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RUSVM SAM 2 > Acute Renal Failure > Flashcards

Acute Renal Failure Flashcards

1
Q

What is acute renal failure?

A

Decreased GFR leading to the retention of nitrogenous wastes

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2
Q

How can acute kidney injury be classified? On what basis are they classified?

A 
Risk 
Injury
Failure 
Loss 
End-stage kidney disease

Classified based on proportion of serum creatinine increased and urine output decrease

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3
Q

What are etiologies for pre-renal acute kidney injury?

A

Insuffient blood flow to kidney

  • dehydration
  • hypoxia
  • ischemia
  • hypotension
  • decreased circulatory volume
  • anesthesia
  • hypoadrenocorticism
  • trauma
  • surgery
  • heatstroke
  • hypoalbuminemia
  • hypoperfusion
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4
Q

What are renal etiologies of acute kidney injury?

A 
Renal hypoperfusion -> tubular hypoxia 
Obstruction 
Vasoconstriction 
Thrombosis and DIC 
Transfusion rxn 
Infectious (Leptospirosis) 
Immune mediated 
Neoplasia 
Secondary to systemic dz 
Nephrotoxic s
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5
Q

What are some nephrotoxic agents?

A

Ethylene glycol
NSAIDS
Aminoglycosides

Radiocontrast agents 
Trimethoprim sulphonamides 
Methotrexate 
Cyclosporine 
Cimetidine 
Dextran 4 
Heavy metal 
Raisins

Myoglobin (endogenous)

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6
Q

What are post-renal etiologies of acute renal injury?

A

Urine leakage -> lead to uroabdomen/septic peritonitis

Obstruction -> pressure on collecting tubule disrupt aquaporins and distrust normal hydrostatic and oncotic pressure

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7
Q

What are the 4phases of acute renal failure?

A

Initial -> extension -> maintenance -> recovery

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8
Q

What is the initial phase of acute renal failure?

A

No clinical signs

Triggered by ischemic event

Definable by a decrease in urine output or increase in creatinine

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9
Q

What is the extension phase of acute renal failure?

A

Continued hypoxia and inflammation
Proximal tubule most susceptible to toxic ischemic damage

Compromised Na:K pumps -> cells swelling and damage

Increased cytosolic Ca

Loss of brush border or apical and basal cell surfaces

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10
Q

What is the maintenance phase of acute renal failure?

A

1-3weeks duration
Urine output is increased or decreased

Urine=ultrafiltate

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11
Q

What is the recovery phase of acute renal failure?

A

Polyuria

Extreme Na loss
Weeks to months to recover

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12
Q

What causes of acute tubular necrosis (intrinsic renal failure)?

A

Intra-renal vasoconstriction

Tubular dysfunction

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13
Q

What are causes of intra-renal vasoconstriction ?

A

Imbalance between the vasoconstrictors (endothelium) and vasodilator (NO)

Endothelial injury

Decreased O2

ATP-> AMP (energy deficit)

Mitochondrial damage
Oxidant injury
Na/K pump stops working- cellular swelling

Intracellular acidosis
Intracellular hypercalcemia

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14
Q

What are causes of tubular dysfunction?

A

Tubular obstruction from crystals or detached RTE cells

Cytoskeletal injury with loss of polarity

Loss of tight junctions between cells

Cell necrosis

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15
Q

What are risk factors for acute renal failure?

A

Dehydration, hypovolemia
Anesthesia
Hypoxia
Systemic inflammatory response syndrome

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16
Q

What are renoprotective drugs?

A

Ca channel blockers

Selective DA-2 receptor agonists (vasodilation)- dopamine

Selective DA-1 receptor agonists- fenoldopam

Erythropoietin analogs
F

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17
Q

How can you prevent acute renal failure ?

A

BP > 80mmHg
CVP < 10mmHg

Correct hypoxia

  • PCV > 30%
  • SpO2>96%
  • PaO2>80mmHg

ECG - avoid hyperkalemia induced bradyarrhythmia

Fluid bolus - 10-15ml/kg crystalloids or 2-5ml/kg colloid

Pressures if low BP or no response from fluids

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18
Q

How would you diagnose AKI/ARF?

A

Predisposing cause
Reduced urine output < 0.5ml/kg/hr

UA- casts, 
Azotemia 
FexNa> 1%
Renal tubular biomarkers 
-GGT:CREA
-NAG:CREA 
-
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19
Q

What is the treatment of acute renal failure?

A

FLUIDS

Correct shock- 60-90ml/kg (canine); 45ml/kg (feline) over a hour given in 15min interval boluses

Correct dehydration: %dehydration xBW = liters

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20
Q

What are the components of maintence fluids?

A

Insensible fluid loss (sweat and respiration)

Sensible fluid loss (urine, feces, vomit)

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21
Q

What is the average maintenance level of fluid ?

A

60ml/kg/day

*can vary in ARF

22
Q

What would you use to rehydrate a patient with ARF?

A

Crystallioids (RLS, normosol R)

0.9% NaCl if hyperkalemia then reduce to 0.45% Na with 2.5% dextrose

23
Q

What is oliguria?

A

<0.5ml/kg/hour urine production

Not producing sufficient amount of urine

24
Q

Treatment for oliguria???

A

FLUID

Mannitol
Furosemide
Dopamine
Ca channel blockers

25
What is the best way to determine if your patient is overhydrated??
Central venous pressure -if over 10cmH20 then overhydrated
26
MOA of mannitol
Osmotic diuretic Increase circulatory volume-flashes through tubules Decreases cell swelling Reduced cellular aggregation Free radical scavenger Blunts the influx of Ca intracellularly
27
When is mannitol contraindicated?
Anuria | Dehydration
28
What is the MOA of furosemide?
Loop diuretic Inhibit NA-K-2Cl symporter in ascending loop of Henle Increased urine production without increasing GFR Renoprotective
29
When is furosemide contraindicated?
Dehydration Lethargy Tachycardia Ototoxicity
30
What is the MOA of dopamine with renal failure?
May convert to non-oligura Not effective in cats Only benefit as a pressor when ARF is secondary to CO failure or severe hypotensive
31
How do calcium channel blockers treat acute renal failure ?
Pre-glomerular vasodilation Prevent Ca moving intracellularly Use in post-transplant as renoprotective agent Standard of care in leptospirosis
32
What is the definitive treatment for acute renal failure?
Dialysis AKA extracoproeal renal replacement therapy (ERRT)
33
When in dialysis indicated?
Fluid overload with pulmonary edema Hyperkalemia Progressive azotemia Acute toxicity
34
What are complications for periotneal dialysis?
Dialysis disequilibrium syndrome (cerebral oedema) Blockage of the peritoneal drain by omentum
35
What is the therapy for ethylene glycol toxicity?
4-methylpyrazole/ fomepizole
36
What is the therapy for renal failure due to NSAIDS?
Misoprostal (PGE analogue)
37
Treatment for leptospirosis?
Penicillin and doxycycline
38
Specific therapy for pyelonephritis?
Culture | Fluoroquinolones or TMS
39
Therapy for aminoglycoside toxicity?
Ticarcillin IV- binds getamycin
40
Treatment for TMS toxicity?
Urinary alkalinization (citrate or bicarb)
41
Why do you see acidosis with hyperkalemia ?
H+ is exchanged for K+
42
T/F: all the following are complications due to hyperkalemia.. bradycardia, sinus arrest, muscle weakness, and ileus
True
43
How can you correct hyperkalemia ?
Insulin Dextrose Ca gluconate (cardioprotective) Correct acidosis with bicarb
44
When is bicarb as a treatment for acidosis contraindicated?
When CO2 elevated (will lead to excess H+ ions) | Could lead to paradoxical CNS acidosis
45
Hypocalcemia associated with renal fialure is caused by? How is it treated?
Deficiency of calcitriol Treat with calcium gluconate 10%
46
How is hypercalcemia associated with renal failure treated?
Diuretics or ERRT Furosemide/glucocorticoids Calcitonin Biphosphonates
47
How can you treat a hyperphosphatemia associated with renal fialure?
Reduce PO4 intake by protein restriction diet and oral phosphate binders that are dosed with food Aluminum hydroxide/carbonate
48
How would you treat a hypertension associated with acute renal fialure?
Avoid ACE -> inhibit arterial vasoconstriction (hypoxia) Amlodipine and hydralaizne
49
How does hypertension arise from acute renal failure ?
Secondary to RAAS activation and fluid overload
50
What treatments can be used in uremic gastropathy?
Omeprazole Pantoprazole Famotidine Ranitidine
51
What is the prognosis for kidney disease caused by leptospirosis or obstruction?
Good outcome
52
What is the prognosis for kidney disease with decreased urine production, hypothermia, and hyperkalemia ?
Poor outcome

RUSVM SAM 2 (44 decks)

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