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REGUB IC2 > Acute Kidney Injury (Medicine) > Flashcards

Acute Kidney Injury (Medicine) Flashcards

1
Q

Treatment of Hyperkalaemia

A
  1. Salbutamol Nebulisers
  2. 10u Actrapid in 50mls 50% Dextrose
  3. 500ml 1.26% NaHCO3 over 1 hour
  4. 10 ml of 10% of Calcium gluconate (only if ECG changes)
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2
Q

Measurement of Kidney Function

A
  • Creatinine
  • eGRF
  • Urine Output
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3
Q

Scale of AKI problem

A
  • AKI is common (10-20% hospitalised patients)
  • a/w harm (need dialysis, peventable iatrogenic, 40% don’t survive)
  • costly
  • development of AKI is modifiable
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4
Q

Why do patients die of AKI in hospital?

A
  • Delay in recognition of AKI in post-admission patients
  • Poor assessments of risk factors of AKI
  • Poor management of AKI
  • Missed complications of AKI
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5
Q

Causes of AKI

A

Pre-renal (reduced renal perfusion)

  • Hypotension
  • Hepatorenal syndrome
  • Renal Artery Stenosis
  • Renal Artery clot

Renal

  • Drugs (NSAIDS, ACEi, ARBs, Gentamicin)
  • GN/Vasculitis
  • Contrast
  • Interstitial nephritis
  • Myeloma
  • Rhabdomyolisis

Post-renal (obstruction)

  • prostate enlargement
  • renal stones
  • pelvic cancer
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6
Q

Percentage of AKI that is hospital acquired or Community acquired, and causes respectively.

A 
Hospital acquired (50.3%)
- Renal causes (Drugs)
Community acquired (49.7%)
- Pre-renal causes
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7
Q

Big Risk Factor for AKI

A

Chronic Kidney Disease (CKD)

>50%

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8
Q

AKI Prevention
The risk of AKI is contributed to by the acute insult and background morbidity.
What are the acute insult and background morbidity?

A

Background morbidity

  • Elderly
  • CKD
  • Cardiac failure
  • Liver disease
  • Diabetes
  • Vascular disease
  • Background nephrotoxic medications
Acute insult
- Acute STOP
Sepsis & Hypoperfusion
Toxicity
Obstruction
Parenchymal Kidney Disease
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9
Q

What are STOP aki?

A

Sepsis & Hypoperfusion

  • Severe sepsis
  • haemorrhage
  • Dehydration
  • Cardiac failure
  • Liver Failure
  • Renovascular insults

Toxicity

  • Nephrotoxic drugs
  • Iodinated Radiological Contrast

Obstruction

  • Bladder outflow
  • Stones
  • Tumour
  • Surgical ligation of ureters
  • Extrinsic compression (e.g lymph nodes)
  • Retroperitoneal fibrosis

Parenchymal Kidney Disease

  • GN
  • TIN
  • Rhabdomyolysis
  • HUS
  • Myeloma kidney
  • Malignant Hypertension
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10
Q

Prevent AKI - The 4 M’s

A
  1. Monitor the patients
    - Obs & EWS
    - Regular fluids
    - Maintain fluid charts
    - assess urinary output and daily weights
  2. Maintain circulation
    - fluid resuscitation
    - oxygenation
  3. Minimise Kidney Insult
    - Avoid NSAID’s Gentamycin, iodinated contrast
  4. Manage Acute Illness
    - recognise and treat sepsis promptly
    - diuretics for hypervolaemia in heart failure. (not to maintain urine output)
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11
Q

What kind of things do you need to consider if one of your patients has CKD?

A
  • Increased risk for AKI

- medication handling (if someone is anuric, their eGFR is 0ml/min, regardless of creatinine)

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12
Q

Recognising AKI early:

The AKI network Classification

A

Stage 1
Increase in serum creatinine >150-200% from baseline
Urinary output (UO) less than 0.5 ml/kg per h for >6 h

Stage 2
Increase in serum creatinine > 200-300%
UO less than 0.5 ml/kg per h for >12 h

Stage 3
Increase in serum creatinine >300%
UO less than 0.3 ml\kg for 24 h or anuria for 12 h

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13
Q

Recognising AKI early:

AKI identification

A
  • Identify AKI (serum creatinine > 1.5 x basline) and presume normal baseline if no previous results available.
  • clarify whether Dx likely to be pre-renal, renal or post-renal causes (can co-exist)
  • Immune symptoms
    rash, new arthritis, nasal crusting/bleeding, haemoptysis, new deafness, mouth ulcers, alopecia, iritis/episcleritis, mononeuritis multiplex or neuropathy
  • Obstructive symptoms/signs
    poor stream, hesitancy, frequency, nocturia, PV bleeding, stones
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14
Q

Recognising AKI early:

AKI Examination

A
  • Fluid status, BP, JVP, loin tenderness, palpable bladder, rash, oedema, signs of autoimmune disease
- Urine dipstick
Must be done in all:
AKI
Non-dialysis CKD
DVT or PE
Oedematous patients
Suspected UTI
  • Everyone gets US Kidney to check size and outrule obstruction.
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15
Q

Dipstick results (Blood only) - differentials (4)

A

Trauma
Malignancy
Stones
Rhabdomyolysis

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16
Q

Dipstick results (Blood & protein) (4)

A

GN
Vasculitis
UTI
Malignant Hypertension

17
Q

Dipstick Results (Protein only) (4)

A

GN
Amyloid
Severe HTN
Diabetic nephropathy

18
Q

Dipstick Results (-ve for blood and proteins)

A

Pre-renal or post-renal
Interstitial nephritis
Drugs
Myeloma - cast nephropathy

19
Q 
Dipstick results (shows leucocyte or nitrites)
What should you do?
20
Q 
Dipstick results ( shows protein on Dipstick)
What should you do?
A

Send urine protein creatinine ratio

21
Q

Management of AKI, the 4 M’s (same as prevention)

A
  1. Monitor the patients
    - Obs & EWS
    - Regular bloods - daily or twice daily (U/E, TCO2, CPM, FBC)
    - Maintain fluid charts
    - assess urinary output (+/- catheter) and daily weights
  2. Maintain circulation
    - fluid resuscitation
    - oxygenation
  3. Minimise Kidney Insult
    - Avoid NSAID’s Gentamycin, iodinated contrast
  4. Manage Acute Illness
    - recognise and treat sepsis promptly
    - diuretics for hypervolaemia in heart failure. (not to maintain urine output)
    - stop metformin if eGFT <30ml/min or creatinine rising
    - Suspect vasculitis or pulmonary renal syndromes
    - Follow contrast nephropathy guidelines when imaging with IV contrast is done
    - Avoid gadolinium based dye for MR scans if eGFR < 30ml/min
22
Q

What to consider in contrast nephropathy?

A
  1. Assess Risk
    - High volume (>100ml) iodinated contrast procedure & CKD with eGFR <60 (particularly diabetic nephropathy) or AKI
    - other risk factors (STOP)
  2. Is contrast procedure necessary?
  3. Resuscitate to euvolemia
  4. Give Prophylaxis if high risk of AKI
    - Volume expansion (unless hypervolaemic) with normal saline or 1.26% bicarbonate
  5. minimise contrast, use low or iso-osmolar contrast
  6. Monitor function to 72 hours in high risk
    - if oliguria or rising creatinine, early referral to renal team
  7. Hold diuretics/ACEi/ ARB/ NSAIDs on the day
23
Q

What is the potassium level to be considered as hyperkalemia?

24
Q

Management of Hyperkalemia due to AKI?

A
  • Eliminate dietary sources

- Stop offending meds (diuretics, trimethoprim)

25
Q

Immunology Screen for AKI

Criteria

A
  1. Age > 40
  2. Haematuria
  3. Proteinuria
  4. Others
26
Q

Immunology Screen for AKI

Age >40

A

SPEP and UPEP (myeloma screen)

27
Q

Immunology Screen for AKI

Haematuria

A 
ANCA
ANA
C3
C4
HBV
HCV
28
Q

Immunology Screen for AKI

Proteinuria

A 
HIV
ANA
C3
C4
HBV
HCV
29
Q

Immunology Screen for AKI

Others

A

Cryo if rash
ENAs if ANA +ve
anti-GBM if rapidly declining renal function/ haematuria/ lung pathology

30
Q

Between AKi and long term renal & CV outcomes, which one is more worrisome?

A

AKI

  • greater risk for death (hazard ratio 1.85)
  • MAKE defined as a need for long-term dialysis, a 25% decline in eGFR or death

REGUB IC2 (1 decks)

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