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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
Q

What is the best way to determine if your patient is overhydrated??

A

Central venous pressure

-if over 10cmH20 then overhydrated

26
Q

MOA of mannitol

A

Osmotic diuretic
Increase circulatory volume-flashes through tubules

Decreases cell swelling
Reduced cellular aggregation
Free radical scavenger
Blunts the influx of Ca intracellularly

27
Q

When is mannitol contraindicated?

A

Anuria

Dehydration

28
Q

What is the MOA of furosemide?

A

Loop diuretic
Inhibit NA-K-2Cl symporter in ascending loop of Henle

Increased urine production without increasing GFR

Renoprotective

29
Q

When is furosemide contraindicated?

A

Dehydration
Lethargy
Tachycardia
Ototoxicity

30
Q

What is the MOA of dopamine with renal failure?

A

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
Q

How do calcium channel blockers treat acute renal failure ?

A

Pre-glomerular vasodilation

Prevent Ca moving intracellularly

Use in post-transplant as renoprotective agent

Standard of care in leptospirosis

32
Q

What is the definitive treatment for acute renal failure?

A

Dialysis AKA extracoproeal renal replacement therapy (ERRT)

33
Q

When in dialysis indicated?

A

Fluid overload with pulmonary edema
Hyperkalemia
Progressive azotemia
Acute toxicity

34
Q

What are complications for periotneal dialysis?

A

Dialysis disequilibrium syndrome (cerebral oedema)

Blockage of the peritoneal drain by omentum

35
Q

What is the therapy for ethylene glycol toxicity?

A

4-methylpyrazole/ fomepizole

36
Q

What is the therapy for renal failure due to NSAIDS?

A

Misoprostal (PGE analogue)

37
Q

Treatment for leptospirosis?

A

Penicillin and doxycycline

38
Q

Specific therapy for pyelonephritis?

A

Culture

Fluoroquinolones or TMS

39
Q

Therapy for aminoglycoside toxicity?

A

Ticarcillin IV- binds getamycin

40
Q

Treatment for TMS toxicity?

A

Urinary alkalinization (citrate or bicarb)

41
Q

Why do you see acidosis with hyperkalemia ?

A

H+ is exchanged for K+

42
Q

T/F: all the following are complications due to hyperkalemia.. bradycardia, sinus arrest, muscle weakness, and ileus

A

True

43
Q

How can you correct hyperkalemia ?

A

Insulin
Dextrose

Ca gluconate (cardioprotective)

Correct acidosis with bicarb

44
Q

When is bicarb as a treatment for acidosis contraindicated?

A

When CO2 elevated (will lead to excess H+ ions)

Could lead to paradoxical CNS acidosis

45
Q

Hypocalcemia associated with renal fialure is caused by? How is it treated?

A

Deficiency of calcitriol

Treat with calcium gluconate 10%

46
Q

How is hypercalcemia associated with renal failure treated?

A

Diuretics or ERRT
Furosemide/glucocorticoids
Calcitonin
Biphosphonates

47
Q

How can you treat a hyperphosphatemia associated with renal fialure?

A

Reduce PO4 intake by protein restriction diet and oral phosphate binders that are dosed with food

Aluminum hydroxide/carbonate

48
Q

How would you treat a hypertension associated with acute renal fialure?

A

Avoid ACE -> inhibit arterial vasoconstriction (hypoxia)

Amlodipine and hydralaizne

49
Q

How does hypertension arise from acute renal failure ?

A

Secondary to RAAS activation and fluid overload

50
Q

What treatments can be used in uremic gastropathy?

A

Omeprazole
Pantoprazole
Famotidine
Ranitidine

51
Q

What is the prognosis for kidney disease caused by leptospirosis or obstruction?

A

Good outcome

52
Q

What is the prognosis for kidney disease with decreased urine production, hypothermia, and hyperkalemia ?

A

Poor outcome

RUSVM SAM 2 (44 decks)

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