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Renal Flashcards

1
Q

Define AKI

A

• Rapid loss of kidney function (over hrs/days) • Reversible • Leads to retention waste products (urea, Cr) • Dysregulation of ECV and electrolytes

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2
Q

Categorise causes of AKI Commonest causes?

A

Pre-renal Renal Post-renal NB Pre-renal + ATN account for 80%

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3
Q

Pre-renal causes of AKI

A

Hypovolaemia (haemorrhage, D+V) hypotension (shock, sepsis, anaphylaxis) HF, Cirrhosis, nephrotic syndrome, Renal hypoperfusion (NSAIDs, ACEi, ARBs, RAS)

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4
Q

Renal (intrinsic) causes of AKI

A

GLOMERULAR – glomerulonephritis, HUS TUBULAR – acute tubular necrosis INTERSITIAL – acute interstitial nephritis (e.g. NSAIDs, AI), VASCULITIDES – Wegener’s granulomatosis. Eclampsia

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5
Q

Post-renal causes of AKI

A

Stones (renal calculi) Neoplasm (bladder, prostate) Urethral tricture Prostate Hypertrophy Infection - TB, schisto

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6
Q

Who get’s AKI? % of admissions?

A

Elderly, multi-morbidity, frail 20% hospital admissions have AKI

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7
Q

Risk Factors for AKI

A

• Age >65 • CKD, comorbidities e.g. HF, DM • Hypovolaemia, sepsis • Nephrotoxic drugs= DAMN (Diuretics, ACEi/ARBs, Metformin/contrast Media, NSAIDs)

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8
Q

Syndrome of AKI Signs AKI

A

• HTN • Distended bladder • Dehydration -> postural hypotension • Fluid overload (HF, cirrhosis, nephrotic syndrome): raised JVP, pulmonary + peripheral oedema, BP high or low • Pallor, rash (uraemia)

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9
Q

Syndrome of AKI Sx AKI

A

1) Loss fluid balance - Reduced UO (Oliguria/anuria) - pulmonary + peripheral oedema (SOB, swelling) 2) High Cr and Urea - arrhythmias (high K, acidosis) - pruritis, N+V, anorexia, carditis, enceph. (high Urea)

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10
Q

Name of Classification for AKI Features

A

KDIGO classification 3 stages of AKI Includes serum Cr + UO Stage 1 = 1.5-2x incr. baseline Cr + <0.5ml/kg/hr for >6hr (or >50% rise in Cr in last 7 days or rise in creatinine of 26 micromol/L or more in 48 hours)

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11
Q

Features AKI

A

Low UO + Fluid overload High U + Cr Low eGFR Hyperkalaemia Acidosis

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12
Q

Ix

A

Assess Patient A-E approach (IV access, IV fluids) Obs - (cause AKI, complications AKI) Hydration status + WEIGHT Catheterise - for hourly UO LOOK FOR CAUSE Urinalysis- L,N (UTI), proteinuria (nephrotic syndrome), haematuria (nephritic syndrome) Urine MC+S - infective cause, malignancy FBC (infection) Drug Chart - DAMN nephrotoxic drugs Renal USS (size kidneys, hydronephrosis) MONITOR/CHECK FOR COMPLICATIONS U+Es!! (Na, K, U, Cr) VBG (K + acid-base status), ABG if hypoxic (oedema) ECG (hyperkalaemia) CXR (pulmonary oedema)

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13
Q

Mx of AKI

A
  1. Treat the CAUSE (e.g. fluids, ABx in sepsis) 2. Monitor + Optimize fluid balance - catheter + IV fluids?, monitor serum Cr, Na, K, Ca, Phosphate, glucose 3. Treat complications e.g. hyperkalaemia 4. Stop nephrotoxic drugs (DAMN drugs) 5. Consider for dialysis
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14
Q

Complications of AKI

A

• Pulmonary oedema • Acidaemia, uraemia, hyperkalaemia • bleeding (HIGH UREA impairs haemostasis -> bruising, nose bleed, GI bleed )

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15
Q

How to treat hyperkalaemia (3 steps)

A

10ml 10% Calcium gluconate (stabilise cardiac membrane) 10 units Insulin + 50ml 50% glucose over 5-15 mins Salbutamol 5mg nebulised (Move K intracellularly) Calcium resonium (15g PO or 30g PR), loop diuretics, dialysis (to remove K from body) Haemofiltration (if anuric)

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16
Q

ECG changes seen in hyperkalaemia

A

tall-tented T waves small P waves Increasing PR interval widened QRS Sine-wave pattern -> VF

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17
Q

Acute vs chronic renal failure

A
  • Cant tell for sure, treat as acute - Renal USS - CRF bilateral small kidneys ○ Except : ADPKD, amyloidosis, diabetic nephropathy - Chronic features = comorbitiy (DM, HTN), long Hx Sx, previous abnormal bloods, hypocalcaemia (lack Vit D hydroxylation)
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18
Q

How to tell if pt volume depleted?

A

Oliguria (<0.5ml/kg/hr) or anuria Low JVP Postural hypotension Tachycardia Reduced skin turgor, dry mucous membranes

19
Q

Signs of GU tract obstruction?

A

Catheter Palpable bladder Oligo/anuria Enlarged Prostate

20
Q

Mx Pulmonary oedema

A

Sit up + high flow O2 Morphine 2.5mg IV + Metoclopramide 10mg IV Furosemide IV ?g GTN spray If no response - CPAP, haemofiltration

21
Q

Mx Bleeding in AKI

A

NB. High urea impairs haemostasis -> cannot clot -> bruising, mucosal bleeding, epistaxis, GI bleed Give FFP + plt as needed Tranfuse to keep Hb >10

22
Q

Indications for Dialysis

A
  1. Refractory Hyperkalaemia >7mM 2. Refractory Pulmonary Oedema 3. Severe Metabolic acisosis pH<7.2 4. Sx uraemia - encephalopathy, pericarditis 4. Poisoning e.g. aspirin
23
Q

Define CKD

A

Abnormality of kidney function or structural damage (or both) For >3 months Irreversible

24
Q

Epi CKD

A

Approx. 1 in 10 people have CKD 2% progress to end stage renal CKD

25
Syndrome CKD Symptoms
Majority ASx (Sx Stage 4 +) Lethargy, itch (uraemia), SOB (oedema), cramps at night (electrolyte imbalance), bone pain (bone disease), swelling UO: polyuria, oliguria, nocturia, anuria
26
Syndrome CKD Signs
HTN Raised JVP, Pulmonary+peripheral oedema, SOB/inc. RR Palpable bladder Bilateral masses +/- hepatomegaly Pallor, cachexia
27
Hx in CKD
Often ASx DM HTN UTIs FHx DHx (neprotoxic drugs)
28
Causes CKD
Common: DM, HTN Others: Intrinsic kidney disease (GN), Obstructive uropathy, nephrotoxins
29
Staging CKD
GFR + (urine) ACR GFR Stages 1-5 ACR Stages 1-3 ACR not PCR as detect smaller amounts protein Increased stage = risk of progression to ESRF + mortality
30
How is eGFR calculated?
eGFR = serum creatinine, age, sex, ethnicity - basically calculated Cr clearance by kidneys Creatinine from muscle breakdown (increased in CKD) Muscle mass, age, gender, ethnicity affect Cr Hence all included in MDRD equation to calculate eGFR
31
Normal GFR
120ml/min \>90 is normal age-related decline
32
Ix in CKD
Bedside * BP, BMI * Urine dipstick: Haematuria, UTI, ACR Bloods * FBC (anaemia, infection), U+Es * lipids, HbA1c, (look Cr, Na, K, U, eGFR) * bone profile (low Ca, high Ph, high ALP, high PTH) Imaging * Renal USS (if G4/5 - **usually small kidneys \<9cm**), or large - ADPKD, amyloidosis) * CXR - pulm oedema, pleural effusion * AXR - calcification form stones * Bone XR - pseudofractures in renal osteodystrophy * CT KUB - cortical scarring f/pyelonephritis
33
How do you manage CKD?
1. Patient Information (think kidneys, NHS website) 2. Optimise Risk factors * Self Management: lifestyle advice (diet, fluids, exercise, smoking, alcohol), sick day rules (DAMN-T drugs) * Avorvastatin 20mg 1 prevention * Antiplts (Apixaban) 3. Manage comorbidities * HTN - ACEi or ARB (aim \<140/90), if DM then \<130/80) * Anaemia - aim Hb\>10g/dl. Give iron, EPO, darbapoeitin * Bone disease - reduce phsophate in diet, phosphate binders, Vit D (colecalciferol) 4. Monitor * accelerated progression * FBC (renal anaemia) * bone profile (renal osteodystrophy)
34
Define accelerated progression in CKD
Persistent decrease in eGFR of ≥ 25% + change CKD category OR A persistent decrease in eGFR of 15mL/min/1.73m^2 **within 12 months**
35
Complications from CKD
* Fluid overload (SOB, peripheral oedema) * HTN * Anaemia * Bone disease * CVD * Electrolyte disturbances, metabolic acidosis * malnutrition * ESRD + RRT
36
# Define : 1) Dialysis 2) Renal replacement therapy
Dialysis = haemodialysis, peritoneal dialysis, haemofiltration RRT = dialysis + renal transplant
37
Indications for RRT
* Renal failure - GFR \<15ml/min + Sx * in 10% CKD pts * Polycystic kidney disease * Diabetic or hypertensive nephropathy
38
Tell me about haemodialysis
* commonest RRT * 2 types: AV fistula and teck line * Involves regular filtration of the blood in hospital/home * 3x week, lasts 3-5hrs each * AV fistula - countercurrent flow of blood + dialysate across semi-permeable membrane, and ultrafiltration (fluid removed by low hydrostatic pressure of dialysate)
39
Why do an AV fistula?
Put AV fistula surgically in to increase blood flow in artery + veins NB. AV fistula surgery done \>8wks before dialysis (often lower arm)
40
How to examine AV fistula
1. Put fingers over it (see if thrill) 2. auscultate (should hear pulsatile murmur as blood flows w/systole) ## Footnote **If not these signs/reduced then -\> failed i.e. fistula _stenosed_**
41
Tell me about Tech lines
* 2 ports * One sits in vena cava (IN) * one in right atrium (OUT) * One scar
42
Risks/complications of haemodialysis
* Stenosis of AV fistula * fluid imbalance - decrease BP, pulmonary oedema * electrolyte imbalance * psychological factors * **disequilibration syndrome** (1st dialysis, rapid changes plasma osmolarity -\> cerebral oedema) * aluminium toxicity (in dialysate)-\> dementia
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Year 6 (9 decks)

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