[HYHO] HPS Session 2 AKI Flashcards
What is the definition of acute kidney injury?
Increase in serum creatinine of greater than or equal to 0.3mg/dL within 48 hours
OR
Urine output of <0.5mL/kg/hour for >6 hours
What is cardiorenal syndrome?
A condition which therapy to relieve congestive symptoms of HF is LIMITED by a decline in renal funciton
How is GFR calculated?
Using creatinine
What is an issue with using creatinine to measure GFR?
Can UNDERESTIMATE the degree of dysfunction
What are the 3 potential causes for AKI?
Prerenal
Intrinsic
Postrenal
What are the potential causes of prerenal AKI?
Hypovolemia
Decreased cardiac output
Decreased effetive circulating volume
Impaired renal autoregulation
What are the causes of intrinsic AKI?
Glomerular
Tubules/Interstitum
Vascular
What are the causes of postrenal AKI?
OBSTRUCTION
(e.g. bladder outlet obstruction, pelvourethral obstruction)
What is key to determining the source of an AKI?
Careful history taking
What is a common example of an event in the hx. of a patient that can present with AKI?
Exposure to IV contrast
Typically increases serum creatinine (25-50%) after administration
Describe what the symptom correlates with:
Blue toes
Possible cholesterol emboli
Describe what the symptom correlates with:
Appearance of ‘drug rash’
Acute Interstitial Nephritis (AIN)
Describe what the symptom correlates with:
Signs of volume contraction (tachycardia, skin tenting, dry oral mucosa, etc…)
Dehydration
Describe what the symptom correlates with:
Jaundice and ascites
Liver disease with portal hypertension
What are the symptoms/signs associated with AKI?
Decreased urine output
Worsening dyspea
Orthopnea
Paroxysmal nocturnal dyspnea
Worsening edema
S3 gallop
Hypotension
JVD
Liver distention
Distended abdomen (fluid wave)
Where is skin testing best evaluated?
Skin of the forehead
What is paroxysmal nocturnal dyspnea (PND)?
Episodes of sudden dyspnea and orthopnea that awaken patient from sleep,
prompting patient to sit up or stand up
What is anasarca?
Severe generalized edema that extrends from the lower extremity proximally
What is a fluid wave?
Detects large volumes of free abdominal fluid
How would you perform a fluid wave exam?
- Patient places ulnar surface of their hand along the abdominal vertical midline
- Physician places one hands on one flank and taps gently on the opposite flank
- ( + ) sign = physician feels a fluid wave emanating into the contralateral side
What is puddle sign?
Lower sensitivity than fluid wave detection, also…it’s really awkward.
Literally. Look at the image. You make your patient assume the position.
This is an auscultatory percussion sign, pt. holds this position on their hands and knees for 5 min. The physician then listens with stethescope while flicking a finger over a localized flank area of the abdomen.
(+) sign= increase in intensity and clarity of sound
Osteopathic structural exam (OSE)
Levels: Kidney
Sympathetic?
Parasympathetic?
Sympathetic = T10-T11
Parasympathetic = Vagus nerve
Osteopathic structural exam (OSE)
Levels: Upper ureters
Sympathetic?
Parasympathetic?
Sympathetic = T10-11
Parasympathetic = Vagus nerve
Osteopathic structural exam (OSE)
Levels: Lower ureters
Sympathetic?
Parasympathetic?
Sympathetic = T12-L2
Parasympathetics= Pelvic splanchnic nerve
Osteopathic structural exam (OSE)
Levels: Bladder
Sympathetic?
Parasympathetic?
Sympathetic = T12 - L2
Parasympathetics = Pelvic splanchnic nerve
Where are the (dare I say) chapman points for the kidney?
Anterior/posterior?
Anterior = One inch lateral and one inch superior to the umbilicus
Posterior = Between the transverse process of T12 and L1
5 model approach
What are the considerations you would make for AKI with…
Biomechanical?
SD of OA, AA
SD of thoracic spine at viscerosomatic levels (T10-11)
SD of the psoas muscles
5 model approach
What are the considerations you would make for AKI with…
Respiratory/Circulatory
O2 via mask/nasal canula
Lymphatics:
(Thoracic inlet MFR, diaphragms, Thoracic area [pectoral traction, doming the diaphragm, thoracic pump], Abdominal area [abdominal pump, sacral rocking, pelvic diaphragm], Extremities [effleurage, petrissage, pedal pump], Rib raising)
5 model approach
What are the considerations you would make for AKI with…
Neurologic?
Consider the sympathetics and parasympathetics of:
–> Kidneys, ureters (upper and lower), bladder
–> Chapman points
–> Rib raising treatment
5 model approach
What are the considerations you would make for AKI with…
Metabolic/Erergetic/Immune?
Loop diuretics
Fluid restriction
Remove offending agents (NSAIDS, PPI)
Adjust meds based on renal function
Monitor I/O’s, weights
5 model approach
What are the considerations you would make for AKI with…
Behavioral?
Exercise
Diet — restrict fluids, decrease salt intake
Avoid offending agents
Better management of CHF
What are the (4) mechanisms to account for AKI in conjunction with AHF?
Neurohormonal adaptations
Reduced renal perfusion
Increased renal venous pressure
Associations with heart failure with preserved ejection fraction (HFpEF)
What are the (9) possible treatment options for AKI?
- Remove offending agents (NSAIDS, PPI, etc)
- Loop diuretics
- Adjust medications
- Supportive care = oxygen
- Monitor weight
- Fluid restriction
- Monitor electrolytes
- Case management/manager
- Dietary consult
What is the MAJOR drug used in the treatment of AKI?
Loop diuretics
(furosemide)
What type of diuretics should be avoided in treating AKI?
K+ sparing diuretics
(they will complicate K+ management)
What is a living will?
Summarizes choices about future medical care
(typically addresses resuscitation and life support)
What is a durable power of attorney for healthcare (DPAHC)?
Authorizes another person (or surrogate) to make decisions on the patient’s behalf
If a patient has elected some restriction in their living will (do not resuscitate, do not intubate, etc), the physican MUST???
DOCUMENT the order appropriately.
The presence of the living wil alone will NOT prevent resuscitation
What is the KDIGO criteria?
KDIGO = Kidney Disease Improving Global Outcomes
It is a set of criteria used to “stage” the level of kidney disease
What is STAGE 1 of KDIGO?
Increase in serum creatinine of greater than or equal to 0.3mg/dL / 50 to 99% increase
OR
Urine output of <0.5 mL/kg/hour for 6 to 12 hours
What is STAGE 2 of KDIGO?
Increase in serum creatinine of 100 to 199% of normal
OR
Urine output of <0.5 mL/kg/hour for 12 to 24 hours
What is STAGE 3 of KDIGO?
Increase in serum creatinine of >220% of normal
OR
Urine output of <0.3 mL/kg/hour for more than 24 hours
OR
Anuria for greater than 12 hours
OR
Initiation of renal replacement therapy
