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Renal > AKI > Flashcards

AKI Flashcards

1
Q

What are some common definitions of AKI?

A 
Solute clearance (urea, creatinine) 
Urine output (oliguria) 
Distinguish patients with pre-existing renal impairment
Some defined by requirement for dialysis (AKI3)
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2
Q

What is the definitive definition of AKI?

A

An abrupt (<48hours) reduction in kidney function:
Absolute increase in serum creatinine by >26.4
OR
Increase in baseline creatinine by >50% (1.5 times baseline)
OR
Reduction in UO (harder to measure)

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3
Q

What is stage 1 AKI?

A

Increase >26 in creatinine or increase in 1.5-1.9x the reference Cr
<0.5ml/kg/hr urine for more than 6 hours

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4
Q

What is stage 2 AKI?

A

Increase in more than 2-2.9x reference SCr

More than <0.5ml/kg/hr of urine for more than 12 hours

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5
Q

What is stage 3 AKI?

A

More than 3x reference SCr OR increase to >354 OR need for RRT
Less than 0.3 ml/kg/hr for more than 24 hours or 12 hours of anuria

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6
Q

What are risk factors for AKI?

A 
Older age
CKD
Diabetes
Cardiac failure
Liver disease
PVD
Previous AKI
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7
Q

What exposure risk factors can cause an AKI?

A 
Hypotension
Hypovolemia
Sepsis
Deteriorating NEWS
Recent contrast
Exposure to certain medications: gentamicin for example
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8
Q

What are the 3 different causes of AKI?

A 
Pre-renal (functional) 
Renal (structural) 
Post renal (obstruction)
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9
Q

What causes hypovolemia related pre-renal AKI?

A

Hemorrhage

Volume depletion - diarrhoea, vomiting, burns

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10
Q

What causes hypotensive related pre-renal AKI?

A

Cardiogenic shock

Distributive shock - sepsis, anaphylaxis

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11
Q

What can cause renal hypoperfusion?

A

NSAIDs/ COX-2
ACEi/ ARBs
Hepatorenal syndrome

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12
Q

What is the definition of pre-renal AKI?

A

Reversible volume depletion leading to oliguria and increase in creatinine

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13
Q

What is normal urine output and therefore what is oliguria?

A

Normal: 0.5 ml/kg/hr, e.g. 30mls/hr in a 60 kg patient
Oliguria: <0.5 mls/kg/hr

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14
Q

Describe normal renal perfusion?

A

Decreased renal perfusion causes the release of renin which in turn causes vasoconstriction of the efferent arteriole via angiotensin 2, maintaining GFR

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15
Q

Why does ACEI increase the risk of AKI?

A

Reduce angiotensin 2, therefore in decreased renal perfusion the kidneys cannot respond normally and the efferent arterioles will stay vasodilated resulting in a decreased GFR

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16
Q

What will untreated pre-renal AKI lead to?

A

Acute tubular necrosis

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17
Q

What will cause acute tubular necrosis?

A

Combo of factors leading to decreased renal perfusion

Common causes are sepsis and severe dehydration

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18
Q

How is hydration assessed?

A

Clinical observations (BP, HR, UO)
JVP, CRT, oedema
Pulmonary oedema

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19
Q

How is pre-renal AKI treated?

A

Fluid challegnge for hypovolaemia:
Crystalloid (0.9% NaCl) or colloid (gelofusin)
Do NOT use 5% dextrose
Give 250 ml bolus at a time and repeat
Get senior help when 1000ml is used with no affect - needs vasopression

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20
Q

Why is hartmann’s not used in treatment of pre-renal AKI?

A

Contains potassium

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21
Q

Why is 5% dextrose not used for treatment of pre-renal AKI?

A

It will not stay in the capillaries so wont increase the circulating volume

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22
Q

What is renal AKI?

A

Disease causing inflammation or damage to cells causing AKI

Split by structure: blood vessels, glomerular disease, interstitial disease, tubular injury

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23
Q

What are the vascular causes of renal AKI?

A

Vasculitis - GPA, MPA, goodpasture’s

Renovascular disease

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24
Q

What is the glomerular cause of renal AKI?

A

Glomerulonephritis

25
Q

What are the interstitial nephritis causes of renal AKI?

A

Drugs - penicillins, trimethoprim, NSAIDs, PPI
Infection - TB
Systemic - sarcoidosis

26
Q

What are the tubular injury causes of renal AKI?

A

Ischaemia - prolonged renal hypoperfusion
Drugs - gentamicin
Contrast
Rhabdomyolysis

27
Q

What are the symptoms of AKI?

A

Constitutional: anorexia, wt loss, fatigue, lethargy
Nausea and vomiting
Itch
Fluid overload - SOb, oedema

28
Q

What are the signs of AKI?

A

Fluid overload including HTN, oedema, pulmonary oedema, effusions
Uraemia - itch, pericarditis
Oliguria

29
Q

What clues in the history can point to a renal cause?

A 
Sore throat (step pyogenes; rheumatic fever) 
Rash (vasculitis or lupus) 
Joint pains (lupus and vasculitis) 
Diarrhoea and vomiting
Haemoptysis (TB, GPA, goodpastures)
30
Q

What can be seen on urinalysis of renal AKI?

A

Protein and blood - this will NOT be seen in pre-renal

31
Q

What drugs are important to look out for in renal AKI?

A 
ACEi 
PPI
NSAIDs
Gent and vanc
Recent contrast
32
Q

What blood tests can aid in the diagnosis of renal AKI?

A 
Eosinophilia (eGPA, intestitial nephritis; reaction to a drug)
Cholesterol microemboli (renal failure and trash foot) 
CK for rhabdomyolysis
33
Q

What are you looking for in U&Es?

A

Marker of renal function (Na, K, Ur, Cr)

Is potassium high - MEDICAL EMERGENCY

34
Q

Why is an FBC and coagulation screen done in AKI?

A

Abnormal clotting - DIC in sepsis

Anaemia - lack of erythropoietin

35
Q

What can urinalysis show in AKI?

A

Haematoproteinuria in renal AKI

36
Q

Why is an USS doone in suspected AKI?

A

Obstruction (postrenal)

Size - hydronephrosis

37
Q

What immunological markers are done in suspected AKI?

A 
ANA - lupus
ANCA - GPA, eGPA, MPA
GMB - goodpastures 
Immunoglobulins 
C3/4 - lupus
38
Q

What is protein electrophoresis and BJP done for?

A

Myeloma

Patient over 50 with hypercalcaemia and anaemia = DO THESE TESTS AND SUSPECT MYELOMA

39
Q

What will RAS show on ultrasound?

A

One large kidney

40
Q

How is a good perfusion pressure established in AKI?

A

Fluid resuscitate

If still not achieving adequate BP - inotropes/vasopressors

41
Q

What is the further treatment of AKI?

A

Treat underlying cause e.g. antibiotics in sepsis
Stop nephrotoxins
Dialysis if remains anuria and uraemia

42
Q

What are the life-threatening complications of AKI?

A 
Hyperkalemia
Fluid overload - pulmonary oedema
Severe acidosis (pH <7.15) 
Uraemic pericardial effusion 
Severe uraemia (Ur >40)
43
Q

What is post-renal AKI?

A

AKI due to obstruction of urine flow leading to back pressure (hydronephrosis) and thus loss of concentrating ability

44
Q

What can cause post-renal AKI?

A

Stones
Cancers
Strictures
Extrinsic pressure

45
Q

What will obstruction look like on USS?

A

Dilated renal pelvis

46
Q

How is post-renal AKI treated?

A

Catheterisation
Nephrostomy
Refer to urology for ureteric stenting

47
Q

How is hyperkalemia assessed?

A

ECG - predisposes to VT, VF and bradycardia

Muscle weakness

48
Q

What level of potassium is considered life-threatening?

A

More than 6.5

49
Q

What are the ECG changes of hyperkalemia?

A 
Peaked T waves
Prolonged PR interval
Depressed ST segment
Prolonged QRS
Sine-wave pattern (this is peri arrest)
50
Q

What is the 1st line treatment in hyperkalemia?

A

Stabilise myocardium

10 ml 10% calcium gluconate over 2/3 mins

51
Q

What is performed after treatment with calcium gluconate in hyperkalemia?

A

Need to move K+ back into cells:
10 units actrapid with 50mls 50% dextrose over 30 mins
Salbutamol nebs over 90mins

52
Q

What is the treatment for chronic hyperkalemia but NOT used in the acute setting?

A

Calcium resonium

53
Q

What should you do if someone is severely acidotic with a very low bicarb?

A

Give sodium bicarbonate

54
Q

What are the urgent indications of haemodialysis?

A

Hyperkalemia over 7
Severe acidosis - pH <7.15
Fluid overload - diuretics will NOT work
Urea >40, pericardial rub/effusion

55
Q

What medicines should you stop on sick days (D+V OR fevers, shakes and sweats)?

A 
ACEi
ARB
NSAIDs
Diuretics 
Metformin
Empagliflozin
56
Q

Does furosemide cause hyper or hypokalemia?

A

Hypokalemia

57
Q

What drugs commonly cause hyperkalemia?

A 
Spironolactone
ACEi
Amiloride
Beta-blockers 
CCB
58
Q

What drugs should be avoided in those with AKI?

A 
NSAIDs
ACEi/ARB
Diuretics
Gentamicin
IV Contrast for CT 
Trimethoprim/co-trimoxazole as will cause hyperkalemia and cause increased creatinine
Potassium sparing diuretics

Renal (22 decks)

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