Exam 4 (AKI/Dialysis) Flashcards
AKI is defined as?
Decline in kidney function over 7 days or less
AKD is defined as?
7-90 days after AKI, before CKD
Stages of AKI based on serum creatinine?
1 = 1.5-1.9x, 2 = 2.0-2.9, 3 = 3.0 or greater
What are biomarkers of functional change in AKI?
serum creatinine, BUN, GFR
What are biomarkers of kidney damage in AKI?
NGAL, TIMP2 and IGFBP7, KIMI
What are the six risk factors for AKI?
age (>65), African American, CKD, DM, nephrotoxin, decreased effective circulatory volume
What is the number one way to prevent AKI?
maintain euvolemia and normal electrolytes, and organ perfusion
What is the mean arterial pressure recommended for organ perfusion?
MAP > 65 mmHg
What is the treatment recommendation for AKI?
isotonic, sodium-containing crystalloids
What drugs do not help with AKI?
loop diuretics, dopamine, fenoldapam
What is the goal urine output for intravascular volume repletion?
at least 0.5 mL/kg/hr
What medications should be temporarily held in hemodynamic AKI?
ACEi/ARBs, NSAIDs, SGLT2i, calcineurin inhibitors
What is required for the diagnosis of pre-renal AKI?
fractional excretion of sodium <1% or urea <35% IF on loop diuretic
How do you treat pre-renal AKI?
hold loop and thiazide diuretics
How do you treat intrinsic AKI (glomerulonephritis)?
immunosuppression
How do you treat intrinsic AKI (acute tubular necrosis)?
supportive care
How do you treat intrinsic AKI (tubulointerstitial nephritis)?
glucocorticoids (prednisone)
How do you treat intrinsic AKI (vasculitis)?
immunosuppression
How do you treat post-renal AKI?
relieve obstruction (Foley catheter)
Why can you not use serum creatinine for assessing kidney function?
serum creatinine lags behind change in GFR by 1-2 days
How is A affected (PK?)
unchanged
How is D affected?
can be increased, decreased, or unchanged
How is M affected?
decreased phase I enzyme capacity, NO change in phase II
How is E affected?
decreased renal elimination
How is PD affected?
increase BBB permeability, decreased platelet aggregation
What are six drugs that can accumulate metabolites?
allopurinol, cefotaxime, meperidine, morphine, primidone, sodium nitroprusside
Which opioids are not toxic?
fentanyl and methadone
Which opioids are somewhat toxic?
hydromorphone, oxycodone, and hydrocodone
Which opioids are toxic?
morphine, codeine, and meperidine
What affects the loading dose of a drug the most?
volume of distribution
What drugs have loading dose exceptions?
digoxin, and hydrophilic antibiotics
What are the antimicrobial agents that do not require dose adjustment?
metronidazole, azithromycin, nafcillin, tigecycline, oxacillin, linezolid, doxycycline, moxifloxacin, erythromycin, quinupristin/dalfopristin, ceftriaxone, clindamycin
What are the target total and free phenytoin concentrations?
total = 10-20 mcg/mL, free = 1-2 mcg/mL
Corrected phenytoin formula for patient with CrCL less than 20?
(measured phenytoin concentration)/[(0.2 x albumin) + 0.1]
Corrected phenytoin formula for patient with CrCL greater than 20?
(measured phenytoin concentration)/[(0.275 x albumin) + 0.1]
Which DOAC has the least and most renal clearance?
apixaban = least, dabigatran = most
Which parenteral anticoagulant has the least and most renal clearance?
fondaparinux = least, bivalirudin = least
What is the formula for calculating CrCL?
(140 - Age)/(72 x SCr) x IBW, where IBW = 45.5 or 50 + 2.3 x number of inches over five feet
What are the metformin adjustments needed with renal dysfunction?
eGFR < 30 = contraindicated/stop, 30-45 half dose, > 45 no adjustment
What is the sulfonylurea recommendation with renal dysfunction?
glyburide = bad, glipizide = better
Which DPP4i does not require a dose adjustment with renal dysfunction?
linagliptin
Thiazides are not effective if the creatinine clearance is what?
< 30 mL/min
What are the dose adjustments needed for loop diuretics with renal dysfunction?
25-50 = 2x dose, <25 = 4x the dose
What are the methods of drug removal during dialysis?
diffusion and convection
What are three types of hemodialysis access in order of infection and thrombosis?
arteriovenous fistula, arteriovenous graft, and central venous catheter
Hemodialysis uses _____ as a clearance mechanism, hemofiltration uses?
diffusion, convection
What are drug factors that can influence drug removal by dialysis?
molecular weight, protein binding, Vd (lipophilicity)
What are patient factors that can influence drug removal by dialysis?
albumin, fluid status, blood pressure
When should drug concentration monitoring occur for hemodialysis, peritoneal, and CRRT?
hemodialysis = prior, peritoneal = random, CRRT = random
What are six complications of hemodialysis?
hypotension, cramping, fatigue, infection, thrombosis, and bleeding
What are three treatments for hypotension from hemodialysis?
NaCl 0.9% bolus, decrease fluid removal, midodrine
midodrine dosing? Midodrine adverse effects?
2.5-10 mg po prior to HD; bradycardia, HTN, peripheral ischemia
What are four treatments for cramping from hemodialysis?
NaCl 0.9% bolus, decrease fluid removal, Vitamin E, quinine
What is a treatment for thrombosis from hemodialysis?
alteplase
What are three complications of peritoneal dialysis?
peritonitis, fluid overload, hyperglycemia
What is the loading dose for vancomycin?
25-35 mg/kg (maximum of 3g)
What is the target range for vancomycin?
15-20 mg/L
What is the target AUC for vancomycin?
400-600 mcg/mL
What is the normal Vd for vancomycin?
0.7 L/kg
