Acute Kidney Injury Flashcards
Acute kidney injury (AKI) is a clinical syndrome that _____ the course and _____ the outcome in a significant number of hospitalised patients.
complicates
worsens
Acute kidney injury (AKI)
Recent evidence, in both basic science and clinical research, is beginning to change our view for AKI from a _________ syndrome to a syndrome where the kidney plays an active role in the progress of ________
single organ failure
multi-organ dysfunction.
The concept of Acute Renal Failure (ARF) has undergone significant re-examination in recent years.
T/F
T
Acute Renal Failure (ARF)
Traditionally, emphasis was given to the most severe acute reduction in kidney function, as manifested by _________ and often by ______ or _____
severe azotaemia
oliguria or anuria.
Acute Renal Failure (ARF)
However, recent evidence suggests that even relatively mild injury or impairment of kidney function manifested by ____________ in _______ or _______ , is a predictor of serious clinical consequences
small changes in serum creatinine (sCr) and/or urine output (UO)
Acute _______ is the term that has recently replaced the term Acute ________.
Kidney Injury (AKI)
Renal failure (ARF)
Acute Kidney Injury (AKI)
AKI is defined as an abrupt (within _____ ) decrease in ______, which encompasses both _____ (___________) and _______ (__________).
hours
kidney function
injury; structural damage
impairment; loss of function
Acute Kidney Injury (AKI)
is a syndrome that often has a sole and distinct pathophysiology.
T/F
F
rarely
Acute Kidney Injury (AKI)
Furthermore the syndrome is quite (common or rare?) among patients without ______ and it is essential that health care professionals, particularly those without specialisation in renal disorders, detect it easily
Common
critical illness
Classification of AKI includes _______,______, and ______
pre-renal AKI, acute post-renal obstructive nephropathy and intrinsic acute kidney diseases.
Classification of AKI
Of these, only ‘________’ AKI represents true kidney disease, while _______ and ______ are the consequence of _________ diseases leading to the decreased glomerular filtration rate (GFR).
intrinsic
pre- renal and post-renal AKI
extra-renal
Classification of AKI
If these pre- and/or post-renal conditions persist, they will eventually evolve to ————- and hence __________ disease.
renal cellular damage
intrinsic renal
Epidemiology of AKI
In urban areas of developing countries, main causes of AKI are _______ acquired (renal ischaemia, sepsis and nephrotoxic drugs)
while in rural areas it is more commonly a consequence of _______ acquired disease (diarrhoea, dehydration, infectious diseases, animal venoms etc.).
hospital
community
Epidemiology of AKI
__________ of AKI especially in developing countries is also a major problem that relates with the true knowledge of its impact in many parts of the world
Under-reporting
Epidemiology of AKI
In developed countries the prevalence of AKI is _____easing.
In hospital in-patients it is estimated to occur up to ____% and is more common
in critically ill patients, in whom its prevalence is estimated to be up to ___%.
incr
15
60
Epidemiology of AKI
On the other hand, community AKI is usually (common or uncommon?) although a recent study estimated its incidence at _____% among all hospital admissions.
However even this incidence remains an underestimate of the true impact of community acquired AKI due to ______________________
Uncommon
4.3
non-referral of patients to hospitals.
Epidemiology of AKI
The majority of AKI cases in children are secondary to ________ mechanisms (e.g.___,_________ after surgery) and secondary to _____.
volume responsive
diarrhoea, renal hypoperfusion
Sepsis
Epidemiology of AKI
Multiple studies have shown that AKI in the elderly (usually defined as older than _____ years) is increasingly common and that there is an age- dependent relationship between AKI and older age.
This has been attributed in part to anatomic and physiologic changes in the ___ kidney and in part to various _______ as that may require procedures and/or medications that act as ________ and alter renal haemodynamics or are nephrotoxic.
65
ageing
comorbidities; kidney stressors
Classification of AKI
In 2002 a system for diagnosis and classification of acute impairment of kidney function was developed through a broad consensus of experts, resulting in the _______ criteria.
RIFLE
Classification of AKI: the RIFLE criteria.
With this system three severity grades are defined (___,_____, and ______) and two outcome classes (______ and _______ ).
Risk, Injury and Failure
Loss and End-Stage Renal Disease (ESRD)
Classification of AKI: the RIFLE criteria
The severity criteria of AKI are defined on the basis of the changes in _____ or ______ where the worst of each criterion is used.
The outcome criteria are defined by the _____________ of kidney function.
serum creartinie (sCr) or urine output (UO)
duration of impairment
Classification of AKI
The importance of RIFLE criteria is that they ____________________.
move beyond ARF
Classification of AKI
The term “acute kidney injury/impairment” has been proposed to encompass the “entire spectrum of the syndrome from ___________________ to _______________”.
minor changes in markers of renal function to requirement for renal replacement therapy (RRT)
Classification of AKI
AKI encompasses ______ and ____ as well as other, less severe conditions. It includes patients (with or without?) actual damage to the kidney but with _______ relative to _______
ATN and ARF
Without
functional impairment
physiologic demand.
the RIFLE definition is free of ambiguities.
T/F
F
the RIFLE definition is not free of ambiguities.
Classification of AKI; RIFLE
Pickering et al showed that there was a mismatch between ______ in ____, and _____ in _____ (estimated with MDRD or Cockroft-Gault formulae)
increases in sCr concentration
decreases in GFR
Classification of AKI
In 2007, the _________ (AKIN) group proposed a modified version of the RIFLE criteria, which aimed to improve the ______ of AKI diagnostic criteria.
Acute Kidney Injury Network
sensitivity
Classification of AKI: AKIN definition
There were several changes: an absolute increase in sCr of at least 0.3 mg/dL (26.5 μmol/L) was added to stage 1; the _____ criterion was removed; patients starting _______ were classified as stage 3, irrespectively of ____ values; and _______ were removed.
GFR
RRT
sCr
outcome classes
Classification of AKI: the AKIN definition
Only _____ criterion (___________) has to be fulfilled in order to qualify for a stage.
one
sCr or UO
Classification of AKI: the AKIN definition
____ becomes more important for AKI diagnosis in the AKIN definition: changes between two sCr values within a ______ period are required, while _____ was proposed in the original RIFLE criteria.
Time
48-hour
one week
Classification of AKI: the AKIN definition
Severity of AKI in AKIN is staged over the course of ______ by the fold-change in sCr from baseline.
7 days
Classification of AKI
The latest classification of AKI proposed by the Acute Kidney Injury Working Group of KDIGO (Kidney Disease: Improving Global Outcomes), is based on the ___________, and had the aim of ____________
previous two classifications
unifying the definition of AKI.
Aetiology of AKI
There are numerous potential causes of AKI, mainly related to a focal mismatch between ________ and _______ (because of impaired _______) to the nephrons and increased ______ (due to ______).
oxygen and nutrient delivery
microcirculation
energy demands; cellular stress
Aetiology of AKI
For many years the diagnosis and management of AKI was based on the concept of classification to three main categories: ______,_____,______[
pre-renal, intrinsic and post-renal
Aetiology of AKI
In Pre-renal AKI, renal _______ leads to a _____eased GFR ((with or without?) damage to the renal parenchyma), as an adaptive response to various extra-renal insults.
hypoperfusion
decr; without
Aetiology of AKI
It is known that maintaining a normal GFR is dependent on __________.
adequate renal perfusion
The kidneys receive up to ____% of cardiac output and thus any failure of the systematic circulating blood volume or isolated failure of the intra-renal circulation can have a profound impact on renal perfusion
25
Aetiology of AKI
Post-renal AKI occurs after (acute or chronic?) _____ of the urinary flow, which increases _______ and thus ____eases GFR.
Acute
obstruction
intra-tubular pressure
decr
Aetiology of AKI: Post-renal AKI
In addition, acute urinary tract obstruction can lead to impaired _______ and _____ processes that also contribute to diminished _____.
renal blood flow
inflammatory
GFR
Aetiology of AKI
Post-renal AKI can develop if the obstruction is located at _________________ (from the ________ to ____)
any level within the urinary collection system
renal tubule to urethra
Aetiology of AKI: Post-renal AKI
Urinary obstruction may present as ____ or intermittent urine flow (such as _____ alternating with ____) but may also present as ______ or _____ AKI
anuria
polyuria; oliguria
nocturia or nonoliguric
Aetiology of AKI
Timely reversion of pre-renal or post-renal causes usually results in _________, but late correction can lead to ______
prompt recovery of function
kidney damage
Aetiology of AKI
Intrinsic renal aetiologies of AKI can be challenging to evaluate because of the ______________.
Generally, four structures of the kidney are involved including _______,______,_______,______
wide variety of injuries that can occur to the kidney
tubules, glomeruli, the interstitium, and intra-renal blood vessels.
Aetiology of AKI: Intrinsic renal aetiologies of AKI
Acute tubular necrosis (ATN) is the term used to designate AKI resulting from _________.
damage to the tubules
Aetiology of AKI: Intrinsic renal aetiologies of AKI
AKI from glomerular damage occurs in severe cases of __________
acute glomerulonephritis (GN).
Aetiology of AKI: Intrinsic renal aetiologies of AKI
AKI from vascular damage occurs because injury to ______ decreases _____ and diminishes ____
intra-renal vessels
renal perfusion; GFR
_______ is the most common type of intrinsic kidney injury.
Acute tubular necrosis
Aetiology of AKI: Intrinsic renal aetiologies of AKI
acute interstitial nephritis occurs due to _________ to a variety ______ or _____
an allergic reaction
medications
An infection
Special clinical scenarios-Rhabdomyolysis
Rhabdomyolysis is a syndrome that is characterised by the _______ and ——— of _________ and subsequent release of its contents (i.e. myoglobin, sarcoplasmic proteins) into _______ and ______.
breakdown and necrosis
damaged skeletal muscle
extracellular fluid and circulation
Special clinical scenarios-Rhabdomyolysis
These products from rhabdomyolysis may be ____________, leading to AKI via different mechanisms, such as ________ secondary to _______, renal vasoconstriction, inflammation and tubular damage associated with ________ production.
filtered through the glomeruli
intratubular obstruction
protein precipitation
reactive oxygen species
Rhabdomyolysis usually develops in the setting of one or more of the following situations:
(1) Disruption of the _____ and/or ______ for metabolism
(2) Excessive ______
(3) Impaired _______ production
(4) and/or increased _________
substrates; oxygen
metabolic demand
cellular energy
intracellular calcium influx.
Rhabdomyolysis usually develops in the setting of one or more of the following situations:
(1) Disruption of the substrates and/or oxygen for metabolism (i.e. ______,_____,______),
(2) Excessive metabolic demand (i.e. ________),
(3) Impaired cellular energy production (i.e. ________,_______),
(4) and/or increased intracellular calcium influx.
ischaemia, hypoxia, crush injuries
strenuous exercise
hereditary enzymatic disorders, toxins
Rhabdomyolysis
The clinical presentation of this multifactorial and multicausal syndrome varies from an asymptomatic but detectable elevations of _____ and _____ in blood to a life threatening condition with ________
CK and myoglobin
fulminant AKI.
rhabdomyolysis induced AKI is one of the leading causes of AKI.
T/F
T
Drug-induced AKI
Medications frequently show ____ effects on the kidney as glomerular, interstitial and tubular cells encounter _________ of medications and their metabolites, which can induce changes in kidney function and structure.
toxic
significant concentrations
Drug-induced AKI
Renal ______ cells are particularly vulnerable to the toxic effects of drugs because of their role in ________ and _________ , which exposes them to high levels of circulating toxins.
tubular
concentrating and reabsorbing glomerular filtrate
Drug-induced AKI
Renal toxicity can be a result of _____ changes, _______ to cells and tissue, ______ tissue injury and ______ of renal excretion.
haemodynamic
direct injury
inflammatory
obstruction
Contrast Induced Acute Kidney Injury (CI- AKI)
Contrast induced AKI (CI-AKI) previously known as _______ is a syndrome in which acute renal dysfunction is diagnosed following ______ administration of contrast agents.
contrast induced nephropathy (CIN)
intravascular
Contrast Induced Acute Kidney Injury (CI- AKI)
Contrast agents are used widely for ______ and _______ purposes.
Their nephrotoxic potential was first suggested at least ____ years ago
diagnostic and therapeutic
50
Contrast Induced Acute Kidney Injury (CI- AKI)
Animal models of CI-AKI suggest several potential mechanisms of nephrotoxicity, including renal ischaemia, vasoconstriction, formation of reactive oxygen species and direct tubular toxicity, which lead to decreased renal perfusion
Maddddd
Bad stuffs 🚶♂️🚶♂️
________ is considered one of the most common causes of AKI among hospitalised patients
Contrast Induced Acute Kidney Injury (CI- AKI)
Acute kidney injury and extra-renal organ dysfunction
Recent evidence in both basic science and clinical research are beginning to change our view for AKI from a ___________ syndrome, to a syndrome where the kidney plays an active role in the evolution of ___________
single organ failure
multi-organ dysfunction.
AKI is an isolated event
T/F
F
AKI is not an isolated event
The _____ and the ____ are the two most commonly involved organs in multi-organ failure.
kidney
lung
Acute lung injury (ALI) and AKI are common complications of _____ and the development of either increases mortality
sepsis
Kidney-lung crosstalk in the critically ill patient
Currently there is growing interest in the potential cross-talk that exists between these organs when injured, with one organ ______ or _______ to injury to the other.
causing or contributing
Kidney and cardiac disease are common but do not coexist.
T/F
F
Kidney and cardiac disease are not only common but often coexist.
Heart-kidney crosstalk: the cardiorenal syndrome
( acute or chronic?) cardiac disease can contribute (directly or indirectly?) to acute and/or chronic _____ of renal function and vice versa.
Both acute and chronic
Directly
worsening
Heart-kidney crosstalk
The term _______ (CRS) is often used to describe this condition and represents an important model for the exploration of the pathophysiology of cardiac and renal dysfunction.
cardiorenal syndrome
Kidney-liver interactions: Hepatorenal syndrome
Here it is important to distinguish ___________ as distinct from the well-recognised ____________
hepatic dysfunction as a result of AKI
hepatorenal syndrome (HRS).
Kidney-liver interactions
Ischaemic AKI induces ________ and promotes inflammation apoptosis and tissue damage to _______.
This is not hepatorenal syndrome
oxidative stress
hepatocytes
Liver injury do not often correlate with severity of kidney injury.
T/F
F
They do
Kidney-liver interactions: Hepatorenal syndrome
On the other hand the concept of HRS is very well recognised; it is a/an (reversible or irreversible?) functional renal impairment that occurs in patients with ________ or in patients with fulminant _______
reversible
advanced liver cirrhosis
hepatic failure.
Kidney-liver interactions: Hepatorenal syndrome
On the other hand the concept of HRS is very well recognised
It is characterised by a marked decrease in _____ and ______ in the (presence or absence?) of other causes of renal injury.
GFR; renal blood flo
Absence
Hepatorenal syndrome
HRS is rare
T/F
F
HRS occurs in approximately 40% of patients with advanced cirrhosis
T/F
T
Biochemical features of AKI
___________ _____kalemia
_______magnesemia
_______natremia
_________phosphatemia
Metabolic _________
___________uricemia
(Low or high?) levels of urea
(Low or high?) levels of nitrogen
(Low or high?) urine output
______eased Hco3
________eased GFR
(Low or high?) serum creatinine
Massive hyper
Hypo
Hypo
Hyper
Acidosis
Hyper
High
High
Low
Decreased
Decreased
High
__________ Kidney and ______ is seen in Turner’s syndrome
Horshoe kidney
Coarctation of aorta
Horshoe kidney is seen in _____ syndrome
Turner
