AKI Flashcards
Definition of AKI
An abrupt , within ____ reduction in kidney function currently defined as :
- Absolute incr in ____ within 48 hrs or
2.INCR in ___ which is known or presumed to have occurred within the prior ___ OR - A reduction in ___
48 hrs
- Scr of >0.3 mg/dL
- Scr>50% (>1.5x baseline), 7 days
- urine output (Documented oliguria of <0.5 mL/kg/hr for >6 hrs)
ETIOLOGY : Hemodynamic
-Intravasc ___
DECR ____
___ /Shock
___ or constriction
___ vasoconstrictors
___ vasodilators
volume depletion
circulating volume
hypotension (Hemmorhage or sepsis)
renal vascular occlusion
afferent arteriole (CI)
efferent arteriole (ACE ARB Renin I)
ETIOLOGY : Intrinsic and Obstructive
___disorders
___necrosis
Acute ____
N
B
P
C
Glomerular
acute tubular
interstitial nephritis
Nephrolithiasis
BPH
Pregnancy
Cancer
Hemodynamic AKI
Presentation
-SCr?
BUN/Scr ratio?
Marked and acute decr in __
onset?
Urinalysis is likely ???
FeNa< ___
Urine Na?
Abrupt incr Scr
>20
urine output
hours to days
normal unless sustained hypotension leading to tubular damage
<1%
<20 meq/L
Calculation of fractional Excretion of Sodium FeNa ?
= (Urine Na * Plasma Cr ) / (urine Cr *Plasma Na) ALL MULTIPLIED BY 100
Drug induced hemodynamic AKI
Which drugs ? (4)
ACEI/ARB/Renin inhibs (Dilate EA)
CI , cyclo and tacro (Constrict AA)
Diuretics (Hypovolemia)
NSAIDS/COX2 Inhibs (aff vasoconstrict)
Acute Tubular Necrosis : Presentation
Onset ?
Rise in scr over ____
FeNa ?
Urine Na?
What can be present on UA?
Sx’s? (3)
Etiology ? (3)
days to weeks
days
>1
>40 meq/L
Casts
N/V/Oliguria
Prolonged hypotension or decr renal perfusion such as sepsis or blood loss
-if u leave acute hemodynamic aki untx’ it can cause this
-rhabdomyolysis
-nephrotoxins
Nephrotoxins that can cause acute tubu necrosis
A,A,C,C,I,P,R,V
Aminoglycosides (Elevated trough concs over 3 days, multiple daily dosing, duration over three days)
Amphotericin B
Cisplatin
Cyclophosphamide
Ifosfamide
pentamidine
radiocontrast media
vancomycin
Acute Interstitial Nephritis
Presentation ?
+/- (4)
FeNa?
Urine Na?
Onset?
Diagnosis often confirmed by ?
Etiiology ? (3)
nephrotoxins that can cause this?
Body rash, UA positive for protein and WBCS, blood or urinary eosinophils, gallium scan of kidney.
>1 %
>40
Days to weeks
Renal Biopsy
idiopathic, viral meds
NSAIDS, quinolones, semisynthetic penicillins (ampi, nafcil, oxa)
Sulfonamides, rifampin
Tubular Disorders
Presentation
+/- LOW SERUM ? (3) HIGH SERUM?
urinalysis?
High urinary ?
gradual rise in Scr
Onset months to yrs
Nephrotoxins?
Potass, phos, bicarb, chloride
+/- Urinalysis with glucose , protein
+/- high urinary phos
Tenofovir (Fanconi)
Ifosfamide (Fanconi)
Lithium (Nephrogenic DI)
Obstructive Nephropathy
Presentation —>
Rise in ?
___pain
F, C
N/V
A___
U___
H___
H__
+/- UA with __,__ and __
Etiology ? (C,N,M,P,E,P,P)
Rise in scr acute and chronic forms
flank
fever/chills
anuria
urinary hesitancy
Hematuria
hydronephrosis
Crystals, RBCS and WBCs
Congen vesicoureteral reflux
nephrolithiasis
medications
pregnancy
enlarged prostate
prostate cancer
pelvic cancer
Drug induced Crystalluria?
Adam and Ida never met queen sally turner
acyclovir, allopurinol, indinavir, nelfinavir, mtx, quinolones, sulfonamides, triamterene
High Risk and AKI STages 1-3 Prevention and tx
Discontinue all ___
Ensure __ and ___
COnsider functional ___
Monitor __ and __
Avoid ___
COnsider alts to __
Nephrotoxins
adequate volume and perfusion P
hemodynamic monitoring
scr, urine output
hyperglycemia
radiocontrast procedures
Volume Status : Hydration
What’s preferred and why?
Dosing?
Sodium chloride or sodium bicarb , they improve renal blood flow
Sodium Chloride 0.9% 1L over 2 hrs
Loop Diuretics :
Diuretics are reserved for ?
Often used by physicians to?
USed in pt’s who are __ and respond to ?
Volume overload
convert oliguric AKI to non oliguric aki
volume overloaded, initial dose of loop diuretic
Indications for ACUTE DIALYSIS : AEIOU
Describe each term
Acidosis : Metabolic acidosis with pH <7.1
Electrolytes : HYPERkalemia with K>6.5 meq/L or rapidly rising potass
Intoxication : OD with salicylates, lithium, methanol, ethylene glycol, theophylline, pentobarb
Overload : Volume overload resistant to diuretics evidenced by pulm congestion, ededma, Weight gain
Uremia : Signs ->Percarditis , neuropathy, unexplained decline mental status, no absolute Scr/BUN indication for dialysis
HEMODIALYSIS FOR AKI
IHD what criteria? (3)
CRRT (4)
Pt’s with hemodynamic stability, overdose cases, hyperkalemia
Hemodynamic INSTABILITY,
ICU pt’s catabolic and with better control of uremia,
excessive volume overload, Sepsis, SIRS
Types of CRRT
1. CVVH
-___ venovenous hemofiltration
-___ clearance
-NO ____
-Replacement solution administered either __ or ___
Large molecules
- CVVHD
-Continuous ____
-___ clearance
-___ only
Small to medium molecules - CVVHDF
-What is it?
___ and ___ clearance
__ and replacement solutions (20L)
Blood flow maintained by ___
continous
convective
dialysis solution
pre , post filter (25-50L)
venovenous hemodialysis
diffusive
dialysate
Continuous venovenous hemodiafiltration
convective, diffusive
dialysate
pump
Determinants of Drug Removal By Dialysis
Drug dependent factors? (4)
Therapy dependent factors? (5)
protein binding, volume of distrib, molecular weight, drug charge
Type of modality, effluent flow rate, blood flow rate, fluid replacement (pre/post)
Hemofilter
Drugs with a high degree of _____ are ___ to be removed by dialysis
Only ___ or ____ is removed by dialysis
Examples?
protein binding >90%, LESS LIKELY
unbound, free drug
Ceftriaxone or warfarin
Drugs with Small ___ are located in intravascular space and more ____
Drugs with large Vd (>___) likely distributed at other tissue sites
Vd , <0.3 L/kg
likely to be removed by dialysis
> 1L/kg
Molecular weight
Most drugs have a MW of ?
-It’s not a major determinant of removal since?
-Which drugs are heavier ?
<1500 daltons (1 Da = 1 g/mol)
new hemofilters have large pore size
daptomycin, vancomycin
