AKI Management & Presentation

Question 1

Bio markers in AKI

Answer 1

• Urinary Neutrophil Gelatinase Associated Lipocalin (NGAL)
• Urinary Interleukin 18
• Urinary Kidney Injury Molecule 1 (KIM-1)

Question 2

Risk Factors for AKI

Answer 2

Old age
HPT
Diabetics
Metabolic syndrome
CKD
Race or ethnic group
Heart Disease
Liver disease

Question 3

Pre-renal causes of AKI

Answer 3

Hypovolemia
Decreased effective blood volume
* Congestive heart failure
* Cirrhosis
* Nephrotic syndrome
* Sepsis
Renal Vasoconstriction
* Hepatorenal syndrome
* Hypercalcemia
Blood loss
Dehydration
Vascular occlusion
Impaired renal auto regulation + GFR
-NSAIDS in renal hypoperfusion setting
-ACE-I/ARB in bilateral RAS
-Cyclosporine

Question 4

Causes of Increase in Creatinine without AKI - Drugs that inhibit tubular excretion of Creatinine

Answer 4

Trimethroprim
Cimetidine
Probenecid

Question 5

Causes of Increase in Creatinine without AKI - False elevation (Cr assays interface)

Answer 5

Glucose
Ascorbic acid
Acetoacetate
Cefoxitine
Flucytosine

Question 6

Causes of Intrinsic Renal Azotemia

Answer 6

• Large renal vessel disease
  Thromboembolic disease
• Renal microvasculature and Glomerular disease
  Inflammatory: Glomerulonephritis, allograft rejection
  Vasospastic: Malignant hypertension, scleroderma crisis, pre-eclampsia,contrast
  Hematologic: HUS-TTP, DIC
• Acute Tubular Necrosis - Ischemic and Toxic
• Tubulointerstitial Disease - Acute Interstitial Nephritis (AIN), Acute cellular allograft rejection, viral (HIV, BK virus), infiltration (sarcoid)
• Intratubular obstruction
  Myoglobin, hemoglobin, myeloma light chains, Uric acid, tumor lysis, drugs (indinavir, acyclovir, foscarnet, oxalate in ethylene glycol toxicity)

Question 7

Clinical Features of Interstitial nephritis

Answer 7

Mostly nonspecific
Features of AKI
Mild proteinuria
Sterile pyuria (sometimes WBC casts)
Microscopic hematuria

Question 8

Drug Induced (Hypersensitivity) Interstitial Nephritis

Answer 8

• Drug exposure (days, weeks and sometimes months)
• Commonly Fever, Skin rash, Eosinophilia (peripheral/urine)
• Glomeruli normally not affected
• Exception: NSAID’s, Nephrotic Syndrome

Question 9

Causes of Post-Renal AKI

Answer 9

• Stones - Bilateral
• Blood clots - Massive and bilateral
• Papillary necrotic tissue - From ATN
• Urethral disease: anatomical - posterior valve. functional - anti chili ethics, L-DOPA
• Benign Prostatic Hyperplasia
• Bladder disease: anatomic - cancer, schistosomiasis. Functional - neurogenic bladder

Question 10

Covid and AKI

Answer 10

• Presents with hematuria and/or proteinuria
• Proteinuria is LMW rather than albuminuria - suggests tubular origin
• Pre-renal or intra-renal AKI

Question 11

Findings on history

Answer 11

Acute illness
Exposure to nephrotoxins
Episodes of hypotension
Nocturnal, Urinary Frequency or hesitancy
Recent surgery
Other risk factors

Question 12

Complications of AKI

Answer 12

• Volume overload
• Hyperkalemia
• Severe metabolic acidosis
• Severe complications of uremia i.e. pericarditis, neuropathy, unexplained decline in mental status, uremic bleeding
• Overdose with a dialyzable drug/toxin