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RENAL Flashcards

1
Q

What is azotemia?

A

Elevated nitrogen containing compounds (urea, creatinine)

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2
Q

At what 3 locations can azotemia occur?

A

Pre, renal, or post-renal

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3
Q

If a patient has severe azotemia that is symptomatic and can cause metabolic acidosis and electrolyte disturbances – what is this known as?

A

Uremia

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4
Q

How do we stage AKI?

A

RIFLE (risk, injury, failure) class

AKIN (acute kidney injury network) stage

KDIFO (kidney disease improving global outcomes) guideline

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5
Q

What is something that a nurse would call and notify you about that has changed for the patient, that would trigger you to think about AKI?

A

Decreases in urine output to less than 3ml/kg over 6 hours (or 0.5ml/kg/hr)
**Falls under KDIGO

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6
Q

We should always be checking creatinine levels when someone first enters the hospital, and re-checking. What change would indicate to us AKI?

A

Rises greater than 0.3mg/dl

**Falls under KDIGO

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7
Q

What are some of the clinical manifestation of AKI?

A

Often none

Edema, HTN, decreased UO, and changes in labs

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8
Q

What lab changes would you note with AKI?

A

Albuminuria, increased BUN, hyperkalemia, and hyponatremia

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9
Q

What would be some examples of prerenal azotemia?

A

Dehydration!!!! → Hypovolemia (may include blood loss)

Prolonged renal ischemia (acute tubular necrosis)

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10
Q

What are the two components of ATN? What causes each?

A

Ischemia (prolonged pre-renal)

Nephrotoxicity (NSAIDs, Abx, contrast dye)

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11
Q

What are some causes of Renal (intrinsic) Azotemia?

A

Glomerulonephritis (immune modulated) vs. Nephrosis (ischemia, contrast, toxins, DIC, precipitation)

Nephritis → Immune modulated

Minimal change disease (nephrotic syndrome)

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12
Q

What are some causes of postrenal azotemia?

A

Urinary obstruction = Prostatism, tumors, calculi, occasional urethra obstruction

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13
Q

What are some classic diagnostic testing we do for AKI?

A

UA, BUN, Cr, K, Na, Phosphate, Ca, CBC, and Renal/Pelvic US

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14
Q

How do we prevent AKI?

A

Sustain renal perfusion (fluid balance, blood volume, BP)

Don’t clog the pipes → prepare for planned exposure to contrast dye and check labs before!

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15
Q

What is the #1 most important step for treating AKI?

A

You must figure out the cause!!!

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16
Q

How do we treat AKI?

A

Meticulous limitation of intake = water, meds, proteins, K, Na, phosphate
If everything fails then consider a renal consult → Dialysis

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17
Q

What must we have prepped and ready for a renal consult?

A

BMP, Mg, Phosphate, UA, hemoglobin, and Renal US

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18
Q

What are some underlying medical co-mordidities that can lead to chronic kidney disease?

A

AKI, HTN, DM, and vascular disease

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19
Q

If the GFR is 60-89, what stage CKD?

A

2 (mild)

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20
Q

If the GFR is 30-44, what stage CKD?

A

3B

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21
Q

If the GFR is less than 15, what stage CKD?

A

5 (end stage)

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22
Q

If we have a patient in the hospital with CKD, what’s out #1 goal?

A

To prevent the development of acute-on-chronic kidney disease

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23
Q

If we have someone in the hospital with CKD, how do we manage them?

A

Diet (low sodium, potassium, protein, and phosphate)

Avoid nephrotoxins (NSAIDs and contrast)

Water management (think about your IVF!!!)

24
Q

What is the primary intracellular cation?

25
AKI, CKD, diet high in potatoes or bananas, hemolysis, metabolic acidosis, beta blockers, insulin deficiency, or aldosterone antagonists – can all cause what?
Hyperkalemia
26
What do we see on EKG with hyperkalemia?
Peaked T waves! With widening PR, QRS
27
What do we see on PE with hyperkalemia?
Weakness and Paralysis
28
How can we treat hyperkalemia?
Treat the cause IVF Kayexelate Limit potassium Insulin + dextrose Beta adrenergics (albuterol neb)
29
If a patient has metabolic alkalosis due to excessive V/D (laxatives) or renal diuretics/hypomagnesemia – what can they all lead to?
Hypokalemia
30
What do you see on PE with Hypokalemia?
Weakness, rhabdomyolysis Glucose intolerance
31
What would you see on EKG with hypokalemia?
U waves
32
How do you treat hypokalemia?
Potassium replacement! (PO vs. IV for symptomatic, should be KCl) ALWAYS CHECK Mg AND REPLACE IF NEED BE!!! Consider hyperglycemia and DKA
33
What is the primary extracellular cation?
Sodium | ***AKA we’re moving onto the natremias…
34
If we discover that someone is hypernatremic – what must we figure out next?
If their urine is dilute or highly concentrated
35
What would cause a patient to be hypernatremic with highly concentrated urine?
Extrarenal water loss (on a desert island) Fever, sweating, diarrhea, mechanical ventilation
36
What would cause a patient to be hypernatremic with dilute urine?
Osmotic diuresis (something is in there, and it’s got to come out) DKA, Diabetes insipidus (central = low ADH, Nephrogenic = unresponsive to ADH)
37
If we have determined that a person is hypernatremic with dilute urine – what do we need to figure out next?
Polyuric? (is their urine output greater than 3L/day) If yes, is the urine osmolality: +300mOsm/L (indicating osmotic diuresis) Or Less than 150mOsm/L (indicating diabetes insipidus)
38
If a patient is just dehydrated and that’s why they are hypernatremic – what do we do?
NS initially → transition to ½ NS
39
How fast can we correct hypernatremia due to dehydration?
SLOW! No faster than 0.5mEq/L/hour (to avoid cerebral edema)
40
What does hyponatremia often indicate?
Increased water with relation to sodium | Often associated with elevated ADH
41
Almost all patients that are hyponatremic are they also: hypoosmolar or hyperosmolar?
Hypoosmolar | *Just don’t worry about hyperosmolar
42
So, when we figure out someone with Hyponatremic Hypoosmolar – what must we figure out next?
Volume status! Hypervolemic, Hypovolemic, or Euvolemic Assess with Hx, exam, Urine Na, and urine osmolality
43
What would be some causes for HypERvolemic Hyponatremic?
CHF!!! Cirrhosis or nephrotic syndrome → they have EDEMA
44
What would we see on labs with hypervolemic hyponatremic?
Na = 125 (140 is NORMAL) Baroreceptors are increasing ADH secretion since circulation is inadequate (ADH is high) → thus the kidneys are retaining both water and salt
45
If a patient is hypOvolemic hyponatremic – where should we look for the source?
Renal or Non-renal causes Renal = Urine Na 30+mmol/L Non-renal = Urine Na less than 30mmol/L
46
If the urine Na is over 30 in a hypOvolemic hyponatremic patient – what are some possible causes?
Diuretics!!! (thiazides) Primary adrenal insufficiency Cerebral salt wasting
47
If the urine Na is less than 30 in a hypOvolemic hyponatremic patient – what are some possible causes?
GI!!!! Vomiting, diarrhea, dehydration
48
If a patient is euvolemic but their labs come back with a sodium of 116 – what are they?
Euvolemic Hyponatremic
49
In a Euvolemic hyponatremic patient, what must we look at next?
Can they concentrate their urine UrOsm 100+ (urine remains relatively concentrated, despite excess water in blood) UrOsm less than 100 (unable to concentrate urine)
50
What are some causes of Euvolemic hyponatremia with concentrated urine?
SIADH!!!! Secondary adrenal insufficiency, renal insufficiency, hypothyroidism
51
What are some causes of Euvolemic hyponatremia with inability to concentrate urine?
Psychogenic polydipsia (they’re literally drinking from the toilet) Tea & Toast diet
52
So, like we said earlier almost all of Hyponatremias are associated with elevated ADH levels – what would cause elevated ADH in a hospitalized patient?
Pain, volume depletion, trauma, meds (SSRI, diuretics), neoplasms, neurophyschiatric meds
53
How do we treat acute symptomatic hyponatremia?
Saline (normal 0.9%) Loop diuretic Recheck Serum Na and Urine Osmol every 1-2 hours
54
How do we treat chronic symptomatic hyponatremia?
Brief stint of 3% saline (ALWAYS from nephrology input) Stop NaCl when suren Na rises, Urine Osm falls, or symptoms resolve
55
What must we remember about the IVF we give for hyponatremia?
The UrOsm should be LESS than whatever you’re giving
56
How do you treat chronic ASYMPTOMATIC hyponatremia?
Fluid restriction (best/safest initial) Increase solute intake D/C offending agents ADH receptor antagonist
57
How do you treat hypovolemic hyponatremia?
NaCl

HOSPITAL (12 decks)

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