HYHO AKI Flashcards
Acute kidney injury is defined as what?
- Increase in serum creatine of >0.3 mg/dL within 48 hours or within 7 days
OR
- Urine output is less than 0.5mL/kg/hour for > 6hours
What is cardiorenal syndrome?
a condition in which therapy to relieve congestive symptoms of HF is limited by a decline in renal funtion, manifested by reduced GFR.
How is GFR calculated?
Give an example of how this can underestimate the degree of dysfunction.
- 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.
Prerenal azotemia (BUN/Cr _____) is more common in ____.
BUN/Cr more than 20
HF
How many patients with HF will develop moderate-severe kidney impairment?
30-60%
What can cause pre-renal AKI?
- Hypovolemia
- Decreased CO
- Decreased effective circulating volume seen in CHF or liver failure.
- Impaired renal autoregulation due to NSAIDS, ACE-I or ARB, cyclosporine
What can cause intrinsic AKI?
- Damage to glomerulus
- Damage to tubules and interstitium (ischemia, sepsis or infection or nephrotoxins)
- Vascular pathologies (vasculitis, malignant HTN or HUS-TTP)
What causes post-renal AKI?
Obstruction distal to the kidney
What can eliminate obstructive causes of kidney injury?
Lack of hydronephrosis on ultrasound
On ultrasound, what will see in a patient with chronic kidney disease?
- Smaller kidneys
- Cortical thinning
- Cystic kidneys
Exposure to IV contrast causes what effects in patients?
↑ in serum Creatinine within 48 hours.
Urine Na+ _____ is expected with HF. What is this due to?
- Less than 25mEq/L
- Reduced renal perfusion, which causes [+ of RAAS and sympathetic NS].
Urine Na+ is _____ in HF patients undergoing diuretic therapy.
Higher
On PE, what can the following indicate:
- Blue toes
- Drug rash
- Blue toes: cholesterol emboli
- Drug rash: Acute intersitial nephritis (ANI)
On PE, the following can indicate:
- - Signs of volume contraction (tachycardia, skin tenting, dry oral mucosa)
- - Jaundice or ascites
- - Signs of volume contraction (tachycardia, skin tenting, dry oral mucosa): dehydration
- - Jaundice or ascites: liver disease with portal HTN
What are signs of volume contraction (_____)?
Dehydration
Tachycardia, skin tenting, dry oral mucosa.
A patient with cardiorenal syndrome will have what 2 symptoms?
[Signs of volume overload + signs of HF]
What can we perform on PE to see if a patient is dehydrated?
Skin tenting: pinch skin on forehead.
If dehydrated, skin will remain elevated.
What are symptoms of AKI? (6)
- ↓ urine output
- Worsening dyspnea, including at rest, orthopnea and PND
- Worsening edema that bcomes ansarca or ascites
- Tachycardia (S3)
- Hypotension
- JVD
What are signs of respiratory distress
1. Tachypnea
2. Hypoxia
3. Increased work of breathing
Sudden dyspnea and orthopnea that awakens patient from sleep, causing the patient to sit or stand. Wheezing or coughing may be present.
Paroxysmal nocturnal dyspnea
PND can be mimicked by what?
nocturnal asthma attacks
Ansarca is severe generalized edema that extends from __________.
Lower extremity, proximally.
Ansarca can cause _____ and is associated with what?
ascites and subcutaneous edema
HF, cirrhosis, severe malnutrition and renal failure
________ detects large volumes of free intrabdominal fluid.
- (+) finding:
- (-) finding:
Fluid wave
- (+) finding: highly specific for ascites
- (-) finding: only 50% sensitive, so does NOT exclude ascites.
How is a fluid wave conducted?
- Patient places ulnar surface of hand only midline of abdomen
- Doc places one hand on one flank and taps the opposite flank
- (+) sign: doc feels moderate to strong fluid wave on opposite side.
How is a puddle sign, a _______ sign, conducted?
Auscultory percussion sign
- Patient is on all 4s for 5 minutes
- Doc listens with diaphragm of stethoscope while flicking a flinger over flank, starting at lowest point and moving to opposite flank.
- (+) sign: 40-50% sensitive in testing ascites
- sudden increase in intensity and clarity of sound, signaling that the stethoscope and passed the edge of peritoneal fluid.
Sympathetic region of the:
- Kidney
- Ureters (upper)
- Ureters (lower)
- Bladder
- Kidney: T10-11
- Ureters (upper): T10-T11
- Ureters (lower): T12-L2
- Bladder: T12-L2
What parasympathetic nerve supplies:
- Kidney
- Ureters (upper)
- Ureters (lower)
- Bladder
- Kidney: vagus nerve
- Ureters (upper): vagus nerve
- Ureters (lower): pelvic splanchnic nerve
- Bladder: pelvic splanchnic nerve
What are the anterior and posterior chapmans points of the kidney?
Anterior: 1 inch lateral and 1 inch superior to belly button
Posterior: between TP of T12-L1 on ipsilateral side
What is the Five Osteopathic Treatment Model to hollistically treat a patient?
- 1. Biomechanical
- 2. Respiratory/Circulatory
- 3. Neurologic
- 4. Metabolic/Energetic/ Immune
- 5. Behavioral
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?
Examine
- SD of OA/AA
- SD of T10-T11
- SD of the psoas muscle
What can be done to improve respiratory/circulatory function of a AKI patient?
- O2 via mask/nasal canula
-
Lymphatics
- Thoracic inlet MFR
- Diaphragm
- Thoracic area: pectoral traction, dome diaphramg, thoracic pump
- Abdominal area: pump, sacral rocking, pelvic diapragm
- Extremeties: effleurage, petrissage, pedal pump
- Rib rasing
What thoracic and abdominal lymphatic treatments can be done on a patient with AKI?
Thoracic:
- pectoral traction
- dome diaphragm
- thoracic pump
Abdominal diaphram:
- pump
- sacral rocking
- pelvic diaphram
What lymphatic treatments can be done on extremeties in a patient with AKI?
- effleurage/petrissage
- pedal pump
what can be done to improve neurlogic function in patients with AKI?
- Examine parasympathetics/sympathetic function of kidneys, ureters and bladder
- 2. Chapmans points of the kidney
- Rib raising
How do we alter metabolic/energic immune function in patients with AKI? (4)
- Give loop diuretics
- Restrict fluid & remove NSAIDS and PPI
- 3. Adjust meds based on kidney fx
- Monitor patients intake/outtake and weight
How can we alter behavioral function in a patient with AKI?
- Excercise
- Diet (restrict fluids)
- Avoid offending agents
-
Manage CHF better, which is what caused AKI
*
-
Manage CHF better, which is what caused AKI
What are the possible mechanisms to cause AKI in a patient with AHF?
- Hemodynamic changes => + sympathetic NS => + RAAS, ↑ vasopression (ADH) and endothelin release => ↑ Na+ and H20 retention => ↑ systemic vasoconstriction
* ↑ cardiac afterload => ↓ CO => ↓ renal perfusion
- Hemodynamic changes => + sympathetic NS => + RAAS, ↑ vasopression (ADH) and endothelin release => ↑ Na+ and H20 retention => ↑ systemic vasoconstriction
- ↓ renal perfusion
- ↑ renal vein pressure, caused by ↑ intra-abdominal/central venous pressure => ↓ GFR
-
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 .
-
Associations with HF with preserved EF
Central venous pressure and GFR are _______-related.
Inversely
What 2 other effects does systemic vasoconstriction caused by HF cause?
- Disproportional reasborption of urea, compared to creatinine
- Overwhelm vasodilator/natriuretic effects of NPs, NO, prostaglandins and bradykinin.
The first thing to do in the face of AKI (low GFR) is to do what?
- Remove offending agents (NSAIDS, PPIs, ACE-I/ARBS, IV contrast).
If there is no offending agent causing the low GFR, a _______should be given next
Loop diuretic (furosemide), adjusting the dose based on renal function.
When is dialysis (aka _____) initiated?
When must it end?
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.
What other treatments should be done in a patient with AKI? (6)
- Supportive care (O2)
- Monitor weight/ intake and outatake
- Fluid restriction (oral and IV)
- Monitor electrolytes
- Assign a case manager
- Diet consult
What should patients with AKI avoid using?
K+ sparing diuretics (spironolactone), because they can make it harder to manage K+.
Why is it important to monitor electrolytes, Mg, Phosphate, BUN/Cr?
electrolyte abnormalities can cause arrhythmias
When should case managers be involved?
Early in care, especially if there are new complications or signs of worsening.
When must advanced directives, code status, DPAHC be addressed?
Early in hospitalization
Long-term management of AKI includes what?
- Discuss dialysis and end of life matterns (will and DPAHC)
- Avoid nephrotic drugs, like OTC NSAIDS and PPIs
- Monitor electrolytes, weight and fluid status regularly.
What is the difference between a living will and a DPAHC?
- 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
Advanced care planning allows what?
how quickly is it done and using what approach?
what is the doctors role
- 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.
If the patient has elected some restriction (do not resuscitate, intubate) in living will, what must the doctor do?
DOCUMENT THE ORDER APPROPRIATLEY, because the prescence of the LW alone will NOT prevent resusictation.
Stage 1 of KDIGO is defined as
- Creatine criteria
- UO criteria
- ↑ in serum Cr of >0.3 or 50-99%
OR
- Urine output <0.5mL/kg/hr for 6 - 12 hrs
Stage 2 of KDIGO is defined as an…
- Creatine criteria
- UO criteria
- ↑ in serum Cr 100-199%
OR
- Urine output <0.5mL/kg/hr for 12 - 24 hrs
Stage 3 of KDIGO is defined as..
- Creatine criteria
- UO criteria
- ↑ in serum Cr more than 200%
OR
- ↑ in serum Cr of 0.3 mg/dL to >4.0 mg/dL
OR
- Urine output <0.5mL/kg/hr for more than 24 hours or anuria for 12 or more hours
OR
- Initiation of dialysis
in patients less than 18 YO, stage 3 AKI is defeined as what
GFR less than 35mL/min
