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Principles 2 > Renal AKI & CKD > Flashcards

Renal AKI & CKD Flashcards

1
Q

What is Acute Kidney Injury (AKI)?

A

The deterioration of renal function over hours to days.
-Dec GFR, so not excreting nitrogenous substances and wastes
-Accumulation of Creatinine and urea in blood
-Dec Urine production
-ATN is most common cause in surgical patients.
-Can be prerenal (Hypoperfusion, obstructive uropathy)
-Mortality < 10% unless in critical illness or MSOF

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2
Q

What are exogenous nephrotoxins?

A

-Antibiotics (additive effect with other factors)
-Anesthetic agents (Enflurane, Keep Sevo to under 2 MAC hours)
-NSAIDs
-Chemotherapeutic agents (additive effect with other factors)
-Contrast

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3
Q

Who is at increased risk of AKI from Radiocontrast Dye?

A

-Threat to patients with diabetic nephropathy, renal vasoconstriction and renal insufficiency
-May take 24-48 hours to develop and peak at 3-5 days

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4
Q

What are endogenous nephrotoxins?

A

-Inc Calcium
-Uric acid
-Myoglobin (Rhabdo)
-Hemoglobin(hemolysis)
-Bilirubin
-Paraproteins

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5
Q

What is Prerenal Azotemia?

A

High levels of nitrogen compounds such as Urea, Creatinine, etc.
-Reversible if underlying cause is corrected
-Elderly are susceptible due to hypovolemia and renovascular disease
-Inc risk occurs with CHF, Liver dysfunction, and Septic Shock
-May need invasive monitoring to assess intravascular status

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6
Q

What are the causes of Prerenal Acute Renal Failure (decreased RBF)?

A

Absolute Decreases:
-Acute hemorrhage
-GI fluid loss
-Trauma
-Surgery
-Burns

Low Output Syndromes:
-Renal artery stenosis
-Relative decrease
-Sepsis
-Hepatic failure
-Allergic reaction

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7
Q

Describe Renal Azotemia?

A

Occurs when the functional unit of the kidney is injured.
-Categorized according to site of injury
-Renal tubules -> ischemia and nephrotoxins
-Can reverse if underlying cause is corrected.
-Irreversible if ischemia is severe or prolonged.
-Acute interstitial nephritis (allergic drug rxn)

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8
Q

What are the etiologies of Renal Acute Renal Failure?

A

Acute glomerulonephritis
Vasculitis
Interstitial nephritis (drug allergy, infiltrative diseases)

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9
Q

What are the causes of Acute Tubular Necrosis?

A

Ischemia
Nephrotoxic drugs (aminoglycosides, nonsteroidal anti-inflammatory drugs)
Solvents (carbon tetrachloride, ethylene glycol)
Heavy metals (mercury, cisplatin)
Radiographic contrast dyes
Myoglobinuria
Intratubular crystals (uric acid, oxalate)

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10
Q

What are the causes of Post Renal Acute Renal Failure?

A

Urinary outflow tracts obstructed:
-Prostatic hypertrophy or cancer of prostate or cervix
-Bladder carcinoma
-Clot retention or nephrolithiasis

Needs quick diagnosis: Potential for recovery inversely related to duration of obstruction

Treatment: Percutaneous Nephrostomy

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11
Q

What are risk factors for Acute Renal Failure (ARF)?

A

-Co-existing renal dz
-CHF
-Advanced age
-Symptomatic CV disease
-Major operative procedures (CPB, AAA repair)
-Sepsis
-Multi-organ system failure
-Iatrogenic: inadequate fluid volume replacement, delayed tx of sepsis, nephrotoxic drugs or dyes

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12
Q

What are risk factors for Perioperative Renal Failure?

A

Pre-existing Renal insufficiency
Shock
High-risk Surgical Procedures
Nephrotoxin Use

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13
Q

What are examples of pre-existing renal insufficiency that increases risk for periop renal failure?

A

Congestive heart failure
Diabetic nephropathy
Hypertensive nephropathy
Liver failure
Pregnancy-induced hypertension

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14
Q

What are high-risk surgical procedures that increase risk for periop renal failure?

A

Renal vascularization
Aortic cross-clamping
Cardiopulmonary bypass
Urologic surgery
Transplantation
Trauma

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15
Q

What are Nephrotoxins that increase risk for periop renal failure?

A

Aminoglycoside antibiotics
Radiocontrast dyes
Nonsteroidal anti-inflammatory drugs

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16
Q

What are the Neuro complications of ARF?

A

Confusion
Asterixis
Somnolence
Seizures

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17
Q

What are the CV complications of ARF?

A

Systemic HTN
CHF
Pulmonary Edema
Cardiac Dysrhythmias
May have dilutional anemia
Potential for CV Collapse

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18
Q

What are the GI complications of ARF?

A

Anorexia
Nausea
Vomiting
Ileus
GI Bleeding

19
Q

What are the S/Sx of ARF?

A

Generalized Malaise ->
Volume Overload (Dyspnea, edema, HTN) -> Lethargic, Nauseated, confused -> Pulmonary edema, hypoxia, hyperkalemia, acidosis -> Encephalopathy (coma, seizures, death)

By the time of symptom onset, significant kidney injury is occurring

20
Q

What is the anesthetic management for ARF?

A

-Fluid Resuscitation: Colloids or crystalloids (NS) acceptable. Keep MAP > 80 mmHg
-Vasopressors: concern with increased renal vasoconstriction
-Dopamine: not supported by literature to treat/prevent ARF. Do have Dopamine receptors in the nephron. Fenoldopam is better (D1 agonist)
-Mannitol: Improves renal outcomes
-Invasive monitoring: BP and frequent blood gases
-Only life saving surgery

21
Q

Which drugs do you increase the interval in the presence of renal failure?

A

Acetaminophen
Acetylsalicyclic Acid

22
Q

Which drugs do you decrease the dose of in the presence of renal failure?

A

Codeine
Fentanyl
Ketorolac
Meperidine
Methadone
Morphine

23
Q

What do you do to the dose of Al/Remi/Sufentanil in the presence of renal failure?

A

No change in dose (? is this right?)

24
Q

What is Chronic Renal Failure?

A

Progressive, irreversible deterioration of renal function
-Result of a wide variety of diseases. #1 Diabetes #2 HTN
-Manifests as overall inability of kidney to excrete waste products, regulate fluid and electrolyte balance and secrete hormones

25
Q

What are the causes of Chronic Kidney Disease?

A

-Glomerulopathies
-Tubulointerstitial Disease
-Hereditary Diseases
-Systemic Hypertension
-Renal Vascular Disease
-Obstructive uropathy
-HIV

26
Q

What are Glomerulopathies that cause CKD?

A

-Diabetes Mellitus
-Systemic Lupus Erythematosus
-Primary glomerular disease
-Focal glomerulosclerosis
-Membranoproliferative glomerulonephritis
-Membranous nephropathy
-Immunoglobulin A nephropathy
-Amyloidosis
-Postinfective glomerulonephritis
-Wegener’s granulomatosis

27
Q

What are the Tubulointerstitial diseases that cause CKD?

A

Analgesic nephropathy
Reflux nephropathy with pyelonephritis
Myeloma kidney
Sarcoidosis

28
Q

What are the hereditary diseases that cause CKD?

A

Polycystic kidney disease
Alport’s syndrome
Medullary cystic disease

29
Q

What electrolyte imbalances are associated with CKD?

A

Hyperkalemia
Hypermagnesemia
Hyperphosphatemia
Hypocalcemia

Metabolic Acidosis.

30
Q

What are the manifestations of CKD?

A

-Unpredictable intravascular fluid volume status
-Anemia
-Uremic coagulopathy (Inc bleeding time & plt dysfunction)
-Neurologic changes (autonomic dysfunction, encephalopathy, peripheral neuropathy)
-CV Changes (CHF, Dyslipidemia, Systemic HTN)
-Renal osteodystrophy
-Pruritus

31
Q

What are the effects of Anemia on the cardiac system?

A

Heart increases CO in response to anemia
-Increases myocardial demand. Increases risk for CAD.
-Right shift of the Oxy-Hgb Dissociation curve

Tx:
-Base anemia on Hgb rather than Hct and tx with Erythropoietin preop if anemic

32
Q

How do you treat Chronic Renal Insufficiency?

A

-Aggressive tx of underlying cause (DM or HTN)
-Transplant or Dialysis

33
Q

What are the pre-op concerns for a patient with Chronic Renal Insufficiency?

A

-Concomitant drug therapy
-Clinical manifestations of disease
-Glucose management
-Antihypertensive therapy continued
-Dialysis in the 24 hours preceding surgery
-Serum K+ < 5.5 mEq/L (may have to use succ for RSI: patients are at risk for delayed bowel emptying)

34
Q

How much does Succinylcholine increase potassium?

A

By 0.5 - 1 mEq/L

35
Q

What is the induction sequence for a patient with Chronic Renal Insufficiency?

A

-Possible RSI (delayed gastric emptying)
-Slow induction: Labile VS (respond as if hypovolemic)
-Positive Pressure ventilation affects venous return, and will impact blood volume and blood pressure
-Succ and K+ level

36
Q

Which induction agents are terminated by renal excretion?

A

Partially:
-Barbiturates

37
Q

Which muscle relaxants are terminated by renal excretion?

A

Gallamine, Metocurine

Partially:
-Pancuronium
-Vecuronium

38
Q

Which cholinesterase inhibitors are terminated by renal excretion?

A

Partially:
-Neostigmine
-Edrophonium

39
Q

Which cardiovascular drugs are terminated by renal excretion?

A

Digoxin, Inotropes

Partially:
-Atropine
-Glycopyrrolate
-Milrinone
-Hydralazine

40
Q

Which antimicrobials are terminated by renal excretion?

A

Aminoglycosides
Vancomycin
Cephalosporins
Penicillin

Partially:
-Sulfonamides

41
Q

What is the effect of inhalation agents on the cardiac system?

A

Decrease contractility and SVR, causing hypotension.
-Dose-dependent cardiac depressants
-Dec intracellular Ca
-Do produce muscle relaxation, so can reduce dosage of NMB agents. However, worried about cardiac depression.

42
Q

What is recommended for maintenance of anesthesia with Chronic renal insufficiency?

A

-N2O is safe to use
-TIVA is recommended (Short-acting)
-Cisatracurium (Hoffman Elimination)
-Regional is highly recommended

43
Q

What is unique about Cis/Atracurium?

A

Eliminated via Hoffman elimination.
-Non-organ dependent
-Depends on pH and temperature

(Remember: Atracurium causes histamine release)

Principles 2 (45 decks)

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