Week 3 Flashcards
definition of AKI?
GFR reduced abruptly (<48 hrs) w/sudden retention of normally cleared endogenous and exogenous metabolites
death dt AKI occurs how?
due to acidosis, high K, fluid accumulation
groups at increased risk of AKI and KD failure?
DM T2, those w/HTN, geriatrics
general presentation of AKI?
Azotemia (N&V, malaise, altered sensorium) Arrythmias from hyperkalemia
Ecchymoses from platelet dysfunction Pericardial effusion, cardiac tamponade
Seizures from electrolyte imbalance Fasciculations and muscle cramps
Perioral paresthesias from hypocalcemia Peripheral edema
Skin/nail pallor Hyper- or hypo volemia
general lab findings w/AKI?
increased serum Cr
decreased urine output (<0.5 mL/kg/hr)
BUN rises first
MC type of RF?
prerenal failure
causes of prerenal failure?
decreased intravascular volume
changes in vascular resistance
low CO
ssxs of prerenal failure?
dehydration, thirst, dizziness, mental status changes
poor skin turgor, collapsed neck veins, dry mucous membranes, hypotensive, orthostatic BP changes, tachycardia
Oliguria (<400ml/d) (IF<100 mL emergency!)
Dipstick: little protein, SG >1.020
Normal microscopic UA: no cells or casts seen Urine osmolality (>350 mOsm/kg)
Urine sodium < 20 mEq/L
FeNa <1%
HIGHER BUN/creatinine >20:1 (faster inc in BUN–azotemia)
prerenal failure UA findings
management and tx of prerenal failure?
tx underlying cause
rapid fluid replacement, IV vol expansion
may need vasopressor drugs (dopamine) to elevate BP and increase renal flow
discont anti-HTN or diuretics
support for reperfusion to KDs: silymarin, garlic
prognosis of prerenal failure?
good and reversible if not damage to renal cells persists and renal blood flow doesn’t fall below 20% of normal
causes of intrarenal failure?
injury in renal tubules, interstitium and vasculature leading to loss of fxn ATN AIN acute GN acute PN vascular diseases
presentation of intrinsic renal failure?
salient hx of URI, diarrhea use of abx or IV drugs back pain, gross hematuria, fever (PN) maculopapular rash (possible with AIN) dehydration and shock
UA: SG <1.010 if tubular cz, ≥1.020 if glomerular cz Urine osmolality; <300 mOsm/kg
Urine sodium >30 mEq/L if tubular cz, <20 if glomerular cz
FeNa >2-3%
Casts: Granular=ATN, AIN
WBC casts=PN
RBC casts=PSGN
Eosinophiluria=AIN
CBC: anemia or infection
CMP: Inc BUN and Creatinine levels
BUN/Creatinine ratio is LOWER: 10-15:1 (as Cr rises)
Early in course Cystatin C will rise when creatinine is still normal (more specific marker)
Dec serum complement, circulating immune complexes
Renal BX will show characteristic changes
intrarenal failure
postrenal failure is dt what?
urinary flow from BOTH KDs obstructed which leads to increased nephron intraluminal back P and decreased GFR
causes of postrenal failure?
obstruction of urine flow dt prostatic enlargement, tumors, urolithiasis, renal V stenosis, neurogenic bladder, post-surgical or trauma, meds
ssxs of postrenal failure?
renal pn and tenderness, lower abd pn, post-surgery urine lead, over-hydration, edema, ileus w/abd distention, enlarged prostate on DRE, distended bladder
Lab: urine osmolality variable; Urine spec gravity >1.010 early, <1.010 late Urine sodium <20 early, >40 late high BUN and creatinine, BUN/Cr 10-20 Microscopic UA: crystals or hematuria US: may show hydronephrosis Cystoscopy may show ureteral obstruction CT or MRI may show mass causing obstruction, hydronephrosis, kinked ureter, Contrast agent-use
postrenal failure
management and tx of postrenal failure?
rapidly tx the obstruction with catheterization or stent
general pt management for all types of AKI/ARF?
determine and treat cause
assess pts vital force
initiate appropriate referral
assess degree of uremia, electrolyte/mineral imbalance and HTN
assess need for ECG, CXR
cystatin C to monitor KD injury
protein intake decreased
monitor vitals, fluid intake and urine output daily; monitor BUN/Cr, electrolytes until stable and then 2-3x/wk with total protein, albumin, glucose, Hct, Hgb 3x/wk
consider rheum, salvia, cordyceps, urtica
antioxidants and anti-inflammatories: vit C, vit E, CoQ10
remove food allergens
support reperfusion: Renafood, silymarin, garlic
criteria for CKD?
GFR < 60 mL/min per 1.73m^2
common causes of CKD?
glomerulopathies tubulointerstitial nephropathies heredity obstructive nephropathy vascular abn
general symptoms of CKD?
HTN, edema, osteodystrophy, anemia of chronic dz, uremia
symptoms of uremia? General Skin ENT Eye Pulmonary CV GI GU Neuromuscular Neurologic/ME
Fatigue, weakness Pruritis, easy bruising Metallic taste, epistaxis SOB Dyspnea on exertion, retrosternal pn on inspiration Anorexia, N&V, hiccup Nocturia, impotence Restless legs, numbness, cramps in legs Irritability, poor concentration depression
signs of uremia? General Skin ENT Eye Pulmonary CV GI GU Neuromuscular Neurologic/ME
Sallow-appearing Pallor, ecchymosis, edema Urinous breath Pale conjunctiva Crackles, pleural effusion Hypertension, cardiomegaly, friction rub Isosthenuria Stupor, asterixis, myoclonus, peripheral neuropathy
stages of CKD?
1 GFR >90 - normal or high
2 GFR 60-89 - mildly decreased
3a GFR 45-59 - mildly to moderately decreased
3b GFR 30-44 - moderately to severely decreased
4 GFR 15-29 - severely decreased
5 GFR <15 - kidney failure
treatment considerations for CKD
monitor BP/temp/pulse/weight optimize nutrition limit protein, Na, Ph; optimize Ca maintain close Ca and Ph balance; keep Ca x Ph below 65 to avoid metastatic calcifications monitor fluid intake and urinary output keep emunctories functioning (charcoal enema, skin brushing, hot mud baths, fever tx, salt bath, mineral bath, wet sheet wrap) support diuresis as needed tx and control: HTN, hypercholesterolemia, hyperglycemia support blood vessel integrity: vaccinium, cratageus, quercetin, bioflavonoids decrease or eradicate renal inflammation: anti-inflam diet, fish oil, ground flax, Salvia, panax, gingko, urtica carnitine replenish tyrosine renal protomorphogen epoetin alfa good quality multivitamin uva ursi, juniper, solidago, eupatorium protective antioxidants - curcumin, coptic, CoQ10, vit C, ALA PUFAs melatonin 3 mg homeopathics diathermy to KDs, COPs gentle resistance exercise manipulation smoking cessation acupuncture/acupressure/ ear seeds mindfulness meditation monitor thyroid fxn, heart fxn, hormones
major indications for dialysis?
ARF, CRF (Cr clearance <8 mL/min), anuria
two forms of dialysis?
peritoneal (intracorporeal)
extracorporal (hemodialysis and hemofiltration)
a. Can do at home or in the office
b. One year of treatment can cost $53,000.
c. Risk of peritoneal infection.
peritoneal dialysis
a. Dialysis unit 3-4 hrs/d, 3-4 times per wk (some possibility of home)
b. One year of treatment can cost $72,000
c. Requires artificial AV shunt
extracorporeal dialysis
3 forms of peritoneal dialysis?
CAPD
CCPD
IPD
indications for peritoneal dialysis?
ARF awaiting hemodialysis infxn in CRF pts long-term home care for non-ambulatory pts, elderly, kids preoperatively to transplant
benefits of peritoneal hemodialysis over extracorporal?
peritoneal reduces protein loss, much better control of K and Ph levels and rarely need water and Na restriction b/c 2 L/d removed in peritoneal fluid
SEs of peritoneal hemodialysis
large amount of CHOs –> hyperglycemia, obesity, dyslipidemia, hypotension from sodium depletion, decreased appetite
hypokalemia
infections and sepsis
perforate an abd organ
chronic use can cause sclerosis, BO, hypothyroidism, seizures, pneumonia, hypoalbuminemia, arrhythmias
protective and replacement herbs and nutrients for pt on peritoneal hemodialysis?
carnitine, fish oil, pantethine, iron citrate or bisglycinate, pyridoxine and cobalamin, biotin, vit E, capsaicin for pruritus
EPO to offset anemia
anabolic steroid to stimulate EPO and counter sarcopenia
extracorporeal hemodialysis requires what concomitant txs? each tx can cause what?
heparin to offset clots
each tx reduces BUN by 50%, relieves hyperK, corrects metabolic acidosis but all are fleeting effects
SEs of extracorporal hemodialysis?
nutritional deficiencies fever and sepsis seizures hyperhomocysteinemia hypotension muscle cramps/restlessness hyperlipidemia arrhythmias insomnia hypoalbuminemia pruritus dementia
concomitant therapies with extracorporal hemodialysis?
moderate protein restriction sufficient carb to maintain kcal water 400-500 mL plus urine lost/d restrict K, Na EFA supplementation water soluble vitamin supplementation
advantages and disadvantages of renal transplant?
advantages: reestablishment of nearly normal constant body physiology and chemistry
dis: BM suppression, susceptibility to infxn, cushingoid body habitus, psychological uncertainty of homograft’s future, later there can be dz in transplanted KD, increased incidence of CA, GU infxn
post renal transplant support?
fish oil to decrease thrombosis
control HTN, hypercholesterolemia, hyperglycemia
support bvs
supportive care: CoQ10, centella, rheum, salvia, magnesium
protect KD and liver from cyclosporine: gingko, cordyceps, silybum
treat cyclosporine induced gout: flaxseed oil, urtica
decrease risk of rejection: ginkgo, silybum, fish oil
protect from renal re-perfusion injury: ALA, quercetin, curcumin, NAC, coptis, garlic
