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Year 6 > Renal > Flashcards

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
Q

Syndrome CKD Symptoms

A

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
Q

Syndrome CKD Signs

A

HTN Raised JVP, Pulmonary+peripheral oedema, SOB/inc. RR Palpable bladder Bilateral masses +/- hepatomegaly Pallor, cachexia

27
Q

Hx in CKD

A

Often ASx

DM

HTN

UTIs

FHx

DHx (neprotoxic drugs)

28
Q

Causes CKD

A

Common: DM, HTN Others: Intrinsic kidney disease (GN), Obstructive uropathy, nephrotoxins

29
Q

Staging CKD

A

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
Q

How is eGFR calculated?

A

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
Q

Normal GFR

A

120ml/min >90 is normal age-related decline

32
Q

Ix in CKD

A

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
Q

How do you manage CKD?

A
  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)
  1. 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)
  1. Monitor
  • accelerated progression
  • FBC (renal anaemia)
  • bone profile (renal osteodystrophy)
34
Q

Define accelerated progression in CKD

A

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
Q

Complications from CKD

A
  • Fluid overload (SOB, peripheral oedema)
  • HTN
  • Anaemia
  • Bone disease
  • CVD
  • Electrolyte disturbances, metabolic acidosis
  • malnutrition
  • ESRD + RRT
36
Q

Define :

1) Dialysis
2) Renal replacement therapy

A

Dialysis = haemodialysis, peritoneal dialysis, haemofiltration

RRT = dialysis + renal transplant

37
Q

Indications for RRT

A
  • Renal failure - GFR <15ml/min + Sx
    • in 10% CKD pts
  • Polycystic kidney disease
  • Diabetic or hypertensive nephropathy
38
Q

Tell me about haemodialysis

A
  • 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
Q

Why do an AV fistula?

A

Put AV fistula surgically in to increase blood flow in artery + veins

NB. AV fistula surgery done >8wks before dialysis (often lower arm)

40
Q

How to examine AV fistula

A
  1. Put fingers over it (see if thrill)
  2. auscultate (should hear pulsatile murmur as blood flows w/systole)

If not these signs/reduced then -> failed i.e. fistula stenosed

41
Q

Tell me about Tech lines

A
  • 2 ports
    • One sits in vena cava (IN)
    • one in right atrium (OUT)
  • One scar
42
Q

Risks/complications of haemodialysis

A
  • 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
43
Q
A
44
Q
A

Year 6 (9 decks)

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