TOPIC 3: therapy of acute kidney injury

Question 1

General measures

Answer 1

1. Volume status assessment:
   - urine volume
   - non visible JVP
   - poor skin turgor
   - hypotension, tacchycardia
2. Signs of volume overload:
   - hypertension
   - increased JVP
   - Lung crepitations
   - peripheral edema
   - cardiac gallop
3. K+ containing fluids should be avoided unless pt is hypokalemic
4. stop nephrotoxic drugs: NSAIDS, ACEi, Gentamicin, amphotericin
5. stop metformin if creatine is >150mmol/L
6. check and adjust doses of renally excreted drugs

Question 2

Therapy for pre-renal AKI

Answer 2

1.if volume depletion–> fluid resuscitation with crystalloids
(aqueous solution of mineral salts or other water soluble molecules eg saline) and this may reverse the injury

2.stop drugs such as NSAIDS, ACEi that had caused the vasoconstriction.

3. in effective volume depletion (edema and ascites in CHF or nephrotic sy:
   - Na+ and water depletion
   - Loop diuretics (furosemide)
   - optimize cardiac function
   - stop drugs

Question 3

Therapy for post-renal AKI

Answer 3

• cathetirization or transrenal drain

- to buy time in case of mass eg surgery you can add retrograde stents or nephrostomy insertion with cystoscopy

Question 4

Therapy for intrinsic AKI

Answer 4

• stop drugs

- treat hypoxia, pre renal disease or sepsis or systemic disease

Question 5

Managing complications

Answer 5

1. hyperkalemia (insulin with glucose, calcium and loop diuretics- K+ wasting diuretics eg furosemide)
2. pulmonary edema (diuretics)
3. uremia (dialysis if encephalopathy or pericarditis if not them just treat symp.)
4. acidemia ( sodium bicarbonate orally or IV or dialysis)

Question 6

Prognosis of AKI

Answer 6

-depends on early recognition and intervention
-more prolonged insult, less likely to recover
burns mortality = 80%
medical illness=30%
poisoning/obstetric=10%