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Renal / Urology > AKI > Flashcards

AKI Flashcards

1
Q

What is an AKI

A

Increase in serum creatinine
Oliguria
Decreased GFR due to loss of filtration + tube function

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2
Q

AKI 1

A

Creatinine >26.5 in 48 hrs or 50% baseline in 7 days
Urine <0.5ml / kg / hr for >6 hours
Normal output = 0.5ml so for average 70kg person = 35ml / hour

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3
Q

AKI 2

A

Creatinine 2-3x baseline

Urine <0.5ml / kg / hr for >12 hours

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4
Q

AKI 3

A

Creatinine 3x baseline or>354
Urine <0.3ml / kg / hr
Requires RRT

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5
Q

When should you act for AKI

A

Don’t wait till creatinine at 400

Creatinine won’t rise till 50% kidney function lost

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6
Q

What are the pre-renal causes of AKI

- Inadequate blood supply to kidney

A

Hypotension (50%)
Sepsis - low BP
Hypovolaemia - D+V / haemorrhage / pancreatitis
Dehydration = high urea
MI / cardiogenic shock or failure
Arterial occlusion
Renal artery stenosis - atherosclerosis or fibromuscular dysplasia in children
NSAID / ACEI = constriction renal artery
Hepatorenal due to renal constriction in cirrhosis
Surgery / post op

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7
Q

What are the renal / intrinsic causes of AKI
- Reduced filtration of blood

Most common in children

A 
Acute tubular necrosis
- Pre-renal 
- Nephrotoxins 
- Haemoglobinruia - haemolytic anaemia 
- Myoglobulinuria from rhabdomyolysis 
- Tumour lysis 
- Myeloma cast 
Acute tubular interstitial nephritis (TIN) 
GN
Infections 
Vasculitis 
Hypertensive crisis 
Thrombotic microangiopathy - TTP / DIC / HUS (see haematology)
- HUS = most common cause in children
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8
Q

What are nephrotoxins

A 
Rhabdomyolysis
NSAID
Gentamicin
Diuretic 
Contrast
ACEI
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9
Q

What are the RF for contrast toxicity

A 
Age 
DM
CKD 
Dehydration
Cardiac failure 
Use of nephrotoxins 
Para-protein
High volume of contrast
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10
Q

What are the post renal causes of AKI
- Obstruction to outflow

Known as obstructive uropathy if causes black pressure into kidney and reduced function

A 
Obstruction 
Kidney stone if bilateral or one kidney 
Prostatic hypertrophy
Prostatic malignancy / cervical / bladder Ca
Fibrosis - IgG 4
Ureteric stricture
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11
Q

What are the RF for AKI

A 
Age
Previous AKI
CKD
Heart failure
Liver failure 
DM 
Vascular disease
Cognitive impairment 
On nephrotoxins / use of contrast mediums

Often elderly - ill, poor oral intake, multiple medication

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12
Q

What are risk events

A 
Sepsis 
Nephrotoxins 
Hypotension
Hypovolaemia
Major surgery
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13
Q

What is important to look at in pre-renal causes

A

BP
Drugs
Fluid intake

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14
Q

What are signs of hypovolaemia

A 
Postural BP
Low urine
Bounding pulse in sepsis or weak if hypovolaemia
Tachycardia
Dry mucous membrane
Flat veins 
Cold hands
Decreased CRT 
Urea elevated
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15
Q

What are signs of hypervolaemia

A 
SOB
Pulmonary oedema
Increased JVP
Peripheral oedema 
Hypotension on dialysis
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16
Q

What do you look for in examination

A 
Assess fluid balance 
HR, BP, JVP, CRT
Palpate bladder 
Signs of uraemia 
CVS - arrhythmia due to complications
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17
Q

What bloods should be done in AKI

A 
U+E = most important 
VBG to ensure not acidotic 
FBC, U+E, LFT, CRP 
Blood culture + lactate if signs of sepsis 
ABG - if RR high 
Bicarb for acid / base 
Bone profile  - Ca, phosphate
CK - rhabdomyolysis
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18
Q

If platelets low would should be done

A

Film for haemolysis

HUS / TTP

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19
Q

What bloods if suspecting intrinsic renal disease

A

Protein on dip
Auto Ab’s / autoimmune screen
Myeloma screen
Complement

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20
Q

What else should be done in AKI

A 
History 
Systemic Sx
Fluid status + vital signs
eGFR
URINE DIPSTICK IF SUSPECT AKI
- Dark suggest haemo / myoglobulinuria 
- Cloudy = infection 
- Glucose / leucocyte / nitrites / protein etc
- Red cell cast = GN
- White cell cast = infection 
Urine PCR 
Renal USS to look for obstruction 
Biopsy
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21
Q

When do you do renal USS

A

Within 24 hours of DK of AKI

  • Look for stones
  • Size of kidney
  • Any thrombosis
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22
Q

When do you biopsy

A

If suspect vasculitis or unknown cause of AKI

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23
Q

What will pre-renal causes have

A

Hypoperfusion
Low BP
Tachycardia

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24
Q

What does post renal cause have

A

No urine output

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25
Q

What is a better variable for kidney function

- What score

A 
Creatinine clearance >eGFR
Use CAGE (creatinine, age, gender, ethnicity) score when deciding drugs
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26
Q

What factors affect result

A

Obesity
Red meat
Muscle mass
Pregnancy

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27
Q

What do you do in presence of risk events or RF

A 
STOP AKI 
Sepsis
Toxins
Optimise BP and volume
Prevent harm
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28
Q

Sepsis

A

Sepsis 6

Monitor O2 and lactate via ABG

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29
Q

Toxins

A

Stop nephrotoxic drugs
Medication review for any AKI or unwell Patient
Change dose dependent on renal status
Advise on sick day rules

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30
Q

What do you do if contrast required

A

Expand with IV fluid 1 hour pre and 6 hours post

NAC if very poor but no evidence

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31
Q

How do you optimise BP and volume status

A 
Avoid dehydration 
Maintain adequate fluid to perfuse 
Consider IV
Review ant-hypertensive
Consider withholding ACEI, CCB, A blocker, diuretic if hypo
May need inotrope / vasopressor support 
Catheter for urine volumes
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32
Q

How do you prevent harm

A

Daily U+E
Fluid balance
H2 / PPI
Nutrition

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33
Q

What are medications to stop on sick days if severe vomiting / diarrhoea

A 
Diuretic
ACEI
ARB
Metformin - lactic acidosis
NSAID
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34
Q

Major causes AKI

A 
Sepsis
Major surgery
Cardiogenic shock
Hypovolaemia
Drugs
Hepatorenal syndrome
Obstruction
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35
Q

When do you involve consultant

A 
AKI 3
AKI 2 not improving 
AKI low platelet (HUS) 
CKD 4/5
COmplications 
Resistant pulmonary oedema
Resistant hyperkalaeia
Rare conditions 
Transplant 
Unknown cause
36
Q

Complications of AKI

A

Acidosis
Electrolyte imbalance
INtoxication
Overload leading to HF and pulmonary oedema
Uraemia leading to encephalopathy / pericarditis

All lead to cardio / respiratory arrest

37
Q

What are indications for RRT and when is it needed more

A 
Acidosis / Decreased HCO3
Increased K refractory
Pulmonary oedema refractory 
Intoxication 
Symptomatic uraemia - more in CKD

If anuric as can’t excrete toxins

38
Q

What should you know before call consultant

A 
Creatinine trend
Premorbid K, bicarb, lactate, Hb, platelet
Urine dip 
Clinical obs / news
Fluid input and output 
Examination - hypo or hyper
Co-morbid
Drugs given
39
Q

What does management depend on

A

Underlying pathology

40
Q

Pre-renal

A

Correct volume depletion / sepsis / cardiac support

41
Q

Renal

A

Biopsy and specialist

42
Q

Post-renal

A

Catheter
Nephrostomy
Urological

43
Q

How do you tell the difference between pre-renal and ATN

A

Pre-renal

  • Kidney act to conc urine
  • High plasma Na to hold on to volume
  • High urine osmolality
  • Low urine Na

ATN

  • High urine Na
  • Kidney lost concentrating ability so once cured increased risk of polyuria and severe dehydration
  • Muddy brown casts on urinalysis
44
Q

How do you manage hypovolaemia

A

Volume replace
Care in cardiac failure
Always examine before
Reassess

45
Q

Risk of 0.9% saline and Hartman

A

Saline - hyperchloraemic acidosis
Hartman - caution if hyperK or oliguric
Can give 2 salt and 1 sugar (dextrose)

46
Q

How do you manage hypervolaemic

A

Oxygen if required
Fluid restrict
Diureitc
RRT

47
Q

AKI with overload + oliguria

A

Urgent referral
Potentially harmful if use diuretic when oliguric
Probably need RRT

48
Q

How do you treat acidosis

A

Treat underlying
RRT
Adequate O2
Bicarb controversial but can use but dangerous drug

49
Q

What can drug induced renal toxicity cause

A

AKI
Nephrotic - NSAID / lithium
Renal tubule dysfunction with K wasting

50
Q

What are pharmacokinetic effects of renal disease

A

Reduced GFR = reduced clearance
Reduced protein = reduced binding
Half life and concentration is increased

51
Q

What are pharmacodynamic effects

A

BBB more permeable
More sensitive to hypertensive as already hypo
Can’t clear drugs until dialysis so same level in blood

52
Q

What are DAMN drugs to stop in AKI

A 
Diureitc
ACEI / ARB
- Reno-protective long term 
Metformin
NSAID
Aminoglycoside - gent
Contrast
53
Q

What does metformin cause

A

Lactic acidosis

54
Q

What should you never prescribe together

A

NSAID and ACEI

Reduce prostaglandin

55
Q

What drugs have narrow therapeutic index / renal excreted so build up in AKI but don’t worsen

A 
Gentamicin / vancomycin 
Metformin
Digoxin
Lithium
Tacrolimus
Opiates
Heparin
Penicillin /cephalosporin
56
Q

When is drug AKI most common

A

Elderly
Hypovolaemic
Polypharmacy

57
Q

What are RF for radio contrast AKI

A 
Age
DM
CKD
Renovascular disease 
HF
High volume of contrast
Dehydration 
Nephrotoins
58
Q

When does AKI from contrast present

A

2-5 days

59
Q

What do you do if someone has poor renal and need to start drug

A 
Reduce dose 
Increase dose interval 
Use liver metabolised drugs
Avoid nephrotoxins
High therapeutic index
60
Q

What is good source of info

A

BNF
Pharmacist
Renal drug handbook - always look

61
Q

What are safe drugs in AKI

A 
Paracetamol
Warfarin
Aspirin 75mg
Clopidogrel
BB
62
Q

What does NSAID cause

A 
AKI 
Nephrotic
Hypertension
Hyperkalameia
Pupillary necrosis - where urine enters ureter
63
Q

Why does NSAID cause pre-renal

A

Decreased vasodilator prostaglandin
Reduced renal blood flow and GFR
Can cause nephritis

64
Q

What drugs cause nephrotic syndrome

A

NSAID
Gold injection
Interferon

65
Q

Other nephrotoxic drugs

A 
PPI 
Penicillin
Rifampicin
Aciclovir
Anti-convulsant
Cisplastin
Calcineurin inhibitor
66
Q

What do aminoglycosidde cause

A

Tubular necrosis

1-2 weeks of therapy

67
Q

What are nephrotoxins not drugs

A 
Contrast
Myoglobin in rhabdomyolysis
Haemoglobulinuria 
Urate in tumour lyrisis
Myeloma cast 
Radiation
68
Q

What is Rhabdomyolysis

A

Breakdown of skeletal muscle after long lie / crush

Release of intracellular K and myoglobulin which affects kidney

69
Q

Typical history of Rhabdo

A

Hx trauma / seizure / hypothermia / elderly collapse / ecstasy / statin + macrolide / crush injury

70
Q

How does it present

A 
AKI with greatly raised creatinine (acute tubular necrosis) as breakdown products toxic to kidney 
Elevated CK
Myoglubilinuria
HYpocalcaemia as myo binds
High phosphate
High K = most dangerous 
Metabolic acidosis
Symptoms 
Muscle pain
Oedema
Fatigue 
Confusion 
Red or brown urine
71
Q

How do you Dx

A 
Serum / urine myoglobin - +Ve for blood 
Plasma CK x5 = best way to Dx 
U+E show AKI 
Increased K and phosphate
Decreased Ca
Do ECG to look for arrhythmia
72
Q

How do you treat

A

IV fluid

73
Q

What else can cause AKI

A

Bacteria
Virus
Parasite

74
Q

When should you consider acute interstitial nephritis

A

All AKI with no obvious pre-renal or post renal cause

75
Q

What drugs cause acute interstitial nephritis

A 
Penicillin
Vancomycin 
Rifampicin 
Aciclovir 
NSAID
Phenytoin 
PPI / H2 
Allopurinol
Furosemide / thiaizde diuretic 
Anti-convulsant - phenytoin 
Warfarin
76
Q

What are other causes of nephritis

A 
Infection 
SLE
Sarcoid
Sjogren
ANCA
77
Q

How does acute interstitial present

A 
AKI  3 days post 
Eosinophilia cast
Patient well - not hypotensive or septic
Hypertension 
May have fever / rash / arthralgia / allergic picture
78
Q

How do you Dx

A

Urine dip = leucocyte + eosinophils as inflammatory where as ATN would not
Biopsy
Sterile pyuria

79
Q

How do you Rx

A

Stop causative agent

Steroids

80
Q

What is prognosis

A

CKD in 40%

81
Q

What is tubulointerstital nephritis with uveitis

A 
Young female
Fever
Weight loss
Painful red eyes
Leucocytes and protein on dip
82
Q

ATN in urine

A

No inflammation so no cellular component in urine

Muddy brown cast

83
Q

When should you consider HUS

A

Hx of diarrhoea illness
Normocytic anaemia
Thrombocytopenia
Renal failure

84
Q

When should you consider TTP

A

Same as above

Neuro signs - headache / confusion / fever

85
Q

FIbromuscular dysplasia

A

Narrowing arteries
Hypertension
Decreasing renal function / CKD
AKI - when ACEI started

86
Q

Wha is better than eGFR

A

Creatinine clearance

87
Q

How does hypercalcaemia cause an AKI

A

Renal tubular damage

Leads to hypokalaemia, DEHYDRATION, increased Na excretion which causes renal vasoconstriction and AKI

Renal / Urology (16 decks)

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