RENAL-Kidney Failure Flashcards
Pt shows the following, what is most likely DX? What other keys to DDX Rise in serum creatinine Decreased GFR oliguria Active urine sediment Casts Na+ urine cont. changes.
Acute Renal Failure
Duration
Acute - hours to days
Rapidly progressing - weeks to months
Chronic - progressive, months/years
Acute insult on chronic failure
Compare UA, creatinine Sx duration
Hospitalized pt’s close monitoring - daily
Monitor events - hypotension, drugs, contrast
This PT present with..what are the at risk for
Hypotension or hyopvolemia (renal perfusion dfx)
DM, HTN: (out of control l/t ERSD)
Trauma- drugs, contrast, car accident
RA
Vascular Dz
Intrinsic Kidney Disease
AKI, ARF
What test will identify Kidney Problems - Markers?
#1-UA micro BMP 24hr urine Polyuria: >2500ml Oliguria: <500ml Anuria: <100ml (body conserve or AKI) Dialysis
Specific gravity
dipstick/UA: 1.005-1.020
What are normal and ABN Serum Cr on BMP
N-0.6-1.2mg/dl, Skeletal muscle, diet
Inc. = glomerular/tubular injury/Dz, not etiology of problem
GFR ususally reduced by ~50% prior to INc. SCR
Normal- does not equal normal GFR
What is on BMP?
Na/K Cl/CO2 BUN/CR Glucose Cystatin C w/ creatinine-rare, early detect
Pt has GI bleedinng and dehyrdated. What determines etiology of AKI?
BUN to Creatinine Ratio
N- 5-20mg/dl
Elevated in: dehydration renal dz, GI bleeding
What determines CKD? What other markers will be needed?
*Urine Microalbumin-Albumin to creatinine ratio
GFR - (120mL/min)
Dec. implies renal Dz
Progression = CKI
Increase = improvement
Pt has the following Wk 1
ASX
Feel off- weak, fatigue, N, edema, Rare Flank
Urinary sx
decreased GFR (20-50%)
Increased creatinine, renal “insufficiency”
Azotemia
The following week the Pt has the following. Creatinine high, GFR 5-10% Lethargy, Confusion, Seizures Edema Pruitius -no rash N/V-anorexia Cramps, neuropain Anemic Metabolic Acidosis-RR
Uremia
Severe azotemia, renal “failure”
Pt has the following…What stage is present?
Medicatin the l/t hypoperfusion, low resistance and Shock.
Volume depletion - intravascular.Dehydration, blood loss (trauma, GI) burns, hypoalbuminemia
MI, CHF, arrhythmias, PE, PNA,etc. Decreased cardiac output
UA/CMP SrCR inc. SpGr- >1.020 BUN to Creatinine Ratio =/>20/1-Glomeruli, tubules are intact Osmol urine- >500 Na <20 FeNA <1% Bland Oliguria
Prerenal
MC
Acute
“Bland” sediment (no casts)
Reversible, if treated promptly
Acute prerenal on chronic renal failure
What are 3 Intrarenal/Intrinsic Causes?
Glomerular
Tubular
Vascular
Pt has h/o urine sediment*, URI, RA, Mom Hx of IgA nephropathy, DM, etc
BUN to Creatinine ratio also =>20/1 SpGr- >1.020, 1.000 BUN to Creatinine Ratio =/>20/1-Glomeruli, tubules are intact Osmol urine- >500 Na <20 FeNA <1% ***Multiple CAST-RBC Variable
AGN: Acute glomerulonephritis
Intrarenal Cause - Glomerular dz.
Focal: mild AKI – dysmorphic RBC’s, red cell casts (nephritic), mild proteinuria
Diffuse: signif AKI(SCr 4.0) – nephritic w/ heavy proteinuria (nephrotic), HTN, edema
Hospital Elder Pt d/t sepsis from car accident w/ burns, rhabdo, heat stroke, and snake bite in dessert.
Tx not resolving with w/ volume tx d/t Dx of Prenal AKI. BUN/Cr <20/1 (10/1)
Na + urine inc. >2%
Muddy brown, granual, epthtieal casts
BUN to Creatinine ratio also <20/1 SpGr- < 1.000, brown Osmol urine-300 Na >20 FENa high ***Active CAst- WBC, Ftth, Muddy brown Oliguria/Anuria
What is dx? why is volume not helping?
ATN: Acute Tubular Necrosis
Inner kidney can’t filtrate
Pt has h/o inc NSAIDs, Meds d/t RA with current infection of PNA and allergies: fever, rash esinophils
WBC casts, protien, RBC
BUN/CR <20/1
What is the cause and DX
Her Dad has a hx of rapid inc HTN, w. renal artery occulision. Caugh early w/Bruits, emobli
Her mom had Vasciulitis, Thrombocytopenia (HUS/TTP) and sclerodoma
BUN to Creatinine ratio also <20/1 SpGr- < 1.000, brown Osmol urine-<300 Na >20 FENa high ***Active CAst- WBC, Ftth, Muddy brown Oliguria/Anuria
AIN - Acute interstitial nephritis
Intrarenal Causes - Tubular
Dx – renal biopsy but…consider, stop the offender, monitor
Large Vessel Dz:
Small Vessel Dz, Vasculitis common
Hemolytic uremic syndrome
Thrombotic thrombocytopenic purpura
What must occur to DX the PT w/ the following:
oliguria, pain, w/ prostatiis, and Cancer.
US- Stones, blood clots, crystals
BUN to Creatinine ratio also 10/1 or higher SpGr- variable BUN to Creatinine Ratio =/>20/1-Glomeruli, tubules are intact Osmol urine-300 Na <20 FENa high Hematuria Oliguria/Anuria
Post Renal ARF
Must obstruct both kidneys.–Examine body!
What are the ideal was to Estimating GFR @ Bedside
Cockcroft-Gault: Creatinine Clearance (CrCl)-Best for CKD
M-90-140ml/min males;
F- 80-125 females
Modification of Diet in Renal Disease
accurate than CrCl; best for CKD, not acute; commonly used for
GFR >90 normal,
GFR <60 abnormal
CKD-EPI: Chronic Kidney Dz Epidemiology Collaboration
Better in mild Dz; better for risk prediction
Recently: better than CrCl or MDRD
Pediatric GFR
Schwartz formula
24hr urine Creatinine Clearance
What Calculations FENa Distinguishes ATN from Prerenal AKI and advanced AKI only?
FENa = fractional excretion of sodium
Prerenal, AGN <1%
Postrenal =/>1%
ATN: usually high, =/>3%,
AIN variable: 1-3%
What is necessary to Assessing Tubular Function?
What is distinguishes Prerenal vs Tubules?
urine over 24hrs. Na retention = prerenal Na dumping = sick tubules Urine osmolarity Na concentration Fractional Excretion of Na - FENa
A Patient has the following s/s urinary abn, renent travel with illness, the req meds, catheter, contrast imaging?
dizzy, syncope, malaise,edeam weak, n/v? What is difference btwn.
AKI
Volume loss: dizziness, syncope
Urinary abnormalities
The PE showed the following: Toxic ,Vitals: fever, hypotension, tachy? Skin - rash, pettechiae, excoriations HEENT - dehydration Lungs/heart Abdomen - flank pain, bladder, prostate Extremities – edema Neurologic - weakness, reflexes
Workup of AKI Patient
What labs or needed and what order?
Urine – dip, UA w/ micro, culture Chem panel, CBC Spot albumin to creatinine ratio Urine microalbumin Calculate CrCl, GFR 24hr urine collection Urine Na, urine creatinine, urine osmolarity FENa
Pt has the following…What stage is present?
Medicatin the l/t hypoperfusion, low resistance and Shock.
Volume depletion - intravascular.Dehydration, blood loss (trauma, GI) burns, hypoalbuminemia
MI, CHF, arrhythmias, PE, PNA,etc. Decreased cardiac output
UA/CMP SrCR inc. SpGr- >1.020 BUN to Creatinine Ratio =/>20/1-Glomeruli, tubules are intact Osmol urine- >500 Na <20 FeNA <1% Bland Oliguria
Prerenal Correct: volume status, hypotension source of problem: IV fluids, Abx for sepsis Admission: BUN/creatinine, urine volume No need for acute diagnostic imaging (except to investigate cause)
Pt Lab report BUN to Creatinine ratio also <20/1 SpGr- < 1.000, brown Osmol urine-<300 Na >20 FENa high ***Active CAst- WBC, Ftth, Muddy brown Oliguria/Anuria
Intrarenal
Pre- and postrenal causes eliminated Consider admission Remove/Tx offender Renal ultrasound first CT scan of abdomen/pelvis Referral to nephrologist for renal biopsy
PT has s/s of the following, what should you order. Glomerular hematuria with proteinuria Nephrotic syndrome Acute nephritic syndrome Unexplained acute/subacute renal failure Percutaneous procedure - bleeding common
Biopsy detects glomerulonephritis, interstitial nephritis, vasculitis
Contraindications - prior bleeding Dz, hydronephrosis, severe HTN, infection
What must occur to DX the PT w/ the following:
oliguria, pain, w/ prostatitis, and Cancer.
US- Stones, blood clots, crystals
BUN to Creatinine ratio also 10/1 or higher SpGr- variable BUN to Creatinine Ratio =/>20/1-Glomeruli, tubules are intact Osmol urine-300 Na <20 FENa high Hematuria Oliguria/Anuria
Diagnostics - Postrenal
identify cause of obstruction
Post-void residual ultrasound
Catheter to relieve retention
Renal ultrasound to evaluate size, hydronephrosis, structure
CT abd/pelvis W/O contrast for stones,
WITH contrast for tumors
Urologist vs. nephrologist
Pt has New ARF sx New CR>2.0, prenal w/ CKI, CKI sx are worse? What do you do?
Admit
Consult nephrologist early
Outpatient work-up if stable, subacute
Pt has progressive, months to years, ASX, GFR >90 small kidney.
What stage is this Pt?
Nephrons hypertrophy then become sclerotic
GFR and Staging K/DOQI: Stage 1 - GFR >90 - Tx comorbid Dz Stage 2 - GFR 60-89 - follow progress Stage 3 - GFR 30-59 - Tx complications Stage 4 - 15-29 - prepare for dialysis Stage 5 - <15/dialysis - transplant
Who Gets CKD at the highest percentage?
Diabetes - 30-40%
Hypertension - 25-30%
Glomerular Dz - 15-20%
Genetic renal Dz, other
What labs will I run for the following PT ASX, DM oliguria?
BUN/creatinine - progressive increases, Compare
*Estimate GFR to stage pt
Monitor K+
Renal ultrasound - small kidneys
Plain x-rays - renal osteodystrophy
***Subperiosteal resorption = hyperparathyroidism, rare
Pt has all ORGAN systems affected. First had the following:
ASX
Feel off- weak, fatigue, N, edema, Rare Flank
Urinary sx
decreased GFR (20-50%)
Increased creatinine, renal “insufficiency”
Next he had Creatinine high, GFR 5-10% Lethargy, Confusion, Seizures Edema Pruitius -no rash N/V-anorexia Cramps, neuropain Anemic Metabolic Acidosis-RR
Complications of CKD/ESRD Affects nearly all organ systems Azotemia Uremia-Not a lab value or toxidrome “Constellation” of symptoms
This Pt has the following and what is the main cause?
K+ > 6.0
GFR <10-20ml/min (<10%)
oliguric
Hyperkalemia- (get EKG) dialysis non-compliance a big cause Dietary indiscretion NSAID’s, ACE Inhibitors, beta blockers Trauma, acidosis
What is the MC of complication of ERSD?
Cardiovascular
HTN- >200, >120, diff.
D/t NA and water retention
Accelerate atherosclerosis-risk CAD, dyslipideimia
Volume overload -pulmonary edema, CHF
Na and intravascular volume balance is maintained until GFR <10-15ml/min – then fluid overload
(LVH) and dilated cardiomyopathy (DCM) very common – HTN
Acute pulmonary edema = emergent dialysis
Tx w/ loop diuretics, ACEI’s, ARB’s
Be careful with IV hydration in renal failure pt!
What conditions present with the following:
Retention of uremic toxins, fluid overload
Fluid in pericardial sac, restricts ventricular filling
D/T- infectious, neoplastic, autoimmune
emergent dialysis
Cardiac tamponade
Cardiovascular
Pericardial effusion
What is seen in Hematologic CKI complications when ? when GFR <30ml/min
Anemia
Decreased erythrocyte production from Kidney
Normochromic, normocytic – chronic
Common Treat early: recombinant erythropoietin Epogen or Procrit IM
Will platelet count by high or low with Coagulopathies CKI comps?
Platelet count OK but bleeding time prolonged
Treat if symptomatic or prior to surgery
Bleeding is indication for dialysis
Pt w/ CKI has the following what is TX?
Gastrointestinal
Anorexia, nausea, vomiting
Fluid
Diet restriction
GI Bleeding common
Pt present with the following:
GFR 10-15ml/min
Difficulty concentrating to lethargy, confusion, coma
Asterixis, hyperreflexia
Neurologic
Uremic encephalopathy
Accumulation of uremic toxins
Indication for emergent dialysis – reversible
Neuopathies Very common, difficult to treat Paresthesias - stocking/glove pattern Restless leg syndrome Motor involvement - lose DTR’s, foot drop Early dialysis may prevent progression
What are the Mineral Metabolism imbalance with CKI?
HYPOcalcemia,
HYPERphosphatemia
High PTH - secondary hyperparathyroidism
High bone turnover, renal osteodystrophy
Bone pain, spontaneous fractures
TX
Monitor Ca, Phosphorus, PTH
Diet - low phosphorus (no eggs, coke)
Vit D to suppress PTH, increase Ca
Which Hormones are affected in CKI?
Insulin and glucose -Hyper- or hypoglycemia
Thyroid
Low estrogen and testosterone
Impotence and menstrual disorders
Complicated pregnancy - contraception
Pt has the following Sallow appearance, pallor Pruritis Rash-severe, rash white spots on chin. What is the Rash called? Is Pruritis easy to treat?
Pallor from anemia
Pruitis- difficulte
Uremic Frost- rare and severe
What are the Management of CKD?
Treat as Immunocompromised state
Treat reversible causes
Involve nephrologist early in course
Renal-protective measures
HTN, DM control
ACE inhibitors, ARB’s to slow progression
Nutritionist: low Na, K, protein, phosphorous
Smoking/drug cessation
Identify and prepare pt for dialysis
Dialysis
Hemodialysis
Blood from body, thru A-V shunt
Semiperm membrane, dialysate
Blood returned to body
3x/week, 3-4 hour process
Peritoneal dialysis
Dialysate into perioneal cavity, peritoneal membrane acts as dialyzer
At home, ambulatory, continuous
Indications for Dialysis
K/DOQI rec’s (non-emergent)
Non-DM - GFR <10ml/min, Cr 8
DM - GFR <15ml/min, Cr 6
Emergent indications Hyperkalemia (refractory) Fluid overload (refractory to diuretics) Pericardial effusion, coagulopathy (bleeding) Severe metabolic acidosis Uremia SX: Encephalopathy, neuropathy, seizures
Renal Transplant
Treatment of choice for ESRD
Successful = improved quality of life and reduced mortality risk compared to dialysis
Not all patients appropriate candidates
Refer to transplant program when dialysis is initiated (2-3 years wait)
