AKI & CKD

Question 1

What are the criteria of AKI?

Answer 1

Anuria/Oliguria
HTN + Fluid overload
Rapid rise in Creatinine

Question 2

How do you diagnose AKI?

Answer 2

Serum creatinine atleast 1.5x age specific reference creatinine (or previous baseline)

And UO <0.5ml/Kg for >8hrs

Question 3

How do you classify AKI?

Answer 3

1-3
AKI 1 = Creatinine 1.5 ULRI (upper limit reference interval)
AKI 2 = 2-3x
AKI 3 = 3x

Question 4

What can you do to prevent/reduce AKI?

Answer 4

• Maintain good hydration
• Minimise drugs
• Monitor UO, PEWS, BP & WEight

Question 5

What are the major causes of AKI in kids?

Answer 5

• Pre-renal Hypoperfusion e.g. volume depletion or hypotension
• Intrinsic e.g. HUS, ATN or interstitial nephritis (NSAIDs, autoimmune)
• Obstructive

Question 6

What organisms lead to HUS?

Answer 6

Enterohaemorrhagic E.coli (O157:H7)
Shigella

Due to toxins

Question 7

What are the features of HUS?

Answer 7

Triad of:
- Haemolytic Anaemia
- Thrombocytopenia
- AKI

Question 8

How do you manage HUS to prevent AKI?

Answer 8

3Ms:
- Monitor Fluid balance, U&Es, blood gas & BP
- Maintain IV saline & RRT
- Minimise = No Abx

Question 9

Long term management following AKI?

Answer 9

BP & Proteinuria monitoring

Watching out for progression to cKD

Question 10

What causes CKD?

Answer 10

55% CAKUT (oft with systemic syndromes e.g. turner’s or Trisomy 21)

17% hereditary e.g. cystic kidney disease

10% glomerulonephritis

Question 11

How do we grade CKD?

Answer 11

G1-5 based on eGFR:
1 = normal 90+ml/min/1.73m^2
2 = 60-89
3 = 30-59
4 = 15-29
5 = ESRD

Question 12

Kids with CKD will tend to be due to reflux nephropathy from CAKUT e.g. VUR. How is this likely to present?

Answer 12

Lots of UTIs from VUR

Question 13

How could UTIs present in kids and neonates?

Answer 13

Neonates - Fever, vomiting, lethargy & irritability

Children:
- Fever
- Abdo/loing pain
- Vomiting
- Poor feeding
- Lethargy
- Irritability
- Dysfunctional Voiding

Question 14

How can you diagnose a UTI?

Answer 14

Clean catch urine or midstream urine sample (if very sick catheter sample or suprapubic aspiration)

Dipstix for leucocytes & nitrites
Microscopy for pyuria & bacteria
Culture

Question 15

What organisms cause most UTIs in kids?

Answer 15

85% are E.Coli

Question 16

How do we grade Vesicoureteric Reflux?

Answer 16

1-5 and Unilateral vs bilateral

Question 17

Which kids with UTIs would get imaging?

Answer 17

Upper tract symptoms (systemically unwell, high temp etc)
<6months old
Recurrent

Question 18

How do we image in UTIs?

Answer 18

US for structure
DMSA - Scarring
Micturating Cystourethrogram - VUR
MAG 3 - Only works in older kids who are continent

Question 19

How are childhood UTIs treated?

Answer 19

Lower Tract = 3 days oral Abx (trimethoprim or Co-amoxiclav)

Upper tract = 7-10days Abx (Oral if well or IV if systemically unwell)

Question 20

How can we prevent further UTIs?

Answer 20

Hydration
Hygiene
Treat constipation
Image for abnormal Urinary tract

Question 21

What do we monitor in kids with recurrent UTIs in case of CKD?

Answer 21

• HTN (Doppler is gold standard test)
• Proteinuria

Question 22

What is HTN in a kid?

Answer 22

> 95th percentile
90th is borderline

Question 23

What do we need to manage in CKD?

Answer 23

• High urea
• Fluid balance
• Salt & Electrolytes
• Acid-base balance
• BP
• Erythpoietin deficiency
• Bone health

Question 24

How do we treat high urea in CKD?

Answer 24

Control protein intake with nutrition

Question 25

How do we handle the water balance in CKD?

Answer 25

REstrict or give fluids as needed

Question 26

How do we handle electrolyte imbalance in CKD?

Answer 26

REstrict Salt intake
Give K

Question 27

How do we handle acid base balance in CKD? (and what’s the abnormalitiy)?

Answer 27

You get Metabolic Acidosis in CKD due to bicarbonate loss
So give bicarbonate

Question 28

How do we control BP in CKD?

Answer 28

ACEI

Question 29

How do we handle the RBC effects of CKD?

Answer 29

Give Erythropoietin

Question 30

How is bone health damaged by CKD?

Answer 30

Can’t excrete phosphate
-> High phosphate
-> High PTH
-> Metabolic bone disease & CVD

Question 31

How do we manage bone health in CKD?

Answer 31

Low phosphate diet
Phosphate binder
Active Vit D

Growth hormone if ongoing poor growth

Important to watch out for hypercalcaemia with these treatments

Question 32

Summary of management of CKD:

Answer 32

1) Control protein intake (urea)
2) Give/restrict fluids (water balance)
3) Restrict Na & Give K (Electrolyte balance)
4) Give bicarbonate (Acidosis)
5) ACEI (BP)
6) Erythropoietin
7) Low phosphate diet, phosphate binders & Active Vit D (bone health)