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MBBS 3: Internal Medicine > Acute Renal Failure > Flashcards

Acute Renal Failure Flashcards

1
Q

Functions of the kidney?

A
  1. Excretion of nitrogenous waste
  2. Regulation of water, electrolytes and BP
  3. Synthesis
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2
Q

Effect of kidney failure on salt and water homeostasis?

A
  1. Fluid overload
    - peripheral oedema
    - pulmonary oedema
  2. Fluid depletion
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3
Q

Effect of kidney failure on BP control?

A

hypertension

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4
Q

Effect of kidney failure on the removal of uremic toxins?

A

Uremia
1. encephalopathy
2. pericarditis
3. nausea
4. vomiting
5. hiccup
6. bleeding tendency
7. neuropathy

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5
Q

Effect of kidney failure on calcium/phosphate balance?

A
  1. Hyperphosphatemia
  2. Hypocalcaemia
  3. Renal bone disease
  4. Tertiary hyperparathyroidism
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6
Q

Effect of kidney failure on EPO production?

A

anemia

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7
Q

Effect of kidney failure on potassium balance?

A

hyperkalemia

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8
Q

Effect of kidney failure on acid-base balance?

A

metabolic acidosis

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9
Q

Relevance of kidney disease?

A
  1. CKD = cardiovascular risk
  2. CVS events are common and the major cause of morbidity and mortality from CKD
  3. CKD is now affecting younger populations in their economic prime
  4. Likelihood of CVS death is far greater than progression to ESRD
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10
Q

Definition of acute renal failure?

A

Rapid decline in GFR over days or weeks

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11
Q

AKI results in?

A
  1. Retention of nitrogenous wastes, creatinine and other toxins
  2. Oliguria occurs in ≈ 50%
    Note: May be reversible
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12
Q

Causes of in hospital morbidity and mortality?

A

because of underlying illnesses and high incidence of subsequent complications
Complicates ≈ 5% of hospital admissions, ≈ 30% of ICU admissions

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13
Q

Criteria for AKI categories?

A
  1. change in serum creatinine levels
  2. urine output
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14
Q

Category 1 for AKI?

A
  1. 1.5 – 1.9 times increase in SCr from baseline or
    >0.3mg/dl increase in se
  2. <0.5ml/kg/hr for 6 to 12 hours
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15
Q

Category 2 for AKI?

A
  1. 2.0 – 2.9 x increase in SCr from baseline
  2. <0.5ml/kg/hr for >12 hours
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16
Q

Category 3 for AKI?

A
  1. 3.0 x increase in SCr from baseline or Creatinine >4mg/dl
  2. <0.3ml/kg/hr over 24 hours or
    Anuria > 12 hours
17
Q

Undergraduate classification of AKI?

A
  1. Pre Renal - Circulatory Failure = “Shock”
  2. Renal - The cells of the kidney
  3. Post Renal - Obstruction
18
Q

Pre-renal failure?

A
  • 50 – 60% of all cases
  • Renal parenchyma preserved
  • Falling renal blood flow leads to a falling GFR
  • This might be due either to changes in the circulation, or to intrarenal vasomotor changes that drop glomerular perfusion pressures
19
Q

Prerenal causes of AKI?

A
  1. Hypovolaemia
    - dehydration or haemorrhage
  2. Hypotension without hypovolaemia
    - cirrhosis or septic shock
  3. Low cardiac output
    - cardiac failure or cardiogenic shock
  4. Renal artery stenosis
20
Q

Post renal AKI?

A

Mechanical obstruction of the urinary collecting system
- Renal pelvis, ureters, bladder, or urethra
- Obstructive uropathy

21
Q

Postrenal causes of AKI?

A
  1. Ureteric obstruction
    - Stone disease, tumor, fibrosis, ligation during pelvic surgery
  2. Bladder neck obstruction
    - Benign prostatic hypertrophy (BPH), CA prostate, neurogenic bladder, tricyclic antidepressants, ganglion blockers, bladder tumor, stone disease, hemorrhage/clot
  3. Urethral obstruction
    - Strictures, tumor, phimosis
  4. Intra-abdominal hypertension
    - Tense ascites
  5. Renal vein thrombosis
22
Q

Describe prerenal AKI?

A
  • caused by renal hypoperfusion
  • Integrity of renal parenchyma is preserved = pre-renal
  • 50-60% of cases
23
Q

Causes of intrinsic renal failure?

A
  1. tubular
    - interstitial nephritis : 10%
    - ATN : 75-80%
    > ischemic
    > toxic
  2. glomerular
    - glomerulonephritis
  3. vascular
    - vasculitis
24
Q

Describe postrenal failure?

A
  • Obstruction of urine flow
  • < 5%
25
Q

Urine sediment used in differential diagnosis?

A
  1. normal or few RBC, WBC
  2. granular casts
  3. RBC casts
  4. WBC casts
  5. Eosinophiluria
  6. Crystalluria
26
Q

3 phases of acute renal failure?

A
  1. Initial phase: exposure to ischemia / toxin.
    - Evolution of parenchymal injury
    - ARF preventable
  2. Maintenance phase: established injury
    - may last 1-2 weeks or months
  3. Recovery phase: repair and regeneration
27
Q

Management of prerenal ARF?

A
  1. replace fluid and what was lost
    - controversy colloid vs. crystalloid
    - Normal Saline seems best
    - Urinary/GI losses usually hypotonic
  2. If CHF treat arrhythmias, inotropes, reduce preload/afterload
  3. If cirrhosis, paracentesis ± albumin, FFP, shunt
  4. Remove offending drugs
28
Q

Management of intrinsic ARF?

A
  1. Prevention:- optimize cardiac function, volume status
  2. caution with ACEI, NSAIDS, vasodilators
  3. Treat according to specific cause
29
Q

Diagnosis of ARF?

A
  1. History and examination
  2. Routine bloods
  3. Extra bloods – bicarbonate, CK, 4. CRP + blood cultures
  4. ECG
  5. CXR
30
Q

Treatment of ARF?

A
  1. Immediate - Airway and Breathing
  2. Circulation
    - restore renal perfusion (fluid resuscitation ± inotrope)
    - hyperkalaemia
    - pulmonary oedema
  3. Remove causes
    - drugs
    - sepsis
  4. Exclude obstruction & consider ‘renal’ causes
    - are the pre-renal causes sufficient to account for ARF?
  5. Ask for help: ICU or renal unit
31
Q

Indications for dialysis in ARF?

A

A E I O U
A – severe metabolic acidosis of renal origin and refractory to medical therapy
E – electrolyte abnormalities – refractory hyperkalemia =>6.5
I – intoxication with dialysable compounds
O – fluid overload especially pulmonary edema refractory to diuretic therapy
U- uremia – pericarditis, bleeding, confusion (encephalophathy)
Oligo/anuria

32
Q

Features of the ECG in hyperkalemia?

A
  1. loss of P wave
  2. tall peaked T wave
  3. widened QRS with tall T wave
33
Q

Management of hyperkalemia?

A

Most important when K+ >6.0
1. Remove offending agent e.g. drugs
2. 10mls of 10% Calcium gluconate IV
3. 10 units of Soluble insulin with 50mls of 50%dextrose IV – then monitor blood sugar
4. Nebulised salbutamol/albuterol
5. Frusemide if in pulmonary edema
6. Oral Kayexelate (K binding resin)

MBBS 3: Internal Medicine (72 decks)

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