ACUTE KIDNEY INJURY Flashcards
KEY CONCEPTS
AKI CRITERIA
Increased Cr by 26.5 mmol/L within 48 hr
OR
Increased Cr by 1.5x based line within the past 7 days
OR
UOP <0.5 ml/kg/hr for >/6 hr
MANAGEMENT
- TREAT HYPERKALEMIA
Get stat ECG, Tele, IV Access
MANAGEMENT IF ECG CHANGES
OR K > 6.5:
Calcium chloride 1 g IV
OR
Calcium gluconate 2-3 g IV
AND
Magnesium Sulfate 1-2g IV
2 amp D50 + 10 U insulin
Monitor glucose q 30 min
Repeat k at 60 min
Salbutamol 8 puff
Insert foley
Hypovolemic - IV bolus normal saline, NO diuretic
Hypervolemic - furosemide 40 - 80 mg IV
Sodium polystyrene sulfonate (Keyexalate) 50 g PO
MANAGEMENT OF POTASSIUM AND NO ECG CAHNGES AND K > 5.5 and < 6.5:
2 amp D50 + 10 U insulin
Monitor glucose q 30 min
Repeat k at 60 min
Salbutamol 8 puff
Insert foley
Hypovolemic - IV bolus normal saline, NO diuretic
Hypervolemic - furosemide 40 - 80 mg IV
Sodium polystyrene sulfonate (Keyexalate) 50 g PO
- TREAT METABOLIC ACIDOSIS
1 amp NaHC03 IV
- DIALYSIS
INDICATIONS: AEIOU
Acid-Base Disturbance: refractory acidemia
Electrolyte Disorder: hyperkalemia, hypercalcemia, tumor lysis
Ingestions: Methanol, Ethylene Glycol, Salicylates, Lithium, Phenobarbitol, Theophylline, Carbamazepine, Valproate, Methotrexate, Dabigatran, Chloral Hexate, Isoniazid
Overload: oliguria, anuria, CHF
Uremia: urea > 50, uremic pericarditis/effusion, encephalopathy / seizures, bleeding diathesis, persistent severe nausea / vomit, fatigue
- RULE OUT OBSTRUCTION
POCUS KUB - HOLD NEPHROTOXINS
SADMANS:
Sulfonylureas
ACEI
Diuretics
Metformin
ARB
NSAIDs
SGLT2i
- SPECIFIC TREATMENT
PRERENAL
Optimize Volume status with IV FLuids +/- pressors
INTRINSIC RENAL
Stop Causative Agents
Treat Infection
POSTRENAL
Remove obstruction
Insert Foley Catheter
Consult urology or interventional radiology if stent or nephrostomy is needed
- INVESTIGATIONS
U/A
Urine Clx
Urine Microscopy
Urine Electrolytes
+/-Urine Sediment
Urine Osmolality
FENa: <1% = pre-renal vs. >2% = ATN
FEUrea (patients on diuretics)
Urine R+M: 3+ Protein - nephrotic syndrome?
+blood but no RBCs - myglobunuria
Urine Eosinophils: >1% a/w AIN
Renal Ultrasound: hydronephrosis - CONSULT NEPHROLOGY
DOCUMENTATION
HISTORY: ASK ABOUT
Decreased PO intake
Polyurea vs. Oliguria
Diarrhea
Abdominal Pain
Flank Pain
Screen for Uremia:
nausea
Vomiting
drowsiness
fatigue
confusion
Recent use of IV contrast DYE
REVIEW MEDICTIONS:
SADMANS
Sulfonylureas
ACEI
Diuretics
Metformin
ARB
NSAIDs
SGLT2i
PHYSICAL EXAM
Orthostatics
Volume Status - evaluate for signs of volume depletion
CVS: S1 / S2 / S3, JVP, HJR
Lungs: crackles
Skin / Skin: Purpura, rash - autoimmune AKI
POCUS:
Cardiac
KUB - check for enlarged bladder and hydronephrosis
DDx PRERENAL
Decreased Intravascular Volume:
Hypovolemia (GI losses, bleeding, diuretics, insensible losses)
Decreased Cardiac Contractility
Cirrhosis
Systemic Vasodilation (sepsis)
Nephrotic Syndrome
Drugs (Renal Vasoconstriction):
NSAIDs
ACEi/ARB
Contrast
Calcineurin Inhib
HRS
Hyper Ca
Structural (Large Vessel):
RAS
Vasculitis
Dissection
DDx INTRINSIC
Renal-Tubulointerstitial:
Acute Tubular Necrosis (ATN)
Acute Interstitial Nephritis (AIN)
Renal-Vascular Disease
Renal Glomerular
DDx POST RENAL
Bladder Neck Obstruction:
BPH
Prostate CA
Neurogenic Bladder
Obstructing Clot
Drugs:
Antihistamines
Anticholinergics
TCAs
Ureteral Obstruction:
Nephrolithiasis
Malignancy
DDx FLUID RETENTIVE STATES
Dependent Edema
DVT
Hypoprotenemia
Liver Failure / Cirrhosis
Portal Vein Thrombosis
Renal Failure
Nephrotic Syndrome
CHF