Acute Renal Failure

Front 1

What type of AKI has a high survival rate of 70-95%

Back 1

community acquired AKI

Front 2

What AKI has a high mortality rate and has a most common etiology of prerenal?

Back 2

Hospital acquired AKI

Front 3

What kind of AKI accounts for 18-33% of hospital occurrences?

Back 3

Drug-induced

Front 4

20-60% of all AKI patients will require what kind of initial therapy?

Back 4

dialysis (25% of those will progress to chronic renal insufficiency, requiring long-term dialysis)

Front 5

What is the main participant in regulating a constant extracellular balance?

Back 5

kidney

Front 6

When the kidney has achieved a steady state of extracellular balance, what is the rate of excretion equal to?

Back 6

intake + endogenous production OR gfr

Front 7

What are the normal GFRs (m&f)?

Back 7

130-145L/d women and 165-180L/d men

Front 8

What are the three main functions of the kidney?

Back 8

main participant in regulating a constant extracellular balance, hormone secretion, gluconeogenesis/peptide catabolism

Front 9

What is prerenal AKI?

Back 9

results from decreased renal perfusion

Front 10

What is intrinsic AKI?

Back 10

results from structural damage to the kidney

Front 11

What is postrenal AKI?

Back 11

results from obstruction of urine flow from the renal tubule to the urethra

Front 12

What is the kidney responsible for secreting?

Back 12

renin, prostaglandins, kinins, erythropoietin

Front 13

What is the kidney responsible for metabolizing?

Back 13

Vit D (final metabolism to active form, first metabolism occurs in liver)

Front 14

What are the 3 basic physiologic events for the production and elimination of urine?

Back 14

1. Delivery of blood flow to glomeruli
2. Formation and processing of ultra filtrate by the glomerulus and tubular cells
3. Urine excretion through the ureters, bladder, and urethra

Front 15

What is GFR?

Back 15

excretion rate of toxins and drugs (slides); is the volume of fluid filtered from the renal (kidney) glomerular capillaries into the Bowman's capsule per unit time (wiki)

Front 16

What is the time frame fro GFR decline and associated uring output drop and AKI?

Back 16

generally occurs over hours to days but can occur over weeks

Front 17

What are the clinical definitions for AKI?

Back 17

imcrease in Scr of 0.5mg/dL over 24h when baseline Scr < 3, increase in Scr of 1 mg/dL over 24h when baseline Scr >=3mg/dL, decrease of >50% of baseline CrCl

Front 18

What is True GFR?

Back 18

total filtration rate x number of functioning nephrons

Front 19

What three factors maintain glomerular pressure?

Back 19

1. Arterial pressure
2. Afferent arteriolar resistance 3. Efferent arteriolar resistance.

Front 20

What happens during afferent arterilolar constriction at the glomerulus?

Back 20

increased vascular resistance, decreased intraglomerular pressure, decreased gfr

Front 21

What happens during efferent arterilolar constriction at the glomerulus?

Back 21

increased vascular resistance, increased intraglomerular pressure, increased GFR

Front 22

Where does the ultrafiltrate go after leaving the glomerulus?

Back 22

proximal tubule

Front 23

What is the best method for assessing renal function in acutely ill, renally unstable patients?

Back 23

urine formation

Front 24

In renal function decline, what phase occurs over <1-2 days after initial insult?

Back 24

oliguric phase

Front 25

In renal function decline, what phase is a period of increased urine production that occurs only after cause of injury is removed or reduced?

Back 25

diuretic phase

Front 26

In renal function decline what phase is characterized by several weeks to months in length, return of normal kidney function, and normalization of urine production?

Back 26

recovery phase

Front 27

Does the recovery phase occur in all renal function decline cases?

Back 27

No

Front 28

What are patient risk factors for AKI?

Back 28

co-morbid disease that increase kidney injury, volume depletion, urinary tract obstruction, age > 60, male gender, infection, cancer, previous history of AKI, pre-existing renal dysfunction

Front 29

What are possible medication related risk factors for AKI?

Back 29

IV radiographic contrast, nephrotoxic abx drugs, nsaids, angiotensin-converting enzyme (ACE), angiotensin II receptor blockers (ARBs)

Front 30

Why is a decline in renal excretion bad?

Back 30

reduces toxin elimination, promotes retenetion of BUN&creatinine&urea, presons will then begin to show symptoms of this accumulation and increases chances for severe morbidity and death

Front 31

In rifle risk category, what is the GFR/Scr criteria?

Back 31

increased Scr by 50% or decreased GFR by 25%

Front 32

In rifle risk category, what is urine output criteria?

Back 32

UOP < 0.5 ml/kg/h x 6 h

Front 33

In rifle injury category, what is urine output criteria?

Back 33

Scr increased 100% or GFR decreased 50%

Front 34

In rifle injury category, what is urine output criteria?

Back 34

UOP < 0.5 ml/kg/h x 12h

Front 35

In rifle failure category, what is urine output criteria?

Back 35

UOP < 0.3 ml/kg/h x 24 h or anuria x 12 h

Front 36

in rifle loss category, what is the general criteria?

Back 36

persistant ARF > 4 wks

Front 37

In rifle ESRD category, what is the general criteria?

Back 37

ESRD > 3 months

Front 38

What is the clinical presentation in AKI?

Back 38

changes in urine ouput, signs of hypovolemia, unique color and composition of urine (cola-colored suggests bleeding, foaming suggest proteinuria), symptoms of uremia, flank pain, increased weight, increased blood pressure, signs/symptoms of electrolyte abnormalities, bladder distention or prostate enlargement

Front 39

In clinical presentation of AKI, what is the progression of musculoskeletal and neurologic s/sx?

Back 39

weakness --> peripheral neuropathy --> renal osteodystrophy or seizures

Front 40

In clinical presentation of AKI, what is the progression of hematologic s/sx?

Back 40

platelet dysfunction --> anemia

Front 41

In clinical presentation of AKI, what is the progression of electrolytes s/sx?

Back 41

hyponatremia or metabolic acidosis --> edema or hyperphosphatemia --> hypocalcemia

Front 42

In clinical presentation of AKI, what is the progression of cardiovascular s/sx?

Back 42

fluid overload --> hypertension or hyperlipidemia

Front 43

In clinical presentation of AKI, what is the progression of dermatologic s/sx?

Back 43

itching --> worsening itching --> rash/inflammatory skin reactions

Front 44

In clinical presentation of AKI, what is the progression of endocrine s/sx?

Back 44

erythropoetin secretion reduction --> infertility in women

Front 45

What are the monitoring parameters for AKI?

Back 45

urine output, GFR, labs (bun, scr, Na, K, Cl, total C02, calcium, uric acid, phosphate, hematocrit), urinalysis, renal biopsy

Front 46

What in nonoliguric in ml/d?

Back 46

urine output > 500ml/d

Front 47

What in oliguric in ml/d?

Back 47

urine output < 500ml/d

Front 48

What in anuric in ml/d?

Back 48

urine ouput < 50ml/d

Front 49

What is the result of a reduction in urine output on scr?

Back 49

increased accumulation

Front 50

What is the single most important calculation that you will as a pharmacist (will use) on a daily basis in the evaluation of patient clinical presentation? :P

Back 50

Estimated Gfr

Front 51

What is estimated gfr equal?

Back 51

calculated CrCl

Front 52

What is normal BUN?

Back 52

7.0-20mg/dL

Front 53

What is normal Scr?

Back 53

0.6-1.2 mg/dL

Front 54

What is normal Na?

Back 54

135-145 mEq/L

Front 55

What is normal K?

Back 55

3.6-5.0 mEq/L

Front 56

What is normal Cl?

Back 56

98-108 mEq/L

Front 57

What is normal total C02 (HC03)?

Back 57

22-38 mEq/L

Front 58

What is normal calcium?

Back 58

8.5-10.5 mg/dL

Front 59

What is normal uric acid?

Back 59

2-7 mg/dL

Front 60

What is normal phosphate?

Back 60

2.6-4.6 mg/dL

Front 61

What is normal hematocrit (male)?

Back 61

40-50%

Front 62

What is normal hematocrit (female)

Back 62

35-45%

Front 63

What is the Cockcroft-gault equation?

Back 63

CrCl ml/min = ((140-age)(IBW)) / (72*Scr); multiply product by 0.85 if female

Front 64

What does Cockcroft-Gault equation assume?

Back 64

stable renal function

Front 65

In calculating CrCl, when should you uses actual body weight?

Back 65

if actualy body weight is less than IBW

Front 66

What is the calculation for IBW (males)?

Back 66

Males (kg) = 50kg + 2.3(for each inch >5ft)

Front 67

What is the calculation for IBW (females)?

Back 67

Females (kg) = 45kg +2.3 (for each inch > 5ft)

Front 68

What is a non-pathological occurrence that can yield a increased BUN?

Back 68

high protein diet

Front 69

In prerenal ARF, what are some causes of intravascular volume depletion?

Back 69

excessive diuresis, hemorrhage, dever diarrhea, loss of intravascular fluid into the extravascular space "third spacing"

Front 70

In prerenal ARF, what are some causes of decreased systemic circulation?

Back 70

congestive heart failure, cirrhosis, nephrotic syndrome, hepatorenal syndrome

Front 71

In prerenal ARF, what are some causes of systemic vasodilation?

Back 71

sepsis, liver failure, anaphylaxis

Front 72

In prerenal ARF, what are some causes of large vessel renal vascular disease?

Back 72

renal artery thrombosis, renal artery stenosis

Front 73

What are possible drug-induced causes of prerenal ARF?

Back 73

NSAIDS, ace inhibitors, arbs, cox-2 inhibitors, cyclosporin, tacrolimus, diuretics, radiocontrast dye

Front 74

How do nsaids cause auto-regulatory failure in AKI?

Back 74

decrease formation of prostaglandin precursors which usually prevent the over vasconstriction in the kidney

Front 75

How can ACEi cause AKI?

Back 75

Prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor.
Results in decreased levels of angiotensin II.
Causes an increase in plasma renin activity and a reduction in aldosterone secretion. Ultimately blocks ability of kidney to self regulate

Front 76

What were the four listed in class types of intrinsic ARF?

Back 76

Vascular damage, glomerular damage, tubular injury, acute interstitial nephritis

Front 77

What can cause vascular damage during intrinsic ARF?

Back 77

inflammation, emboli, medications (amphetamines, cisplatin, cyclosporin, mitomycin C)

Front 78

What can cause glomerular damage during intrinsic ARF?

Back 78

systemic lupus erythematosus, medications (heroin, lithium, Nsaids, phenytoin)

Front 79

What can cause tubular damage during intrinsic ARF?

Back 79

Ischemia, acute tubular necrosis, toxins

Front 80

For tubular injury of intrinsic ARF, what are the causes of acute tubular necrosis?

Back 80

90% of intrinsic cases - caused by intrarenal vasoconstriction, direct tubular toxicity, intratubular obstruction, or prolonged ischemia from pre-renal causes

Front 81

what are the sources of toxin induced tubular injury during intrinsic ARF?

Back 81

Endogenouos (myoglobin, hemoglobin, uric acid) or exogenous (medications - aminoglycosides, amphotericin B, chemo, cidofocvir, cocaine, foscarnet, radiocontrast dye, tacrolimus; ethylene glycol, pesticides

Front 82

During instrinsic AKI, what are the causes of acute interstitial nephritis?

Back 82

ischemia, infections, medications (PCN, sulfas, NSAIDS, lithium, cyclosporin, tacrolimus)

Front 83

During postrenal AKI, what are the possible causes of obstruction?

Back 83

crystal deposition in renal tubules, ureteral tumor or stricture or stones, bladder carcinoma, bladder neck obstruction secondary to prostatic hypertrophy

Front 84

During postrenal AKI, what are the possible medicinal causes?

Back 84

obstructive: acyclovir, methotrexate, uric acid; nephrolithiasis: allopurinal, indinavir, sulfadiazine, triamterene

Front 85

What is the rph role AKI?

Back 85

medication hx, patient assessment of risk factors and pmh and hpi, estimate GFR, dose meds based off of renal function (Scr can NOT be the only determinate for the dose), recognize AKI early

Front 86

What is normal GFR?

Back 86

100-125ml/min/1.73m^2

Front 87

What population is Scr an unreliable marker in?

Back 87

elderly, malnourished, children, critically ill

Front 88

During urinalysis, what does a high specific gravity, osmolality suggest?

Back 88

high values indicate prerenal causes and stimulation of sodium and water retention

Front 89

During urinalysis, what does urine sediment mean?

Back 89

hyaline casts normal; granular casts and cellular debris suggest structural damage

Front 90

During urinalysis, what does WBC mean?

Back 90

suggests inflammation

Front 91

During urinalysis, what does eosinophils mean?

Back 91

associated with acute allergic intersitial nephritis

Front 92

What is the measure for microalbuminuria?

Back 92

>30mg/24h

Front 93

What is the measure for overt proteinuria?

Back 93

>300mg/24h

Front 94

What is the equation for the calculation of fractional excretion of sodium?

Back 94

FEna = ((Una X Scr) / (Ucr X Sna)) x 100

Front 95

What is the advantage of fractional excretion of sodium calculation?

Back 95

differentiating prerenal from acute intrinsic renal failure

Front 96

If the fractional excretion of sodium yields a value <1% in AKI, what does it mean?

Back 96

suggests retention of sodium and water -> prerenal etiology versus intrinsic cause

Front 97

In prerenal and function, what are the possible physical examination findings?

Back 97

hypotension, dehydration, petechia if thrombotic, ascites

Front 98

In intrinsic, what are the possible physical examination findings?

Back 98

rash, fever

Front 99

In postrenal, what are the possible physical examination findings?

Back 99

distended bladder, enlarged prostate

Front 100

In prerenal and function, what is the BUN/Scr ratio?

Back 100

>20:1

Front 101

In intrinsic, what is the BUN/Scr ratio?

Back 101

15:1

Front 102

In postrenal, what is the BUN/Scr ratio?

Back 102

15:1

Front 103

In prerenal and function, what is the Urine sodium?

Back 103

<20 mEq/L

Front 104

In intrinsic, what is the Urine sodium?

Back 104

>40 mEq/L

Front 105

In post renal, what is the Urine sodium?

Back 105

>40 mEq/L

Front 106

What is the fractional sodium excretion in prerenal and functional?

Back 106

<1%

Front 107

What is the fractional sodium excretion in intrinsic?

Back 107

>2%

Front 108

What is the fractional sodium excretion in postrenal?

Back 108

variable

Front 109

What is the urine sediment in prerenal and functional?

Back 109

hyaline casts, may be normal

Front 110

What is the urine sediment in intrinsic?

Back 110

muddy brown granular casts, tubular epithelial casts

Front 111

What is the urine sediment in postrenal?

Back 111

variable, may be normal

Front 112

What is the urine WBC in prerenal and functional?

Back 112

negative

Front 113

What is the urine WBC in intrinsic?

Back 113

2-4+

Front 114

What is the urine WBC in postrenal?

Back 114

variable

Front 115

What is the urine RBC in prerenal and functional?

Back 115

negative

Front 116

What is the urine RBC in intrinsic?

Back 116

2-4+

Front 117

What is the urine RBC in postrenal?

Back 117

1+

Front 118

What is the proteinuria in prerenal and functional?

Back 118

negative

Front 119

What is the proteinuria in intrinsic?

Back 119

positive

Front 120

What is the proteinuria in postrenal?

Back 120

negative

Front 121

What are the desired goals of therapy in AKI?

Back 121

recognize aki early, anticipate and prevent potential problems, remove primary cause of acute renal failure, limit further nephrotoxic exposures/events, correcnt and maintain euvolemia (restore electrolyte and acid-base balance), regain life-sustaining renal function

Front 122

What are the non-pharmacologic prevention points in AKI?

Back 122

hydration (prevent vascular depletion), hydration and sodium loading prior to amphotericin or contrast dye admin, slow infusion rate of amphotericin B, use liposomal formulation of amphotericin B as is less nephrotoxic

Front 123

What are the EBM nephrotoxic preventive drugs mentioned?

Back 123

acetylcystein (most common; 600mg po bid on day before contrast dye), theophylline (not common; 200mg IV 30 mins prior to radiocontrast dye), insulin (maintains tight glycemic control which is associated with 41% reduction in ARF)

Front 124

What are the non-EBM nephrotoxic preventive drugs mentioned?

Back 124

dopamine, loop diuretics, fenoldopam

Front 125

In established ARF, what is the treatment goal?

Back 125

eliminate further harm to kidneys, prevent extension of injury

Front 126

What are the indications for renal replacement therapies?

Back 126

AEIOU - Acidosis, Electrolyte abnormalities, intoxication, volume overload, uremia (BUN > 100mg/dl) or uremic symptoms

Front 127

What is the goal urine output in diuretic use for ARF?

Back 127

0.5-1ml/kg/h

Front 128

What is used to produce diuresis in patients with ARF?

Back 128

mannitol and loop diuretics (reserved for fluid-overloaded patients who make adequate urine in response to diuretics)

Front 129

What are the proposed mechanisms of benefit in mannitol for diuresis in AKI?

Back 129

increased filtration pressure, improved urine flow rates, reduced tubular cell inflammation, improved renal blood flow caused by a decrease in renal vascular resistance; BENEFIT NOT established

Front 130

Who should not get mannitol?

Back 130

anuric or oliguric patients ---> hyperosmolar state

Front 131

What is the moa of loop diuretics?

Back 131

decrease tubule obstruction and cause renal vasodilation resulting in increased renal blood flow by affecting the ascending limb of loop of Henle to increase solute diuresis

Front 132

What were the loop diuretics mentioned in class?

Back 132

bumetanide, furosemide, torsemide, ethacrynic acid (typicall reserved for patients with sulfa compound allergies)

Front 133

What is the equipotent dosing for furosemide, torsemide, and bumetanide?

Back 133

furosemide 40mg = torsemide 20mg = bumetanide 1mg

Front 134

What are the ADEs of loop diuretics?

Back 134

worsen ARF, electrolyte abnormalities, ototoxicity

Front 135

What is the most commonly used loop diuretic?

Back 135

furosemide

Front 136

What are used synergistically with loop diuretics for resistant edema and fluid overload?

Back 136

metolazone and chlorothiazide

Front 137

What is an advantage of metazolone over other thiazide diuretics?

Back 137

effective at GFR <20 ml/min; other diuretics generally not effective at GFR this low

Front 138

What is the dosing for metolazone?

Back 138

5-10mg po

Front 139

What is the dosing for chlorothiazide?

Back 139

500-1000mg IV

Front 140

What meds are used in acute tx of hyperkalemia?

Back 140

calcium gluconate (protects heart), insulin (shifts K out of vascular space and into cells), albuterol (shifts K into the cells), lasix (increases renal excretion of K), kayexalate (removes K from gut in exchange for sodium)