemia
AKI CKD Addison's Rhabdomyolysis Drugs
81
What drugs can cause hyperkalaemia
Aldosterone antagonists (spironolactone / eplerenone) ACEi / ARB Heparin Ciclosporin Beta blockers in renal failure patients
82
Symptoms of hyperkalaemia
fatigue Muscle weakness Palpitations Chest pain (very non-specific)
83
Investigations for hyperkalaemia
Bloods- U+E, eGFR, serum creatinine ECG
84
What is the ECG pattern in hyperkalaemia
Tall T waves Widened QRS Flattening / absence of P waves
85
What is rhabdomyolysis
A condition where skeletal muscle tissue breaks down and releases breakdown products into the blood
86
Causes of rhabdomyolysis
Seizures Prolonged immobility Extremely rigorous exercise beyond the person's fitness level Crush injury Drugs - statin
87
What drug interactions can cause rhabdomyolysis
Statins can interact with - clarithromycin - colchicine
88
What is released by the muscle cells in rhabdomyolysis
Myoglobin Potassium Phosphate Creatine kinase
89
Symptoms of rhabdomyolysis
Muscle aches and pain Red-brown urine Oedema Fatigue Confusion
90
How is rhabdomyolysis usually presented
A patient who has had a fall / prolonged seizure and is found to have AKI on admission
91
Investigations for rhabdomyolysis
CK level Urine - red-brown ECG - to assess for hyperkalaemia U+E - for AKI and hyperkalaemia
92
What level of CK suggests rhabdomyolysis
CK significantly elevated - at least 5 times the upper normal limit 2-4 times is not rhabdomyolysis
93
What are the results suggesting rhabdomyolysis
CK level at least 5 times higher Myoglobinuria - red-brown urine Hypocalcaemia Hyperphosphate Hyperkalaemia metabolic acidosis
94
Management of rhabdomyolysis
rapid IV fluids

Y2 Renal (12 decks)

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