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CDM 1 Exam 2 > Renal: Lecture 2 > Flashcards

Renal: Lecture 2 Flashcards

1
Q

What to look for in drug induced kidney disease?

A

Still looking for doubling in SCr due to medications

Depends on predisposing factors, not everyone will develop

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2
Q

Combo of drugs that can cause kidney issues

A

“Triple Whammy” = ACEi + Diuretic + NSAID

“Nephrotoxic quartet” = ACEi, NSAID, Aminoglycosides, radio contrast media

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3
Q

“Triple Whammy”

A

due to each drug affecting kidney function through different mechanisms

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4
Q

Diuretic will lead to….

A

decreased fluid volume

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5
Q

ACEi/ARBs will lead to….

A

Efferent dilation

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6
Q

NSAIDs will lead to….

A

afferent constriction

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7
Q

What increase Kidney susceptibility to injury

A

Drug-related factors = what drug does to kidney
Kidney-related factors = what happens in kidney
Host-related factors

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8
Q

Angiotensin II is responsible for ….. of the efferent arteriole

A

Constriction

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9
Q

Prostaglandins are responsible for ….. of the afferent arteriole

A

Dilation

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10
Q

Common medications causing Prerenal AKI

A

NSAIDs
ACE/ARBs
Calcineurin inhib

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11
Q

Renal modulators of Hemodynamic autoregulation

A

Angiotensin II
Prostaglandins
Endothelin and Norepi

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12
Q

Pre-disposing factors for DI pre renal AKI

A

Reduced renal blood flow state
Reduced perfusion pressure due to low volume state

Those who relay on renal modulators to keep normal eGFR, these meds will “tip the balance”

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13
Q

How can diuretics/ hyperosmolar radio contrast dyes tip the balance?

A

decrease blood volume

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14
Q

How can NSAIDs tip the balance?

A

decrease renal prostaglandins

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15
Q

How can ACEi/ARBs tip the balance?

A

alter AT2

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16
Q

Which agents alter calcium and endothelin

A

Radiocontrast agents, Cyclosporine

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17
Q

Which agents cause histamine release with Hypotension

A

Radiocontrast agents

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18
Q

Risk for NSAIDs is primarily in patients with…

A

preexisting low flow/volume states or conditions

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19
Q

Prerenal AKI NSAIDs clinical presentation

A 
Low FeNA <1%
Low urine Na
Urine osm >500
Normal urinalysis
BUN:SCr > 20:1
Oliguric (dark, tea-colored pee)

onset 1-5 days of start/dose increase NSAID
time to recovery ~2-7day, based on mechanism of drug
All NSAIDs should be suspect, indomethacin greatest risk

20
Q

Which NSAID has greatest risk for Prerenal AKI

A

Indomethacin, most potent

21
Q

Prevention and Treatment NSAIDs Prerenal AKI

A

Use analgesics with less PG effect

Use lowest dose of NSAID in high-pt

Avoid potent agents

Discontinue drug, usually reversible state

22
Q

Prerenal AKI - ACEi/ARBs pathogenesis

A

Lower the tone of efferent arteriole, which may be maintaining perfusion pressure in select patients

Reduce intraglomerular hydrostatic pressure leading to reduced filtration in select patient

23
Q

Patients who develop Prerenal AKI from ACEi and ARBs usually have….

A

Severe renal artery stenosis
CHF
CKD

24
Q

Pathogenesis of impaired auto regulation with ACEi/ARBs

A

Blocks AT2 = dilation of efferent arteriole = reduction in back pressure/intraglomerular pressure = decreased perfusion pressure and filtration

25
Q

Prerenal AKI - ACEi/ARBs Risk factors

A 
CHF
CKD (Scr >1.6)
Severe renal artery stenosis
Concomitant diuretic use
concomitant NSAID use
Salt restricted diet/hypoantremia
26
Q

Prevention and Treatment ACEi/ARB pre renal AKI

A

start low, titrate upward slowly (start sort acting agent)

reduce diuretic dose “diuretic holiday”
Counsel patients what to monitor
Monitor SCr and Serum K
Monitor for more than predictable rise in SCr

27
Q

How does radiocontrast media cause pre renal AKI?

A

enhance effects of endothelin (vasoconstriction of afferent), caution in patients with similar predisposing causes

Need to hydrate w/ NaCL prior to dye study

28
Q

How can loop diuretics and metolazone cause prerenal AKI

A

Cause dehydration, monitor body weight daily to assess fluid loss

monitor urine color and frequency

29
Q

Most common drug-induced AKI in inpatient setting?

A

Drug induced ATN

30
Q

Most common medications in drug induce ATN

A

Radiocontrast media

Aminoglycosides

31
Q

Radiocontrast media associated with…

A

dialysis

3rd leading cause of inpatient AKI and 34% inpatient mortality

32
Q

risk factors for ATN w/ Radiocontrast media

A 
underlying diabetic nephropathy or CKD
Age >75
CHF
Volume depletion
Aggressive diuresis
33
Q

radiocontrast pathogenic mechanism

A

cause transient pre renal azotemia (via endotelio) and progressive non-oliguric or oliguric ATN

mechanism complex and not fully understood

34
Q

Which radio contrast media are we generally concerned with?

A

Ionic monomers and dimers

35
Q

Contrast induced nephropathy (CIN)

A

**Defined as increase in SCr by 0.5 mg/dL or 25% from baseline

**Usually begins 24-48hrs after procedure, peak in 3-5 days, returns to baseline in 7-10 days

can extend hospital stay + costs

usually transient and nonoliguric

severe form presents as ATN

36
Q

CIN Pathogenesis

A

1st Renal Hemodynamic changes which can progress into direct tubular toxicity, acute tubular necrosis

37
Q

CIN Risk factors

A

occurs in <2% pop

Highest Risk: DM w/ SCr >1.5, CrCl <60

Other: Age >75, HF, Hypotension, Volume depletion, anemia, high dose of radiocontrast (>140ml) and repeated doses,

38
Q

CIN Risk assessment

A

Chart used to calculate risk of CIN and Risk of Dialysis.

Each risk gets a score and its all added together

39
Q

CIN preventative Strategies

A

Avoidance when possible, consider alternative imaging techniques

If pt req contrast: DC metformin and NSAIDs 48hr prior

Gold standard: pre/post hydration start 12hr before/12hr after for high risk patients 1ml/kg/hr NaCL

40
Q

Has any medical or mechanical treatment been proved to be efficacious in reducing risk of CIN?

A

No

41
Q

Crystal Nephropathy mechanism

A

Precipitation of crystals in distal tubular lumen = obstruct urine flow/create back pressure = illicit interstitial reaction

42
Q

Common meds causing Crystal Nephropathy

A

Antibiotics: Ampicillin, cipro, sulfonamides
Antivirals: acyclovir, foscarnet, indinavir
Methotrexate
Triamterene

43
Q

Risk factors for Crystal Nephropathy

A

Volume Depletion
CKD
Excessive Dose
IV admin

44
Q

Preventing postrenal drug induced AKI

A

DC or reduce dose of drug
ensure adequate hydration
Establish high urine flow
Admin orally when possible

45
Q

General management of Drug induced KD

A

short term: stop progression of kidney damage
Long term: restore normal kidney function

General:
Stop offending agent
avoid concomitant nephrotoxin
maintain hydration
RRT if needed

CDM 1 Exam 2 (16 decks)

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