Investigations and management Flashcards
What investigations should you do for AKI?
- Serum creatinine
- Urinalysis
- Urine culture (MSSU)
- Stool culture
- Bloods
- CXR
- Renal USS
What would you be looking for on a CXR?
- Pulmonary oedema
- Pneumonia
What does a urinalysis look for?
- Blood
- Protein
- Leucocytes
- Nitrites
- Glucose
- Urobilinogen
- Conjugated Bilirubin
- pH
- Specific gravity
- Ketones
What would blood +ve on urinalysis indicate?
- Trauma
- Malignancy
- Stones
- Rhabdomyolysis
What would blood and protein +ve on urinalysis indicate?
- Glomerulonephritis
- Vasculitis
- UTI
- Malignant hypertension
What would protein +ve on urinalysis indicate?
- Glomerulonephritis
- Amyloid
- Severe HTN
- Diabetic nephropathy
What would blood and protein -ve on urinalysis indicate?
- Pre- or post-renal
- Interstitial nephritis
- Drugs
- Myeloma (cast nephropathy)
What would ketone +ve on urinalysis indicate?
- Starvation
- DKA
What would glucose +ve on urinalysis indicate?
- Diabetes
- Tubular defect
- SGLT-2 inhibitors
What would nitrites or leucocytes +ve on urinalysis indicate?
- UTI
- Foreign body (catheter/stone)
When would you send for a urine culture?
If urinalysis shows leucocytes or nitrites
When would you get a renal USS?
- Only if there is no other identifiable cause or patient is at rx of urinary tract obstruction
- Look for obstructed kidneys (hydronephrosis), kidney size
What bloods would you order?
- U+Es
- Autoimmune screen (ANCA, ANA, dsDNA, anti-GBM, RhF, C3, C4) if glomerulonephritis or vasculitis suspected
- Immunoglobulins, serum EP and urine for Bence Jones protein -> even if myeloma not suspected
- ABG if EWS ≥3
When would you urgently refer a patient for a same-day referral?
• Stage 3 AKI
• Kidney/UT obstruction
• No identifiable cause
• Sepsis
• Evidence of hypovolaemia
• Deterioration in clinical condition
• Complication of AKI:
Pulmonary oedema
Uraemic encephalopathy
Pericarditis
Severe hyperkalaemiaWhen would you discuss management with a nephrologist?
• CKD 4 or 5
• Specialist management:
Tubulointerstitial nephritis
Glomerulonephritis (proteinuria and haematuria)
Systemic vasculitis
Myeloma
• Inadequate response to treatment
• Renal transplantHow would you manage stage 1 AKI?
- Manage the cause
- Supportive maintenance of hydration
- Stop nephrotoxic medications or adjust medication in relation to renal function
What medications need to be stopped in AKI as they may worsen renal function?
- NSAIDs
- Aminoglycosides
- ACE-i
- ARBs
- Diuretics
What medications need to be stopped in AKI due to increased risk of toxicity?
- Metformin
- Lithium
- Digoxin
How would you treat fluid overload or oedema associated with AKI?
Furosemide
When is dialysis used?
AEIOU
A - Acidosis (pH <7.35)
E - Electrolyte imbalance (hyperkalaemia)
I - Intoxications
O - Overloaded with fluid (pulmonary oedema)
U - Uraemic encephalopathy or uraemic pericarditis
What is normal serum potassium?
3.5-5 mmol/L
How would you investigate abnormal potassium?
- Renal function
- ABGs
- ECG
What are the ECG changes of hyperkalaemia?
- Peaked T-waves
- Small or indiscernible P-waves
- Broad QRS (>3 small squares)
- QRS slurring into ST-segment
How would you treat hyperkalaemia?
- Stabilise myocardium if there are conduction abnormalities or arrhythmias
Calcium gluconate - Short-term shift in potassium back into cells
Insulin/dextrose infusion (monitor BG)
Salbutamol - Removal of potassium from the body
Calcium resonium
Loop diuretics
Dialysis
How do you manage hypokalaemia?
- Correct any underlying electrolyte abnormalities such as hypomagnesaemia
- Potassium chloride in sodium chloride
