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PCM 3 Test 1 > HYHO AKI > Flashcards

HYHO AKI Flashcards

1
Q

Acute kidney injury is defined as what?

A
  1. Increase in serum creatine of >0.3 mg/dL within 48 hours or within 7 days

OR

  1. Urine output is less than 0.5mL/kg/hour for > 6hours
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2
Q

What is cardiorenal syndrome?

A

a condition in which therapy to relieve congestive symptoms of HF is limited by a decline in renal funtion, manifested by reduced GFR.

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3
Q

How is GFR calculated?

Give an example of how this can underestimate the degree of dysfunction.

A
  • Calculated using creatnine, but this can underestimate the degree of dysfunction.
  • For example, frail elderly person has lower muscle mass. Thus, if they have renal insuffiency, they may have NL or mild elevation of creatinine.
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4
Q

Prerenal azotemia (BUN/Cr _____) is more common in ____.

A

BUN/Cr more than 20

HF

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5
Q

How many patients with HF will develop moderate-severe kidney impairment?

A

30-60%

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6
Q

What can cause pre-renal AKI?

A
    1. Hypovolemia
    1. Decreased CO
    1. Decreased effective circulating volume seen in CHF or liver failure.
    1. Impaired renal autoregulation due to NSAIDS, ACE-I or ARB, cyclosporine
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7
Q

What can cause intrinsic AKI?

A
  1. Damage to glomerulus
  2. Damage to tubules and interstitium (ischemia, sepsis or infection or nephrotoxins)
  3. Vascular pathologies (vasculitis, malignant HTN or HUS-TTP)
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8
Q

What causes post-renal AKI?

A

Obstruction distal to the kidney

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9
Q

What can eliminate obstructive causes of kidney injury?

A

Lack of hydronephrosis on ultrasound

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10
Q

On ultrasound, what will see in a patient with chronic kidney disease?

A
  • Smaller kidneys
  • Cortical thinning
  • Cystic kidneys
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11
Q

Exposure to IV contrast causes what effects in patients?

A

↑ in serum Creatinine within 48 hours.

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12
Q

Urine Na+ _____ is expected with HF. What is this due to?

A
  • Less than 25mEq/L
  • Reduced renal perfusion, which causes [+ of RAAS and sympathetic NS].
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13
Q

Urine Na+ is _____ in HF patients undergoing diuretic therapy.

A

Higher

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14
Q

On PE, what can the following indicate:

- Blue toes

- Drug rash

A
  • Blue toes: cholesterol emboli
  • Drug rash: Acute intersitial nephritis (ANI)
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15
Q

On PE, the following can indicate:

  • - Signs of volume contraction (tachycardia, skin tenting, dry oral mucosa)
  • - Jaundice or ascites
A
  • - Signs of volume contraction (tachycardia, skin tenting, dry oral mucosa): dehydration
  • - Jaundice or ascites: liver disease with portal HTN
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16
Q

What are signs of volume contraction (_____)?

A

Dehydration

Tachycardia, skin tenting, dry oral mucosa.

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17
Q

A patient with cardiorenal syndrome will have what 2 symptoms?

A

[Signs of volume overload + signs of HF]

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18
Q

What can we perform on PE to see if a patient is dehydrated?

A

Skin tenting: pinch skin on forehead.

If dehydrated, skin will remain elevated.

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19
Q

What are symptoms of AKI? (6)

A
    1. ↓ urine output
    1. Worsening dyspnea, including at rest, orthopnea and PND
    1. Worsening edema that bcomes ansarca or ascites
    1. Tachycardia (S3)
    1. Hypotension
    1. JVD
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20
Q

What are signs of respiratory distress

A

1. Tachypnea

2. Hypoxia

3. Increased work of breathing

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21
Q

Sudden dyspnea and orthopnea that awakens patient from sleep, causing the patient to sit or stand. Wheezing or coughing may be present.

A

Paroxysmal nocturnal dyspnea

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22
Q

PND can be mimicked by what?

A

nocturnal asthma attacks

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23
Q

Ansarca is severe generalized edema that extends from __________.

A

Lower extremity, proximally.

24
Q

Ansarca can cause _____ and is associated with what?

A

ascites and subcutaneous edema

HF, cirrhosis, severe malnutrition and renal failure

25
Q

________ detects large volumes of free intrabdominal fluid.

  • (+) finding:
  • (-) finding:
A

Fluid wave

  • (+) finding: highly specific for ascites
  • (-) finding: only 50% sensitive, so does NOT exclude ascites.
26
Q

How is a fluid wave conducted?

A
    1. Patient places ulnar surface of hand only midline of abdomen
    1. Doc places one hand on one flank and taps the opposite flank
    1. (+) sign: doc feels moderate to strong fluid wave on opposite side.
27
Q

How is a puddle sign, a _______ sign, conducted?

A

Auscultory percussion sign

  1. Patient is on all 4s for 5 minutes
  2. Doc listens with diaphragm of stethoscope while flicking a flinger over flank, starting at lowest point and moving to opposite flank.
  3. (+) sign: 40-50% sensitive in testing ascites
    1. sudden increase in intensity and clarity of sound, signaling that the stethoscope and passed the edge of peritoneal fluid.
28
Q

Sympathetic region of the:

  • Kidney
  • Ureters (upper)
  • Ureters (lower)
  • Bladder
A
  • Kidney: T10-11
  • Ureters (upper): T10-T11
  • Ureters (lower): T12-L2
  • Bladder: T12-L2
29
Q

What parasympathetic nerve supplies:

  • Kidney
  • Ureters (upper)
  • Ureters (lower)
  • Bladder
A
  • Kidney: vagus nerve
  • Ureters (upper): vagus nerve
  • Ureters (lower): pelvic splanchnic nerve
  • Bladder: pelvic splanchnic nerve
30
Q

What are the anterior and posterior chapmans points of the kidney?

A

Anterior: 1 inch lateral and 1 inch superior to belly button

Posterior: between TP of T12-L1 on ipsilateral side

31
Q

What is the Five Osteopathic Treatment Model to hollistically treat a patient?

A
  • 1. Biomechanical
  • 2. Respiratory/Circulatory
  • 3. Neurologic
  • 4. Metabolic/Energetic/ Immune
  • 5. Behavioral
32
Q

Biomechanical approach: Optimize structure and function of the musculoskeletal system to affect the body’s homeostatic mechanisms

What can be done to improve biochemical function of a AKI patient?

A

Examine

  1. SD of OA/AA
  2. SD of T10-T11
  3. SD of the psoas muscle
33
Q

What can be done to improve respiratory/circulatory function of a AKI patient?

A
  1. O2 via mask/nasal canula
  2. Lymphatics
    1. Thoracic inlet MFR
    2. Diaphragm
    3. Thoracic area: pectoral traction, dome diaphramg, thoracic pump
    4. Abdominal area: pump, sacral rocking, pelvic diapragm
    5. Extremeties: effleurage, petrissage, pedal pump
    6. Rib rasing
34
Q

What thoracic and abdominal lymphatic treatments can be done on a patient with AKI?

A

Thoracic:

  • pectoral traction
  • dome diaphragm
  • thoracic pump

Abdominal diaphram:

  • pump
  • sacral rocking
  • pelvic diaphram
35
Q

What lymphatic treatments can be done on extremeties in a patient with AKI?

A
  • effleurage/petrissage
  • pedal pump
36
Q

what can be done to improve neurlogic function in patients with AKI?

A
    1. Examine parasympathetics/sympathetic function of kidneys, ureters and bladder
  • 2. Chapmans points of the kidney
    1. Rib raising
37
Q

How do we alter metabolic/energic immune function in patients with AKI? (4)

A
    1. Give loop diuretics
    1. Restrict fluid & remove NSAIDS and PPI
  • 3. Adjust meds based on kidney fx
    1. Monitor patients intake/outtake and weight
38
Q

How can we alter behavioral function in a patient with AKI?

A
    1. Excercise
    1. Diet (restrict fluids)
    1. Avoid offending agents
    1. Manage CHF better, which is what caused AKI
      *
39
Q

What are the possible mechanisms to cause AKI in a patient with AHF?

A
    1. Hemodynamic changes => + sympathetic NS => + RAAS, ↑ vasopression (ADH) and endothelin release => ↑ Na+ and H20 retention => ↑ systemic vasoconstriction
      * ↑ cardiac afterload => ↓ CO => ↓ renal perfusion
    1. ↓ renal perfusion
    1. ↑ renal vein pressure, caused by ↑ intra-abdominal/central venous pressure => ↓ GFR
    1. Associations with HF with preserved EF
      * Renal dysfunction can lead to metabolic derangements, causing systemic inflammation and microvascular dysfunction=> cardiomyocyte stiffening, hypertrophy and interstitial fibropsis .
40
Q

Central venous pressure and GFR are _______-related.

A

Inversely

41
Q

What 2 other effects does systemic vasoconstriction caused by HF cause?

A
  1. Disproportional reasborption of urea, compared to creatinine
  2. Overwhelm vasodilator/natriuretic effects of NPs, NO, prostaglandins and bradykinin.
42
Q

The first thing to do in the face of AKI (low GFR) is to do what?

A
  1. Remove offending agents (NSAIDS, PPIs, ACE-I/ARBS, IV contrast).
43
Q

If there is no offending agent causing the low GFR, a _______should be given next

A

Loop diuretic (furosemide), adjusting the dose based on renal function.

44
Q

When is dialysis (aka _____) initiated?

When must it end?

A

Dialysis (renal replacement therapy)

  • Patient progresses to oliguira or anuria, causing changes in fluid, electrolye and acid-base balance.
  • Continue until renal function is reovered or if renal support is not goal of tx anymore.
45
Q

What other treatments should be done in a patient with AKI? (6)

A
    1. Supportive care (O2)
    1. Monitor weight/ intake and outatake
    1. Fluid restriction (oral and IV)
    1. Monitor electrolytes
    1. Assign a case manager
    1. Diet consult
46
Q

What should patients with AKI avoid using?

A

K+ sparing diuretics (spironolactone), because they can make it harder to manage K+.

47
Q

Why is it important to monitor electrolytes, Mg, Phosphate, BUN/Cr?

A

electrolyte abnormalities can cause arrhythmias

48
Q

When should case managers be involved?

A

Early in care, especially if there are new complications or signs of worsening.

49
Q

When must advanced directives, code status, DPAHC be addressed?

A

Early in hospitalization

50
Q

Long-term management of AKI includes what?

A
    1. Discuss dialysis and end of life matterns (will and DPAHC)
    1. Avoid nephrotic drugs, like OTC NSAIDS and PPIs
    1. Monitor electrolytes, weight and fluid status regularly.
51
Q

What is the difference between a living will and a DPAHC?

A
  • Living will: summarizes choices about future medical care (resuscitation, life support, feeding tube, dialysis, intubitation and ventilator)
  • DPAHC (durable power of attorney for healthcare): gives another person right to make decision about patients healthcare
52
Q

Advanced care planning allows what?

how quickly is it done and using what approach?

what is the doctors role

A
    • patients to talk to docs and family about end-of life issues.
    • takes many visits
    • team approach (interprofessional – case manager and nurse staff)
    • give information about prognosis and treatment options to help the pt make decision based on cost/risk and values.
53
Q

If the patient has elected some restriction (do not resuscitate, intubate) in living will, what must the doctor do?

A

DOCUMENT THE ORDER APPROPRIATLEY, because the prescence of the LW alone will NOT prevent resusictation.

54
Q

Stage 1 of KDIGO is defined as

  • Creatine criteria
  • UO criteria
A
    1. ↑ in serum Cr of >0.3 or 50-99%

OR

    1. Urine output <0.5mL/kg/hr for 6 - 12 hrs
55
Q

Stage 2 of KDIGO is defined as an…

  • Creatine criteria
  • UO criteria
A
  1. ↑ in serum Cr 100-199%

OR

  1. Urine output <0.5mL/kg/hr for 12 - 24 hrs
56
Q

Stage 3 of KDIGO is defined as..

  • Creatine criteria
  • UO criteria
A
  1. ↑ in serum Cr more than 200%

OR

  1. ↑ in serum Cr of 0.3 mg/dL to >4.0 mg/dL

OR

  1. Urine output <0.5mL/kg/hr for more than 24 hours or anuria for 12 or more hours

OR

  1. Initiation of dialysis
57
Q

in patients less than 18 YO, stage 3 AKI is defeined as what

A

GFR less than 35mL/min

PCM 3 Test 1 (9 decks)

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