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4th Year Renal > AKI + CKD > Flashcards

AKI + CKD Flashcards

1
Q

Acute kidney injury definition

and

KDIGO guidelines

A

Abrupt and sustained decrease in kidney function.

  1. Rise in serum creatinine >26 micromol/L within 48 hours OR
  2. Rise in serum creatinine >1.5x baseline (before AKI) within 7 days OR
  3. Urine output <0.5ml/kg/h for >6 consecutive hours
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2
Q

Pathophysiology of pre-renal AKI

A
  • Decreased blood flow to glomerulus due to:
    • Volume loss
    • Reduced cardiac output
    • Systemic vasodilation
    • Renal vasclature
  • Decreased blood filtration leading to:
    • Reduced urine output
    • Raised urea (increases more than creatinine)
    • Raised creatinine
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3
Q

Symptoms of AKI

A
  • Oligouria / anuria
  • Confusion
  • Nausea
  • Shortness of breath
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4
Q

Signs of AKI

A
  • Peripheral oedema
  • Chest crackles (pulmonary oedema)
  • Raised JVP
  • Haematuria
  • Proteinuria
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5
Q

Which medications need to be stopped in AKI?

A
  • ACE inhibitor; angiotensin receptor blocker: dilates efferent arteriole
  • Diuretics: reduce flow through tubular capillaries
  • NSAIDs: constricts afferent arteriole
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6
Q

Managment of AKI pre-renal AKI

A
  • IV fluid bolus: treat hypovolaemia with 250-500ml boluses of crystalloid
  • Maintainance fluids
  • Serial VBGs: monitor lactate for tissue hypoperfusion
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7
Q

Renal causes of AKI

A
  • Glomerular
    • Glomerulonephritis conditions
      • IgA nephropathy
      • SLE
    • Amyloidosis
    • May present as acute kidney injury, more commonly will present with nephrotic or nephitic syndrome
  • Interstitium
    • Acute interstitial nephritis
      • Neutrophils/eosinophils infiltrate the interstitium of the kidney
      • NSAIDs
      • Penicillin
      • Diuretics
      • Acicloir
    • May present as AKI, more commonly will present with: rash, joint pain, eosinophils
  • Tubular
    • Acute tubular necrosis
      • Ischaemia
      • Rhabdomyolysis (eg myoglobin)
      • Aminoglycoside antibiotics (eg amikacin, gentamicin)
      • Lead
      • Ethylene glycol (anti-freeze)
      • Aciclovir
    • Good prognoisis as tubular cells continually replace within 1-3 weeks
  • Renal vascular supply
    • Not to be confused with glomerular blood supply (for ultrafiltration)
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8
Q

What does muddy brown casts in urine indicate?

A

Tubular necrosis

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9
Q

Investigations in AKI

A
  • Bloods
    • Serum urea : creatinine ratio
    • WCC
    • CRP
    • Cultures
    • VBG
  • Urine
    • Dipstick
    • MC&S
    • Sodium
  • Imaging
    • Renal US
    • Bladder scan
    • CT KUB (non-contrast)
  • Special tests
    • Renal biopsy
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10
Q

Urea : creatinine ration interpretation

A

Urea : creatinine ratio

  • > 100:1 = pre-renal
  • <40:1 = renal
  • 40-100 = normal/post renal
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11
Q

Distinguishing features of renal AKI

A
  • Unresponsive to fluids or catheterisation
  • Complex medical history
  • Nephrotoxic agent use
  • Low urea : creatinine ratio
  • High urine sodium
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12
Q

Causes of post renal AKI

A
  • General:
    • Urinary tract infection
    • Kidney stone
    • Malignancy
    • Strictures
  • Specific
    • Enlarge prostate. (BPH)
    • Phimosis
    • Occluded in dwelling catheter
    • Pharmacological
      • Anti-cholinergics
      • alpha-adrenergic agonists
      • Calcium channel blockers
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13
Q

Managment of post-renal AKI

A
  • First line
    • Flush catheter OR replace catheter OR insert new catheter
    • Stop medications eg amitrptyline
  • UTI
    • Empirical antibiotics whilst awaiting sensitivities
  • Ureteric stones
    • <5mm: wait to pass
    • 5-10mm: tamsulosin or nifedipine; lithotripsy; uteroscopy
    • >5mm: ureteroscopy; lithotripsy
  • Malignancy
    • surgery and/or chemotherapy
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14
Q

Complications of AKI

A
  • Metabolic acidosis
  • Hyperkalaemia
  • Oedema (due to loss of normal glomerular filtration leading to fluid accumulation)
  • Encephalopathy (secondary to uraemia)
  • Pericarditis (secondary to uraemia)
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15
Q

Criteria for CKD

A

GFR <60 on at least 2 occasions separated by a period of at least 90 days

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16
Q

Most common causes of CKD

A

Diabetes and hypertension

17
Q

Symptoms of CKD

A
  • Lethargy
  • Pruritus
  • Nausea
  • Anorexia
  • Swollen ankles
18
Q

Signs of CKD

A
  • Hypertension
  • Fluid overload
  • Proteinuria (frothy urine)
  • Uraemia sallow: a yellow or pale brown colour to the skin
  • Evidence of underlying cause: eg butterfly rash in lupus
19
Q

Investigations in CKD

A
  • Urine dip: screen for proteinuria and haematuria
  • Urine albumin : creatinine ratio: a ratio of >3mg/mmol is clinically significant proteinuria
  • U&Es: serum creatinine can be used to calculate eGFR
  • FBC: normocytic normochromic anaemia
  • Bone profile and PTH: patients are at risk of hypocalcaemia, hypophosphateaemia, and secondary or tertiary hyperparathyroidism
  • Renal ultrasound
20
Q

What lifestyle advice would you give to a patient with CKD?

A
  • Smoking cessation, exercise, drinking alcohol in moderation
  • Avoid nephrotoxic medications eg NSAIDs
  • Dietary advice: low salt and potassium diets, with fluid restriction if there is evidence of overload
21
Q

Managment of anaemia in CKD

A
  • Target Hb: 100-120 g/dl
  • Iron replacement: commence iron replacement, either orally or intravenously, prior to commencing ESAs; particularly important in patients on haemodialysis
  • Erythropoiesis stimulating agents: eg erythropoietin (EPO)
22
Q

When is renal replacement therapy initiated?

A
  • Typically performed when eGFR is in single digits (CHD stage 5) or there are signs or uraemia
  • Dialysis is usually commenced first, followed by renal transplantation if the patient is eligible
23
Q

Complications of CKD

Cardiovascular

Musculoskeletal

Endocrine

Haematological

Metabolic

A
  • Cardiovascular
    • Cardiovascular disease is the leading cause of death in CKD
    • Heart failure: due to fluid overload
  • Musculoskeletal
    • CKD metabolic bone disease
  • Endocrine
    • Secondary hyperparathyroidism
    • Tertiary hyperparathyroidism occurs after a prolonged period of secondary hyperparathyroidism
  • Haematological
    • Anaemia: usually normocytic and normochromic and is multi factorial; predominantly due to low EPO, but also reduced erythrpoiesis due to uraemia, reduced iron absorption and anorexia due to uraemia
  • Metabolic
    • Uraemia
    • Hyperkalaemia
    • Metabolic acidosis
24
Q

CKD-metabolic bone disease expected laboratory results

Serum calcium

Serum phosphate

Serum vitamin D

Serum PTH

Alkaline phosphatase (ALP)

A
  • Serum calcium: reduced
  • Serum phosphate: increased
  • Serum vitamin D: reduced
  • Serum PTH: increased
  • Alkaline phosphatase (ALP): increased
25
Q

Staging of CKD

A

G1: >90ml/min, with some sign of kidney damage on other tests

G2: 60-89ml/min

G3a: 45-59ml/min

G3b: 30-44ml/min

G4: 15-29ml/min

G5: <15ml/min

4th Year Renal (2 decks)

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