AKI, CKD

Question 1

Def of AKI?

Answer 1

Decline in renal function over hrs/days

High Urea/creatinine

Question 2

General classification of kidney injury?

Answer 2

Pre

Renal

Post

Question 3

Pre-renal causes of kidney injury?

Answer 3

Shock

Renovascular compromise (e.g. NSAIDs, ACEi)

Question 4

Renal causes of AKI?

Answer 4

Acute Tubular Necrosis (ATN)

Acute tubulointersitial nephritis (TIN): drug hypersensitivity

Nephritic syndrome

Question 5

Causes of Acute Tubular Necrosis (ATN)?

Answer 5

Ischaemia: shock, HTN

Direct nephrotoxins: drugs, contrast, Hb

Question 6

Post renal causes of AKI?

Answer 6

SNIPPIN

Stone

Neoplasm

Inflammation: stricture

Prostatic hypertrophy

Posterior urethral valves

Infection: TB, schisto

Neuro: post-op, neuropathy

Question 7

Presentation of AKI?

Answer 7

Uraemia / Azotaemia (nitrogen)

Acidosis

Hyperkalaemia

Fluid overload

Question 8

Investigations of AKI?

Answer 8

ABG: hypoxia (oedema), acidosis, ↑K

ECG: hyperkalaemia

CXR: pulmonary odeam

Renal US: hydronephrosis

Question 9

Pre renal failure Osmolality and Na levels?

Answer 9

Urine is concentrated and Na is reabsorbed →

↑osmolality

Na <20mM

Question 10

What is RIFLE classification of AKI?

Answer 10

3 grades of AKI (risk, injury, failure)

2 outcomes (loss or end-stage kidney disease, ESKD)

Question 11

Risk class of RIFLE classification creatinine, GFR, and urine output levels?

Answer 11

↑Cr x1.5

↓GFR >25%

<0.5ml/kg/h x 6h

Question 12

Injury class of RIFLE classification creatinine, GFR, and urine output levels?

Answer 12

↑Cr x 2

↓GFR >50%

<0.5ml/kg/h x 12h

Question 13

Failure class of RIFLE classification creatinine, GFR, and urine output levels?

Answer 13

↑Cr x 3

↓GFR >75%

<0.3ml/kg/h x 24h, or anuria x12h

Question 14

Definition of Loss outcome of RIFLE classification?

Answer 14

Persistent acute renal failure = complete loss of function >1mo

Question 15

Definition of end-stage kidney disease (ESKD) outcome of RIFLE classification?

Answer 15

complete loss of function >3mo

Question 16

Drugs to stop in AKI?

Answer 16

Stop nephrotoxins: NSAIDs, ACEi, gent, vanc

Stop metformin if Cr > 150mM

Question 17

ECG features of hyperkalaemia?

Answer 17

Peaked T waves-

Flattened P waves

↑ PR interval

Widened QRS

Question 18

Management of hyperkalaemia?

Answer 18

1. 10ml 10% calcium gluconate
2. 100ml 20% glucose + 10u insulin (Actrapid)
3. Salbutamol 5mg nebulizer
4. Calcium resonium 15g PO or 30g PR
5. Haemofiltration (usually needed if anuric)

Question 19

Primary management of pulmonary oedema in AKI?

Answer 19

PODMAN

1. Sit up and give high-flow O2
2. Morphine 2.5mg IV (± metoclopramide 10mg IV)
3. Frusemide 120-250mg IV over 1h
4. GTN spray ± Isosorbide mononitrate (unless SBP <100)

Question 20

If no response to primary management of pulmonary oedema, what’s the Rx?

Answer 20

• CPAP
• Haemofiltration / haemodialysis ± venesection

Question 21

Indications for acute dialysis of AKI patients?

Answer 21

1. Persistent hyperkalaemia (>7mM)
2. Refractory pulmonary oedema
3. Symptomatic uraemia: encephalopathy, pericarditis
4. Severe metabolic acidosis (pH <7.2)
5. Poisoning (eg aspirin)

Question 22

Overview of fluid assessment?

Answer 22

1. cardiovascular
2. Tissues
3. end organ

Question 23

CVS signs of fluid overload?

Answer 23

Postural BP

Raised JVP

High HR

Question 24

Tissue signs of fluid overload

Answer 24

• Cap refill,
• cold/warm hands,
• skin turgor,
• mucous membranes

Question 25

End organ signs of fluid overload

Answer 25

• urine output,
• mental state

Question 26

Triple whammy hit drugs for kidneys?

Answer 26

Avoid if possible:

1. ACEi or angiotensin II inhibitors (sartan)
2. Diuretics
3. NSAIDS or COX 2 inhibitors

Question 27

Def of CKD?

Answer 27

Kidney damage ≥3mo indicated by ↓ function

Question 28

At which stage does CKD give you symptoms?

Answer 28

Stage 4 (GFR<30)

Question 29

CKD stages?

Answer 29

1 GFR >90

2 GFR 60-89

3a GFR 45-59

3b GFR 30-44

4 GFR 16-29

5 GFR <15

Question 30

CKD stage 3a health issues

Answer 30

HTN

increased CVS risk

Question 31

CKD stage 3b health issues

Answer 31

Low calcium secondary to raised PTH

Question 32

CKD stage 4 health issues

Answer 32

anaemia

anorexia

high phosphate

Question 33

CKD stage 5 health issues

Answer 33

Salt/water retention

Acidosis

High K

Question 34

Common causes of CKD?

Answer 34

DM

HTN

Question 35

Urine BJP test?

Answer 35

Bence-Jones protein to diagnose and monitor multiple myeloma

Question 36

Renal US results of CKD?

Answer 36

Usually small (<9cm)

May be large: polycystic, amyloid

Question 37

Complications of CKD?

Answer 37

CRF HEALS (or ‘O CHARLES’)

Cardiovascular disease

Renal osteodystrophy

Fluid (oedema)

HTN

Electrolyte disturbances: K, H

Anaemia

Leg restlessness

Sensory neuropathy

Question 38

Pathophysiology of renal bone disease?

Answer 38

1a. ↓ 1α-hydroxylase → ↓ vit D activation → ↓ Ca → ↑ PTH
1b. Phosphate retention → ↓ Ca and ↑ PTH (directly)
2. ↑ PTH → activation of osteoclasts ± osteoblasts

Question 39

Management of renal bone disease?

Answer 39

1. Phosphate binders: sevelamer, calcichew
2. Vit D analogues: alfacalcidol (1 OH-Vit D3)
3. Ca supplements
4. Cinacalcet: Ca mimetic

Question 40

Management of restless leg?

Answer 40

Clonazepam

Question 41

Management of renal caused anaemia?

Answer 41

EPO to raise Hb to 11g/dL (higher = thrombosis risk)