Green PANCE book Flashcards
a syndrome of rapidly deteriorating glomerular filtration rate (GFR) with the accumulation of nitrogenous wastes (urea, creatinine) referred to as azotemia
Acute renal failure (Acute Kidney Injury)
Serum creatinine increases by more than 0.5 mg/dL or more than 50% over baseline levels
Acute renal failure (Acute Kidney Injury)
The classification of ARF (acute renal failure) in the critical care setting is based on….
GFR
Urine output
Risk of renal dysfunction Injury to kidney Failure of kidney function Loss of kidney function End stage kidney dz
RIFLE classification of renal disease
Reduced renal perfusion and
Acute tubular necrosis
2 diseases that account for majority of ARF
Exposure to nephrotoxins Family hx of renal disease Urologic disease Contributing factors like..... HTN, hypotension, volume loss, CHF or diabetes
increased risk of ARF
N/V/D Pruritus Drowsiness Dizziness Hiccups SOB Anorexia Hematochezia
General symptoms of ARF
Tachycardia and hypotension may indicate a _____ cause of ARF
prerenal
A distended bladder, costovertebral angle tenderness or enlarged prostate may indicate a _____ cause of ARF
postrenal
anuria or oliguria change in volume status (weight) change in mental status edema weakness dehydration rashes JVD uriniferous odor ecchymosis
signs of ARF
The key parameter in measuring renal function
GFR
_____ and _____ are helpful for monitoring renal insufficiency and provide clues to cause
BUN and creatinine
____ provides an estimate of renal function but is more sensitive to dehydration, catabolism, diet, renal perfusion, and liver disease
BUN
Urea is reabsorbed in the nephron during stasis, which causes false elevations of…
BUN
*therefore is not a reliable indicator of renal function
Hypovolemia Hypotension Ineffective circulating volume (CHF, cirrhosis, nephrotic syndrome, early sepsis) Aortic aneurysm Renal artery stenosis or embolic disease
PRE-renal causes of ARF
Acute tubular necrosis
Nephrotoxins (NSAIDs, aminoglycosides, radiologic contrast)
Interstitial disease (acute interstitial nephritis, SLE, infection)
Glomerulonephritis
Vascular disease (PAN, vasculitis)
Intrinsic renal causes of ARF
Tubular obstruction Obstructive uropathy (urolithiasis, BPH, bladder outlet obstruction)
POST-renal causes of ARF
Urinalysis is essentially normal in what types of ARF?
Post renal and Pre renal
Granular casts, WBCs and casts, RBCs and casts, proteinuria and tubular epithelial cells indicate what type of ARF?
Intrinsic
Serum cystatin C is a serum biomarker that can detect…
AKI (acute kidney injury)
Urine sodium under 20 mEq/L
Elevated BUN:Cr ratio of 20:1
Pre renal ARF
Increased urine sodium greater than 40 mEq/L
Decreased BUN:Cr ratio of under 15:1
Intrinsic ARF
a kidney smaller than 10 cm (looked at with renal ultrasonography) indicates a…
chronic problem
Azotemia (increase in BUN)
decreased creatinine clearance
metabolic acidosis
hyperkalemia
lab findings associated with loss of renal function
Treatment= achievement of normal hemodynamics (IV fluids, improving cardiac output)
This is for what type of ARF?
Pre renal
Treatment= adjustment and avoidance of medications and nephrotoxic agents
This is for what type of ARF?
Intrinsic
Treatment= relief of urinary tract obstruction (ureteral stents, urethral catheter)
This is for what type of ARF?
Post renal
Short term dialysis should be implemented when serum creatinine exceeds…
5-10 mg/dL
The progression of ongoing loss of kidney function (GFR)
chronic kidney disease (CKD)
Kidney damage with normal GFR greater than 90 and persistent albuminuria
Stage 1 CKD
Kidney damage with mild decrease in GFR 60-89
Stage 2 CKD
Moderate decrease in GFR from 30-59
Stage 3 CKD
Severe decrease in GFR from 15-29
Stage 4 CKD
Kidney failure with GFR less than 15
Stage 5 CKD
These CKD pts are typically asymptomatic without an increase in BUN or serum creatinine; acid base maintenance is adaptive through an increase in remaining nephron function
Stage 1 and 2
These CKD pts may still be asymptomatic; however, serum creatinine and BUN increase. Other hormones (PTH, erythropoietin, calcitriol) become abnormal
Stage 3 CKD
These CKD pts may become symptomatic with anemia, acidosis, hyperkalemia, hypocalcemia and hyperphosphatemia
Stage 4 CKD
These CKD patients are candidates for renal replacement therapy
Stage 5 CKD
Diabetes
Hypertension
Glomerulonephritis
Polycystic kidney disease
are the most common causes of…..
CKD
Patients with CKD generally progress to…
chronic renal failure
5 year survival rate for chronic renal failure
35%
Uremic symptoms may develop insidiously and include:
fatigue, malaise, anorexia, nausea, vomiting, metallic taste, hiccups, dyspnea, orthopnea, impaired mentation, insomnia, irritability, muscle cramps, restless legs, weakness, pruritus, easy bruising and altered consciousness
Stages 3-5 CKD
Signs include: cachexia, weight loss, muscle wasting, pallor, HTN, ecchymosis, sensory deficits, asterixis, Kussmaul respirations
CKD
Gold standard diagnostic for CKD?
GFR!*
This formula requires the patient age, body weight and serum creatinine
Cockcroft-Gault
Proteinuria is a marker for..
kidney damage
BUN and creatinine are elevated in
CKD
Serum biomarker cystatin C is _____ when the GFR is less than 88
elevated
These 2 drug classes slow the progression of renal dysfunction, particularly in proteinuric patients
ACE inhibitors
ARBs
May result from cellular redistribution from the intracellular to the extracellular compartment, potassium retention, impaired potassium excretion, or elevations caused by increased tissue breakdown**
HYPERkalemia
most commonly associated with renal failure, ACE inhibitors, hyporeninemic hypoaldosteronism, cell death and metabolic acidosis
HYPERkalemia
Can result in dysrhythmias and cardiac arrest
*numbness, tingling, weakness, flaccid paralysis
severe HYPERkalemia
ECG changes evolve as potassium rises to greater than 6. The earliest ECG manifestation is…
peaking of T waves
Flattening of the P wave, prolongation of the PR interval, and widening of the QRS complex are seen with severe…
HYPERkalemia
Can result from a shift of potassium into the intracellular compartment or from potassium losses of extra-renal or renal origin
HYPOkalemia
Can cause: ventricular arrhythmias, hypotension and cardiac arrest
*also..malaise, skeletal muscle weakness, cramps, smooth muscle involvement (leading to constipation)
HYPOkalemia
increased ____ levels result in increased serum calcium and decreased phosphorus
PTH
Parathyroid disorders, chronic renal failure, and malignancy are the most common disorders of….
Calcium and Phosphorus
one of the most common disorders, especially in hospitalized patients with malignancy
HYPERcalcemia
*Vitamin D intoxication, hyperparathyroidism and sarcoidosis can also cause
Drink plenty of fluids
Strain urine
Analgesics (NSAIDs, Opiods)
Alpha blocker or CCB may help w passage
Tx for majority of nephrolithiases (renal calculi)
Elective lithotripsy or uretoscopy may be used in stones measuring….
5-10mm
Gold standard for stones greater than 10 mm if RENAL FUNCTION IS JEOPARDIZED
Urethral stent or percutaneous nephrostomy
Typically results from chronic disease (most common cause is CKD) or HYPOparathyroidism
- Trousseau sign
- Chvostek sign
HYPOcalcemia
Carpal tunnel spasm after BP cuff applied for 3 minutes
*seen in hypocalcemia
Tousseau sign
Spasm of facial muscle after tapping facial nerve in front of ear
*seen in hypocalcemia
Chvostek sign
This electrolyte disorder commonly seen secondary to CKD or excessive use of phosphate-containing laxative or enemas
HYPERphosphatemia
vitamin D deficiency
respiratory alkalosis
burns
hyperparathyroidism
can do what to phosphate levels?
DECREASE
*hypophosphatemia
Most magnesium is stored in..
bones and muscles
Reduced deep tendon reflex
Muscle weakness, hypotension, respiratory depression..CARDIAC ARREST
N/V and flushing
HYPERmagnesemia
IV calcium gluconate is the tx for…
Hypermagnesemia
What happens to bleeding and clotting times in Hypermagnesemia
Increased/prolonged
What can a CKD pt develop if given laxative or antacid
HyperMg
