Case 13 - AKI Flashcards by Dakshita Agrawal

What are the risk factor for sepsis?

Very young or old patients (under 1 or over 75 years)
Chronic conditions such as COPD and diabetes
Chemotherapy, immunosuppressants or steroids
Surgery or recent trauma or burns
Pregnancy or peripartum
Indwelling medical devices such as catheters or central lines
IVDU

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What are the symptoms of sepsis?

Fever, chills and diaphoresis
Tachycardia
Tachypnoea
S: Slurred speech or confusion (often late sign)
E: Extreme shivering or muscle pain
P: Passing no urine (in a day)
S: Severe breathlessness
I: It feels like you’re going to die
S: Skin mottle or discoloured

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What investigations are carried out in sepsis?

Blood gas: Lactate levels (raised in sepsis), BM, pH
Blood culture
FBC
CRP: raised may be sign of bacterial infection
U+E’s: kidneys are often affected early in sepsis
Clotting screen: measure severity of sepsis
LFT’s: source of infection

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What is the treatment for sepsis? Sepsis 6:

High flow oxygen
IV antibiotics: broad spectrum at max dose within 1 hour of identifying high risk pts.
IV fluid resuscitation: 500 ml bolus
Blood culture and consider source control
Check haemoglobin and serial lactate
Hourly urine output measurement

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What are the symptoms of hyperkalaemia?

Fast irregular pulse
Chest pain
Weakness
Palpitations
Light-headed

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What are the ECG changes in hyperkalaemia?

Small/no P waves
Prolonged PR
Wide WRS
Peaked T waves
Slurring into ST (lead V1)
VF

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What are the causes of hyperkalaemia?

Renal failure with oliguria/anuria
Addison’s disease
K-sparing diuretics
Rhabdomyolysis
Metabolic acidosis (DM)

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What are the symptoms of hypernatraemia?

Lethargy
Thirst
Weakness
Irritability
Confusion
Signs of dehydration
Coma
Fits

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What are the causes of hypernatraemia?

Fluid loss > Na loss
Diarrhoea
Vomiting
Burns
Diabetes insipidus
Primary hyperaldosteronism
Excessive fluid resuscitation

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What are the symptoms of hypercalcaemia?

‘Bones, stones, groans and psychic moans’ – bone pain, stones, abdominal groans (pain, nausea and vomiting) and psychiatric overtone (anxiety, depression, fatigue).
Constipation
Polyuria, polydipsia
Anorexia
Weight loss
HTN

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What are the ECG findings of hypercalcaemia?

Short QT interval

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What are the causes of hypercalcaemia?

Malignant - bone mets, PTHrP, myeloma
Primary hyperparathyroidism
Sarcoidosis
Lithium

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What are the symptoms of hypokalaemia?

Muscle weakness
Hypotonia
Hyporeflexia
Cramps
Tetany
Palpitations/arrhythmias
Light-headed
Constipation

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What are the ECG changes in hypokalaemia?

Small/inverted T waves
Long PR
ST depression
Prominent U wave

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What are the causes of hypokalaemia?

Diuretics
Cushings syndrome/Steroids/ACTH
Diarrhoea, vomiting
Pyloric stenosis
Conn’s syndrome

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What are the symptoms of hyponatraemia?

Anorexia
Nausea
Malaise
Headache
Irritability, confusion
Weakness
Dropping GCS, seizures
Oedema
Falls
HF

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What are the symptoms of hypocalcaemia?

SPASMODIC’

Spasms (Chvosteks sign)
Perioral paraesthesia
Anxious/irritable/irrational
Seizures
Increased smooth muscle tone and colic
Wheeze
Dysphagia
Disorientation/confusion
Dermatitis/impetigo
Cardiomyopathy

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What are the ECG findings in hypocalcaemia?

Long QT interval

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What are the cause of hypocalcaemia?

CKD
Hypoparathyroidism
Low Mg
Low VitD

How to treat hypocalcaemia?

Mild – give calcium

- Severe – calcium gluconate IV

How to treat hypokalaemia?

If mild (>2.5mmol/L, no symptoms), give oral K supplement. Consider changing thiazide diuretics to K-sparing diuretics.
If severe (<2.5mmol/L, dangerous symptoms), give IV potassium cautiously.

How to treat hyperkalaemia?

Treat underlying cause
Calcium gluconate or calcium chloride
IV Insulin/dextrose infusion
Salbutamol
Bicarbonate
IV NaCl and diuretic
Haemodialysis

How to treat hyponatremia?

Correct underlying cause, never base treatment on NA concentration alone

How to treat hypernatremia?

Give water orally

- IV Glucose 5%

What is AKI?

- Defined as decrease in kidney function. | - Rise in creatinine and blood urea nitrogen

What are the risk factors of AKI?

- Chronic kidney disease - HF + HTN - Diabetes - Liver disease - Older age (above 65 years) - Cognitive impairment - Nephrotoxic medications - Contrast use - Sepsis

What are the pre-renal causes of AKI?

- Renal artery stenosis - Dehydration - Hypotensions (hypovolaemia) - Sepsis - Shock - Hepatorenal syndrome - Severe HF - Intra-abdominal hypertension/compartment syndrome

What are the renal causes of AKI?

- Glomerulonephritis - Acute tubular nephrosis - Interstitial nephritis - Vasculitis - NSAIDs - ACEi - ARBs - Gentamicin - Vancomycin - Contrast media - Rhabdomyolysis - Myeloma - Tumour lysis syndrome

What are the post-renal causes of AKI?

- Renal stones - Pelvic cancer - Prostate enlargement: BPH

Which medications are considered nephrotoxic?

- NSAIDs - ACEi - ARBs - Gentamicin - Vancomycin - Contrast media

What is stage 1 AKI?

- Serum creatinine >26 μmol/L in 48 hours or 1.5-1.9 x baseline - Urine output <0.5ml/kg/hr for >6 consecutive hours

What is stage 2 AKI?

- Serum creatinine 2.2-2.9 x baseline | - Urine output <0.5 ml/kg/hr for >12 hours

What is stage 3 AKI?

- Serum creatinine >354 μmol/L or >3x baseline or on RRT | - Urine output <0.3 ml/kg/hr for >24 hours or anuric for 12 hours

What are the symptoms of AKI?

- Fever - Rash - Joint pains

What are the signs of AKI?

- Rash - Uveitis - Hydration status - Audible abdo bruits - Palpable bladder

What are the investigations in AKI?

- ABG/VBG: for K+ - ECG: K+ - Urine dipstick

What do the results of urine dipstick in AKI suggest?

- 3+ proteinuria indicates intrinsic renal disease. | - If blood+ and protein+ then consider glomerulonephritis

How to treat AKI?

- IV fluid rehydration 500ml in 15 min in pre-renal AKI - Stop nephrotoxic medications - Relieve obstruction in a post-renal AKI

What does high BP do to the afferent and efferent arterioles?

Constricts the afferent, dilates the efferent

Why are ACE inhibitors and NSAIDs nephrotoxic?

- ACEi dilate the efferent arteriole - NSAIDs block prostaglandins that normally dilate the afferent arteriole (effectively constricting the afferent arteriole)

What is the treatment for ATN?

- Supportive management - IV fluids - Stop nephrotoxic medications - Treat complications

What does urinalysis of ATN show?

Muddy brown casts found on urinalysis is a pathognomonic finding

How long does it take for ATN to recover?

2-3 weeks

What is ATN?

- Damage and death (necrosis) of the epithelial cells of the renal tubules - Damage to the kidney cells occurs due to ischaemia or toxins.

What are the 3 stages of ATN?

1- Oliguric phase: <500ml urine/day 2- Maintenance phase: No longer oliguric, creatinine stable 3- Polyuric recovery phase: large amounts of dilute urine, likely to be hypokalaemia

What are the complications of AKI?

- High K+: Hyperkalaemia - Pulmonary oedema/fluid overload if low urine output – dark + concentrated urine - Metabolic acidosis (kidneys usually excrete H+) - High urea: Uraemic encephalopathy and uraemic pericarditis - Low Ca, high PO4: lead to parathyroid hormone release which leads to bone breakdown.