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SG F2 E5 > AKI- MJ > Flashcards

AKI- MJ Flashcards

1
Q

What is the definition of AKI?

A

>50% decrease in GFR over a period of hours to days, with any accompanying accumulation of nitrogenous wastes in the body and inability to maintain fluid and electrolyte balance

(all occuring over less than 3 months)

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2
Q

What is the KDIGO classification of AKI? (3)

A

Increase in creatinine by > 0.3 w/in 48hrs

OR

Increase in creatinine >1.5x baseline, which occured w/in the last 7 days

OR

Urine volume < 0.5mL for 6 hrs

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3
Q

According to KDIGO, what is the creatinine and urine output criteria for stage 1 AKI?

(note: creatinine criteria is more important than urine output)

A

Creatinine criteria: Cr 1.5-1.9x baseline OR Cr increase >0.3

Urine output criteria: <0.5mL x6-12 hrs

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4
Q

According to KDIGO, what is the creatinine and urine output criteria for stage 2 AKI?

(note: creatinine criteria is more important than urine output)

A

Creatinine criteria: Cr 2-2.9x baseline

Urine output criteria: <0.5ml x >12 hours

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5
Q

According to KDIGO, what is the creatinine and urine output criteria for stage 3 AKI?

(note: creatinine criteria is more important than urine output)

A

Creatinine Criteria:

  • Cr >3x baseline OR
  • Cr >4mg/dL OR
  • Initiation of dialysis

Urine output Criteria:

  • <0.3ml x >24hrs OR
  • anuria x >12hrs
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6
Q

What is the main difference between the AKIN (Acute Kidney Injury Network) from the KDIGO classifications for staging of AKI?

A

The main difference is in stage 3 where AKIN also includes the following serum criteria:

Increases in Cr to >3x baseline (or Cr >4mg/dl) w/ an acute increase of at least 0.5mg/dl

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7
Q

What is the RIFLE (Acute Dialysis Quality Initiative) classification for AKI?

(old, not preferred method)

A
  • Risk- Cr 1.5 x normal
  • Injury- Cr 2 x normal
  • Failure- Cr 3 x normal (acute rise > 0.5mg/dl)
  • Loss- Loss of function for > 4 weeks
  • End- ESRD- Complete loss of function > 12 weeks
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8
Q

If a patient is admitted to the ICU due to AKI, what is the mortality rate of this group?

Of those that survive, 30% remain on what?

A
  • In hospital mortality= 40-65%
  • Those who survive, 30% remain on long term dialysis
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9
Q

How much urine produced in 24hrs is considered nonoliguia? Oliguria? Anuria?

How do you monitor urine output in real time?

A

Nonoliguria= >500ml

Oliguria= <500ml

Anuria= <100ml

Monitor using a foley catheter

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10
Q

Is prerenal, intrinsic or postrenal AKI most common?

A

Prerenal (60-70%)

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11
Q

What labs and diagnostic studies should be ordered for evaluation of AKI?

A

•Labs

  • Urine studies (UA, urine Na, urine osmolality)
  • CBC, serum electrolytes

•Diagnostics

  • Ultrasound or possibly CT
  • EKG
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12
Q

What is the first line diagnostic tool for evaluating the kidney?

A

ultrasound

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13
Q

Is the normal range of serum creatinine higher in a male or female?

Greater than 4mg/dl indicates what?

A
  • Higher in males (b/c of muscle mass)
  • Greater than 4mg/dL= serious renal impairment
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14
Q

What is the relationship between creatinine levels and GFR?

(as GFR decreases, what happens to Cr?)

A

Inverse relationship: As GFR decreases, creatinine increases

(If GFR is 1/2 normal, Cr will be 2x normal)

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15
Q

What is the BUN/Creat ratio for prerenal AKI? What is the Fractional excretion NA (FENa)?

A

BUN/Creat ratio= >20:1

FENA= <1%

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16
Q

What is the BUN/Creat ratio for intrarenal AKI? What is the Fractional excretion NA (FENa)?

A

BUN/Creat ratio= <20:1

FENA= >3%

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17
Q

What is the BUN/Creat ratio for postrenal AKI? What is seen on UA?

A

BUN/Creat= <20:1

UA= Hyaline casts

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18
Q

What is seen on UA for intrinsic AKI?

A

Dark Granular casts

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19
Q

What is the most sensitive way to differntiate prerenal vs acute tubular necrosis (intrinsic)?

A

Fractional Excretion of Sodium (FENa)

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20
Q

What is the FENa in prerenal vs intrinsic AKI?

A

prerenal= <1%

intrinsic= >3%

if 1-3%= either or both

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21
Q

T/F: Do low or high fluid statuses cause prerenal AKI?

A

True

Ex of low: anemia, hemorrhage, dehydration

Ex of high: Cardiovascular states (did not focus on this)

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22
Q

Prerenal Azotemia is characterized by what?

A

Inadequate blood perfusion to the kidneys

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23
Q

What are the 3 main overarching etiologies of prerenal azotemia?

A
  1. Vascular Depletion
  2. Low Cardiac Output
  3. Change in vascular resistance
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24
Q

Prerenal Azotemia etiologies:

Vascular depletion–> hypovolemia from what?

A
  1. Renal loss
    1. Addisons, DKA, etc
  2. Extrarenal loss
    1. Vomiting, diarrhea, pancreatitis, burns, sweating, etc
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25
26
A cause of prerenal azotemia is **low cardiac output**. What are the 6 possible causes of this and of those, which is the most common?
* **_CHF_** (MC) * Pulmonary embolism * Cardiac Tamponade * Positive pressure ventilation * Arrhythmia * Cardiogenic shock
27
A cause of prerenal azotemia is **vascular resistance** caused by what 3 things? (in general)
1. Systemically (**sepsis**, anaphylaxis, anesthesia) 2. **Medications** (**ACE, NSAID**s, Vasopressors) 3. **Renal artery stenosis** (increased resistance and decreased perfusion)
28
What 7 **meds** can cause **vascular resistance** resulting in **Prerenal Azotemia?**
**1. ACE-inhibitors** **2. NSAIDs** 3. Epinephrine 4. norepinephrine 5. high dose dopamine 6. anesthetic agents 7. cyclosporine
29
What are the 9 signs and symptoms of prerenal azotemia?
* **Low urine output** * Dry mouth * **Hypotension** * **Tachycardia** * Thirst * Weight loss (weight gain in CHF) * Decreased skin turgor * Edema (in CHF) * Also symptoms related to heart/liver disease/**sepsis**
30
Do the following diagnostic studies indicate prerenal azotemia, intrinsic renal disease or postrenal azotemia as the cause of AKI? * BUN/creatinine ratio: **\> 20:1** * Urine sodium: **\< 20 mEq/dL** * FENa: **\< 1%**
Prerenal azotemia
31
What is the treatment for prerenal azotemia if the cause is a **volume depletion**?
Fluid Resuscitation
32
What is the treatment for prerenal azotemia if the cause is a **volume overload**? (3 things)
1. Diuresis 2. Inotropes 3. Fluid **restriction**
33
What is the treatment for prerenal azotemia if the cause is a **vascular resistance**? (2 things)
1. Treat cause 2. Inotropes
34
What are the 4 **causes of intrinsic renal disease** (a cause of AKI) and which one is most common?
1. Tubular disease- **_Acute Tubular Necrosis_** (MC- 85%) 2. **Glomerular Disease** 3. Vascular Disease (ex: clots in the kidney) 4. Intersitial disease
35
**Intrinsic Renal Disease causing AKI:** What are the 2 most common causes of **Acute Tubular Necrosis**?
1. Ischemic 2. Toxin Exposure
36
Ischemic causes of acute tubular necrosis are usually preceded by what?
**Prerenal azotemia** * Prolonged low perfusion states (dehydration, sepsis) * decreased GFR and parenchymal cellular perfusion
37
**AKI: Intrinsic Renal Disease** What are the 5 **exogenous nephrotoxins** that can cause **Acute Tubular Necrosis**?
1. Vancomycin 2. Aminoglycosides 3. Amphotericin B 4. Antineoplastics (Cyclosporine) 5. Contrast Nephropathy
38
AKI: Intrinsic renal disease is characterized by what?
Damage or injury within renal parenchyma making it unable to keep its gradients * Necrosis * Apoptosis * Inflammatory response (Nephritic syndromes)
39
AKI: Intrinsic Renal Disease--\> Exogenous nephrotoxins causing ATN The **level of nephrotoxicity of Vancomycin** increases when combined with which medication?
Pipercillin-tazobactam
40
AKI: Intrinsic Renal Disease--\> Exogenous nephrotoxins causing ATN Amphotericin B can cause severe _______ and \_\_\_\_\_\_
vasoconstricion and tissue damage
41
AKI: Intrinsic Renal Disease--\> Exogenous nephrotoxins causing ATN * **Contrast nephropathy** is the ____ leading cause of renal failure in hospitalized patients * This is caused by what 2 things?
* Contrast nephropathy is the **_2nd_** leading cause of renal failure in hospitalized patients * Caused from **renal tubular epithelial cell toxicity** and **renal medullary ischemia**
42
AKI: Intrinsic Renal Disease--\> Exogenous nephrotoxins causing ATN * **Contrast nephropathy** usually occurs within **how many hours** after exposure?
24-48 hours
43
AKI: Intrinsic Renal Disease--\> Exogenous nephrotoxins causing ATN * What are the 7 **predisposing factors of Contrast Nephropathy**?
1. **Diabetes** (10-50%) 2. Age 3. Preexisting renal disease 4. Volume depletion 5. CHF 6. Repeated doses of contrast 7. ACE-I and NSAID use ("PAD CAR V")
44
AKI: Intrinsic Renal Disease--\> Exogenous nephrotoxins causing ATN * How do you **prevent Contrast Nephropathy**?
**1. _Hydration is key_!** (better than any other tx) 2. Acetylcysteinie 3. Sodium Bicarbonate
45
AKI: Intrinsic Renal Disease * What are the **4 endogenous nephrotoxins** that can cause Acute Tubular Necrosis?
1. **Heme containing products** (Hemolytic anemia) 2. **Uric acid** (Chemo MCC, Tumor lysis syndrome) 3. **Paraprotiens** (Bence Jones proteins in multiple myeloma) 4. **Rhabdomyolysis**
46
The following describes which cause of intrinsic renal disease? * 10-15% of cases of intrinsic renal failure * Characterized by edema and tubular **damage from interstitial inflammation** (cell mediated immune rxn) * **Drugs-** MC cause * Can also be Infectious (CMV, Strep)
Interstitial Nephritis
47
What 3 **drugs are the most common caus**e of interstitial nephritis (a cause of Intrinsic Renal Disease)
1. PCN 2. Sulfa 3. NSAIDs
48
What are the 5 **signs/symptom**s of intrinsic renal disease caused by **interstitial nephritis**?
**_•Fever (\>80%)_** **•Rash (20-50%)** * Arthralgias * Plasma eosinophilia * RBC, WBC and white cell casts in UA
49
What is the course of Interstitial Nephritis (a cause of intrinsic renal disease)? * Usually self-limiting * Recovery _____ to \_\_\_\_\_\_ * Rarely progress to ESRD
•Recovery weeks to months
50
What 2 things may be needed in the short term to treat Interstitial Nephritis (a cause of intrinsic renal disease)?
* **Dialysis** may be needed in the short term * **Steroids** may be given- short term, high dose
51
What is the **hallmark of intrinsic renal disease** (a cause of AKI)
**_Unable to concentrate urine_** | (will be on exam)
52
The following are diagnostic findings of which cause of AKI? (prerenal, intrinsic or postrenal) •Urine: * **Dark granular casts** * Urine sodium: **\> 30 mEq/dL** * ABG: **metabolic acidosis** * Serum: * • FENa: **\> 2-3%** * •BUN/creatinine ratio: **\< 20:1**
Intrinsic Renal Disease
53
The following are causes of what?(prerenal, intrinsic or postrenal) ## Footnote **_•OBSTRUCTION!!!_** **•Nephrolithiasis** •Bladder stones **•BPH** * Malignancy * Medications that cause urinary retention * Poorly emptied neurogenic bladder
**Postrenal azotemia** (cause of AKI)
54
55
What are the 8 complications of AKI?
1. Volume regulation 2. Metabolic Acidosis 3. Hyperkalemia 4. Hyperphosphatemia 5. Excertory failure 6. Metabolic failure 7. Hypocalcemia and hypermagnesemia
56
What is the course of AKI? (3 phases, how long does each phase last?)
* Initiation * Maintenance phase--\> days to weeks * Recovery (diuresis) phase--\> weeks to months
57
What are the 4 causes of death in a person with AKI? What is the most common cause?
**_•Infections (30-70%)_** * Cardiovascular events (5-30%) * GI, pulmonary or neurologic complications (7-30%) * Hyperkalemia or dialysis related (1-2%)
58
The following describes which complication of AKI? ## Footnote * Na and water retention leads to HTN and edema * Hyponatremia
Volume regulation
59
The following describes which complication of AKI? ## Footnote * Tubules **fail to regenerate bicarbonate** and **secrete H+ ion**s into urine * **Retention of phosphate** causing a **wide anion gap**
Metabolic Acidosis
60
The following describes which complication of AKI? •**Limited potassium secretion** and **shift out of cells** in e**xchange for H+** ions which accumulates in renal acidosis
Hyperkalemia
61
A **complication** of AKI is **hyperphosphatemia**. What is this due to?
–Due to filtration failure--\> leads to hypocalcemia--\> PTH release
62
The following describes which complication of AKI? * **Erythropoietin production falls**--\> bone marrow is depressed leading to anemia * **Malabsorption** of dietary **calcium** * **Renin is overproduced** causing **HTN**
Metabolic Failure

SG F2 E5 (13 decks)

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