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Acute Care 2 > Renal, Acid Base > Flashcards

Renal, Acid Base Flashcards

1
Q

HRS definition

HRS type 1 vs type 2

A

Development of renal failure in pts w/ advance chronic liver disease. Splanchic circulation is dilated while renal circulation is constricted

HRS1 = acute onset, rapid progression. Med. Survival 2 weeks

HRS2 = slower progression (diuretic resistant, can have normal liver function). Med. Survival 3-6 mo

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2
Q

HRS risk factors

A

Large volume paracentesis w/o giving albumin (volume shifts)

Spont. Bacterial peritonitis

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3
Q

HRS labs and Dx

A

Labs: Low renal function s/p fluid resusitation and stopping renal toxic meds. Liver failure.

Infectious workup

renal US (-) obstruction and intrarenal

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4
Q

HRS management

A

renal function improves w/ fixing liver function

Liver Tx, optimize liver, avoid renal toxic drugs

Cefotaxime for peritonitis

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5
Q

urogenital/renal trauma risk factors

A

Possible trauma 2/2 lumbar injuries, lower rib injuries, pelvic fx, flan pain, hematoma to back, abdominal prostate exam or bleeding rectal or hematuria

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6
Q

s/s trauma

A

S/S: HOTN, shock, hematomas, Cullen sign, RP bleeding, inability to void, distended bladder, flank pain

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7
Q

trauma imaging options/orders

A

retrograde urethrogram = suprapubic catheter if positive, foley if negative

retrograde cystogram = assess bladder; can follow w/ voiding cysto to monitor flow from bladder to urethra

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8
Q

Trauma grading according to capsular rupture, collecting duct and vascular involvement

A

-I = microscopic or gross hematuria; monitor
-II = nonexpanding confined perirenal hematoma or cortical lac < 1 cm deep w/o urinary extravasation
-III = parenchymal lac extending more than 1 cm into cortex w/o extravasation
-IV = parenchymal lac extending through corticomedullary junction and into collecting system. Lac at segmental vein may be present. Thrombosis of renal artery w/o parenchymal laceration
-V = thrombosis of main renal artery. Fx, avulsion or shattered of kidney w multiple tears and laceration

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9
Q

Management of trauma grades

A

No foley if urethral damage suspected

1-3 mostly watch/wait
4-5 require surgery to repair asap.

HD stable may be able to done percutaneous repair

HD ubstable needs ex-lap and likely multiple surgery

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10
Q

RAS definition and risk factors

A

Progressive narrowing of renal artery r/I decreased blood flow can r/i renal atrophy, renal failure

-Atherosclerosis, Renal fibromuscular dysplasia

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11
Q

RAS s/s, labs and Dx

A

HTN, HA, blurry vision
Bruit over renal arteries

Cr, UA
US, CT, MRI to visualize kidney
Renal arteriography

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12
Q

RAS management

A

Manage HTN

Balloon angioplasty w/ stent placement

Renal artery graft/bypass

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13
Q

AKI definition and RIFLE criteria

A

An abrupt (w/I 48 hours) reduction in kidney function as an absolute increase in Sr Cr of more than or equal to 0.3, > 50% increase from baseline (1.5 fold), or a reduction in UOP of < 0.5 mL/Kg/hr for more than 6 hours – AKIN

Staging Modified RIFLE
1 = sCr > 0.3 or > 150-200% from baseline
2 = > 200-300% from baseline
3 = > 300% from baseline

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14
Q

AKI pre-renal causes

A

d/t decr perfusion. NO NEPHRON DAMAGE

-Volume depletion (hemorrhage, GI losses, urinary loss, skin loss)
-Vasodilatory states (sepsis, cards shock, NSAIDS, ACEI, diuretics, anaphylaxis)
-Decreased cards output
-arterial occlusion/vaso spasm
-Liver disease

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15
Q

AKI post-renal causes

A

Postrenal
-obstruction from the papillae to the urethral meatus
-Stones, BPH, tumor, masses, clots, strictures

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16
Q

AKI intrarenal causes

A

Intrarenal
-ATN = ischemia d/t low flow, clots, shock and vascular causes. Nephrotoxic exposure d/t drugs, radiographic contrast media. Rhabdomyolysis, rapid hemolysis
-Glomerular nephritis = immune related, glomerular inflammatory lesions
-Interstitial nephritis = immune reaction to offensive meds (PCN, cephalosporins, sulfas, rifampin, allopurinol) and infection (strep, RM spotted fever, sarcoidosis, SLE)

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17
Q

s/s and labs rhabdo/ATN

A

Rhabdo/ATN = Cr Kinase, urine granular casts, renal tubular epithelial cells. HYK, HYphos, HOCa, HYMg

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18
Q

s/s and labs interstitial nephritis

A

Interstitial nephritis = fever, rash, eosinophilia, UA w/ WBC, RBC, WBC casts, proteinuria. Dx Renal Bx sometimes

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19
Q

s/s, labs and Dx of glomerular

A

Glomerular = HTN, edema, elevated sCr days to months, hematuria, proteinuria, dysmorphic red cells, RBC casts, pyuria. Dx w/ Renal Bx

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20
Q

FENa: when can be used and what does it mean

A

differentiate pre-renal vs intrinsic renal.
CANNOT be used: diuretics, CKD, obstruction, acute glomerular disease

<1 % pre renal
> 2% ATN
1-4 = intrinsic
>4% post renal

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21
Q

cystogram purpose

A

bladder filled w/ water soluble contrast to eval voiding and possible backup into kidneys

22
Q

pre renal management

A

PRERENAL = empiric IV fluids for dehydration, do not overhydrate is c/f postrenal cause, fix H&H, improve heart function, improve liver function, renal artery US for vascular issues

23
Q

contrast induce ATN treatment

A

NS 1-3 mL/kg for 6 hours pre and post exam

24
Q

when to consult nephro

A

Intrarenal causes
-stop offending meds, reestablish blood flow, manage other illness that are causing renal damage. Glomerular and interstitial nephritis may respond to steroids

25
Q

post renal management

A

reestablish flow in urinary tract; remove stones, foley, Bx masses/tumors, urology consult

26
Q

CKD definition

A

Renal dysfunction with 2 or more: albuminuria, abnormal urine sediment, electrolyte issues, histology abnormalities, CT or US showing abnormal kidney structure or small size, Hx renal transplant

27
Q

CKD risk factors

A

Age > 65
Female > male
Race (high to low): AA, Hispanic, Asian, Caucasian

Conditions: RA, glomerular scarring, PKD, HTN, DM, autoimmune, drugs, HyCa, HyPhos

28
Q

CKD s/s

A

fatigue, itching, hair loss/brittle nails, metallic taste, DOE/SOB, anorexia, N, ED/nocturia, irritability, decreased concentration, anemia, FO

29
Q

CKD physical assessment findings

A

bruising, pallor xerosis, broken nails, epistaxis, “urine breath”, rales, pleural effusion, edema, cardiomegaly, NV, stupor, hyperreflexia, decreased sensation, anemia, proteinuria

30
Q

CKD staging

A

-Stage 1 = renal damage w/ normal kidney function. GFR > 90. 90-100% function
-Stage 2 = damage w/ mild loss of kidney function. GFR 60-89
-Stage 3a = mild to mod loss of function. GFR 45-59
-Stage 3b = mod to severe loss of function. GFR 30-44
-Stage 4 = severe loss of function. GFR 15-29
-Stage 5 = kidney failure. GFR < 15

31
Q

normal serum osmo

symptoms at 385, 400-420 and > 420

A

normal 275-295

385 = stupor
400-420 = seizures
>420 = coma, death

32
Q

normal osmolar gap and what it means if the gap is higher than normal

A

measured osmo - calculated osmo should be < 10. > 10 means methanol, ethanol, isopropanol, ethylene, propylene, ketoacids, sortibol, mannitol, glycerol

33
Q

HTN management in CKD

A

watch added Na, maintain hydration
BP goal < 140/80 unless proteinuria then < 125/75
ACE or CCB better than ARB
Stop ACE if K > 5.6 or Cr > 30% baseline
avoid drugs that increase BP NSAIDS, stimulants
protect renal blood flow, watch nephrotoxic drugs like NSAIDS and ABX

34
Q

Fluid overload prevention/management in CKD

A

daily wt, set danger limits on wt gain/loss
watch K and Cr
regulate fluid and Na
if still functioning nephrons then lasix - start 20-80 up to 1G/day

35
Q

anemia management in CKD

A

Treat correctable causes like GIB, and vitamin deficiency
Fe replacement only if indicated by iron studies
Epo if: on HD, if Hgb < 9 and all underlying causes have been treated and pts wants the drug
Epo BB warning; stroke, clots, severe HTN

36
Q

renal osteodystrophy management in CKD

A

-Tied to Ca, vit D and PTH levels
-PREVENT acidosis, HOCa, HYPhos
-Vit d replacement
-Bone scan to determine severity
-Monitor renal weekly and correct

37
Q

Alk phos, Ca, phos and PTH monitoring recommendations based on CKD classification

A

-Annual alk phos if Class 3a-5
-Class 1-3b: Ca/phos q 6-12 mo, PTH once
-Class 4: Ca/Phos 3-6 mo, PTH q6-12 mo
-Class 5: Ca/Phos q1-3 mo, PTH q3-6 mo

38
Q

protein catabolism management in CKD

A

-If CKD progression risk then limit protein to 1.3 g/kg/day; if DM then limit to 0.8
-Minimize trauma, infection and immobilization. Avoid over exercising
-Worse w/ thyroid replacement, steroids and tetracycline. Check TSH and give least amount necessary
-Can give anabolic agents

39
Q

metabolic acidosis treatment in CKD

A

-Sodium citrate 10-30 mL PCHS
-Polycitra: 1 packet PC. Does contain K so monitor level
-NaHCO3 = 1 gram w/ 13 mEq sodium for severe acidosis

40
Q

Hyperphos management in CKD

A

-Increased mortality at all stages with Ph > 4.6
-Dietary restriction: eggs, soda, meat, dairy

If stage IV/V
-Ca carbonate used only in high risk
-Sevelamer or fosrenol
-Aluminum hydroxide in emergency only and limit use to 3 days
-HD

41
Q

Hyperkalemia prevention and management

A

-Dietary restrictions: avoid legumes, dried fruits, spinach, melon
-Caution for pts in hypercatabolic states (trauma, infection etc)
-Maintenance: Kayexalate 30-60 G/day in divided doses

Emergency:
1. EKG: flat p waves, peaked T waves, PR > .20, QRS < 0.10, bradycardia
2. IV Ca
3. 25 units D50 then regular insulin 10 units, 150 mEq HCO3 in D5W
4. Albuterol neb
5. HD for CKD or severe

42
Q

Hypermagnesemia management in CKD

A

s/s: weakness, confusion, decreased RR, decreased reflexes
-stop meds that contain Mg like laxatives, vitamins, antacids

4.0 = decreased reflexes
> 5.0 = prolonged AV conduction
> 10 = CHB
> 13 = cardiac arrest

43
Q

Hyperparathyroid mangement in CKD for 3a-5 and NOT on HD

A

i. CKD 3a-5 and NOT on HD
-PTH high or rising then check Phos, Ca, Vit D and correct levels
-AGAINST calcitriol and Vit D analogs
-Remove parathyroid if poor control w/ meds

ii.Class 5 and NOT on HD
-Aim for level 2-9 times normal
-DO use calcimemetics, calcitriol and vit d analogs

44
Q

Hypocalcemia management in CKD

A

i.Treat if significant AND/OR symptomatic
ii. DO NOT Tx if not on dialysis and asymptomatic
iii. If on HD then use calcitriol and vit d analogs
iv. If Tx pt then treat like a non-HD and use Ca acetate or carbonate if needed. Vit d if bone scan is bad

45
Q

High anion gap acidosis causes

A

CATMUDPILES

CO/cyanide poisoning, aminoglycosides, theophylline, methanol, uremia, DKA, Tylenol poisoning, Fe/isoniazid overdose, lactic acidosis, ethanol/ethylene glycol (antifreeze), salicylates

46
Q

Respiratory acidosis causes

A

COPD, pulm fibrosis, sedation overdose, NM weakness, major airway obstruction

47
Q

Respiratory alkalosis causes

A

hyperventilation, decreased lung compliance (sepsis, PE, PNA), trauma/shock early

chronic = high altitude, pregnancy 3rd trimester

48
Q

metabolic acidosis causes

A

CATMUDPILES, USEDCARP, prolonged cardiac arrest, CKD

49
Q

metabolic alkalosis causes

A

vomiting, high aldosterone (diuretics, cushings), Bicarb intake (antiacids), massive anion infusion (citrate or acetate infusion ex massive blood transfusion, long term TPN)

50
Q

KDIGO AKI definitions for 1-3

A

1: Cr 1.5-1.9 X baseline OR Cr > 0.3 OR UOP < 0.5 mL/Kg/Hr for 6-12 hrs
2: Cr 2-2.9 X baseline OR UOP < 0.5 mL/Kg/Hr for 12 hrs
3: Cr 3.0 X baseline, OR > 4.0 increase OR CRRT OR GFR < 35 mL/min

Acute Care 2 (2 decks)

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