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Nephrology > AKI > Flashcards

AKI Flashcards

1
Q

Definition

A

Significant decline in renal function over hrs or days manifesting as an abrupt and sustained ↑ in Se U and Cr

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2
Q

Causes - pre-renal, renal, post

A

Pre-renal: commonest cause Shock or renovascular compromise (e.g. NSAIDs, ACEi) Renal ATN: Ischaemia: shock, HTN, HUS, TTP Direct nephrotoxins: drugs, contrast, Hb Acute TIN: drug hypersensitivity Nephritic syndrome Post-renal: SNIPPIN

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3
Q

Main cause of AKI

A

Pre-renal and ATN account for ~80%

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4
Q

Presentation

A

Uraemia / Azotaemia Acidosis Hyperkalaemia Fluid overload Oedema, inc. pulmonary ↑BP(or↓) S3 gallop ↑ JVP

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5
Q

Clinical Assessment main features

A

Acute or chronic Volume depleted GU tract obstruction Rare causes

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6
Q

Acute or chronic assessment

A

Can’t tell for sure: Rx as acute Chronic features Hx of comorbidity: DM, HTN Long duration of symptoms Previously abnormal bloods (GP records)

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7
Q

Volume depleted assessment

A

Postural hypotension ↓ JVP ↑ pulse Poor skin turgor, dry mucus membranes

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8
Q

GU tract obstruction assessment

A

Suprapubic discomfort Palpable bladder Enlarged prostate Catheter Complete anuria (rare in ARF)

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9
Q

Rare cause assessment

A

Assoc. ̄c proteinuria ± haematuria Vasculitis: rash, arthralgia, nosebleed

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10
Q

Investigations

A

Bloods: FBC, U+E, LFT, glucose, clotting, Ca, ESR ABG: hypoxia (oedema), acidosis, ↑K+ GN screen: if cause unclear Urine: dip, MCS, chemistry (U+E, PCR, osmolality, BJP) ECG: hyperkalaemia CXR: pulmonary oedema Renal US: Renal size, hydronephrosis

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11
Q

Na concentration in urine - AKI

A

Pre-renal failure, urine is concentrated and Na is reabsorbed → ↑osmolality, Na <20mM

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12
Q

KDIGO/ RIFLE classifcation of AKI

and complications of AKI

A

Hyperkalaemia, pulmonary oedema, bleeding

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13
Q

General treatment

A

Identify and Rx pre-renal or post-renal causes

Urgent US
Rx exacerbating factors: e.g. sepsis
Give PPIs

Stop nephrotoxins: NSAIDs, ACEi, gent, vanc Stop metformin if Cr > 150mM

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14
Q

Monitoring required

A

Catheterise and monitor UO

Consider CVP

Fluid balance Wt.

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15
Q

Hyperkalaemia on ECG

A

ECG Features (in order)

Peaked T waves
Flattened P waves
↑ PR interval
Widened QRS
Sine-wave pattern → VF

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16
Q

Hyperkalaemia treatment

A

10ml 10% calcium gluconate
50ml 50% glucose + 10u insulin (Actrapid) over 5-15 units

Salbutamol 5mg nebulizer

Consider sodium bicarb (don’t give in the same line as calcium = prescipitate)
Haemofiltration (usually needed if anuric)

17
Q

Treating pulmonary oedema

A

Sit up and give high-flow O2

Morphine 2.5mg IV (± metoclopramide 10mg IV)

Frusemide 120-250mg IV over 1h

GTN spray ± ISMN IVI (unless SBP <100)

If no response consider:

CPAP
Haemofiltration / haemodialysis ± venesection

18
Q

Treating bleeding

A

↑ urea impairs haemostasis

FFP + plats as needed

Transfuse to maintain Hb >10

19
Q

Indications for acute dialysis

A
  1. Persistent hyperkalaemia (>7mM)
  2. Refractory pulmonary oedema
  3. Symptomatic uraemia: encephalopathy, pericarditis
  4. Severe metabolic acidosis (pH <7.2)
  5. Poisoning e.g barbiturates, lithium, aspirin, sulphanomides, theophylline
20
Q

Management of AKI algorithm - STEP 1 (Resuscitate and assess fluid status)

A

Resuscitate and assess fluid status

A

B

C: assess fluid statius

CV - postural bp, JVP, HR

Tissues - cold/warm hands, skin tugor, mucus membranes, cap refill

End-organ: mental state, urine output

21
Q

STEP 2 - Treat life threatening complications

A

Treat life threatening complications

  1. Hyperkalaemia
  2. Pulmonary oedema
  3. Consider rapid dialysis
22
Q

STEP 3 - Treat shock or dehydration

A

Treat shock or dehydration

  1. Fluid challenge (500ml in normal patient or 250ml in patients with heart failure over 15 mins for up to 2L)

Aim for CVP of 5-10cm

Once repleted continue at 20ml + UO/h

If not repleted - call for specialist

23
Q

STEP 4 - Monitor

A

Monitor

  1. Cardiac monitor
  2. Urinary catheter
  3. Consider cVP
  4. Start fluid balance chart
24
Q

STEP 5 - Look for post-renal causes

A

Look for post-renal causes

  1. Palpable ± tender bladder
  2. Enlarged prostate
  3. Catheter in situ
  4. Complete anuria
25
Q

STEP 6 - History and Investigations

A

Duration of symptoms

Co-morbidities

Previous blood results

Ix:

Bloods, ABG

Urine dip + MCS + chem

ECG

CXR and Renal US

26
Q

STEP 7 - treat sepsis

A

Blood cultures and empirical Abx

27
Q

STEP 8 - Further management

A

Call urologists if obstructed despite catheter

Care with nephrotoxic drugs: e.g. gentamicin

Nephrology (17 decks)

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