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26 Cards in this Set
- Front
- Back
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What is anuria?
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Less than 50ml/24 hours
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What is oliguria?
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50-500ml/24 hours
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What is non-oliguric?
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More than 500ml/24 hours
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How do you classify prerenal AKI
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Hypoperfusion to the kidney
Can be caused by systemic hypoperfusion: hemorrhage, volume depletion, drugs, CHF Urinanalysis will be normal but concentrated Serum BUN/Scr ratio: >20:1 Low FENa, low urine Na High urine osmolarity |
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How do you classify functional AKI
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Kidney undamaged, often lumped with prerenal
Caused by reduced glomerular hydrostatic pressure In general, medication related (cyclosporine, ACEI, NSAIDS) or patients with ineffective bloodflow (CHF, liver dx) Serum BUN/Scr ratio: >20:1 Low FENa, low urine Na High urine osmolarity |
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Intrinsic AKI
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Kidney is damaged, but common cause is acute tuberular necrosis
Serum BUN/SCr ratio: 15:1 Urine Na>40, FENA>2 Low urine osmolarity |
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Postrenal AKI
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Kidney is undamaged, bladder outlet obstruction is most common cause
Serum Bun/SCr ratio: 15:1 Urine Na >40meq FENA>2 Low urine osmolarity |
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How do you treat established AKI
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Prerenal:
- Normal saline if volume depleted -pressure management -blood products Intrinsic: - Eliominate causative hemodynamic abnormality or toxin, fluid and elyte managemment Postrenal: - relieve obstruction |
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What is the medical therapy for AKI
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1) Fenoldopam - may reduce the need for renal RRT
2) Atrial natriuretic peptide: may reduce need for renal RRT 3) Loop diuretics: consider for oliguric and euvolemic or hypervolemic patients |
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What are the most common causes of acute tubular necrosis
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Aminoglycoside, cyclosporine, amphB, diuretics
Radiographic contrast Cisplatin/carboplatin AmphoB |
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How do you prevent radiographic contrast type nephrotoxicity
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Hydration, begin 6-12 hours before procedure
Avoid diuretics Acetylcysteine - antioxidant and vasodilatory Ascorbic acid: give 3g before procedure and 2gm BID x 2 doses after procedure Theophilline - potentially preventative |
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How do you prevent cisplatin/carboplatin nephrotoxicity
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Hydration
Amifostine: cisplatin chelating agent |
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How do you prevent Amphotericin nephrotoxicity
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Avoid nephrotoxins
IV hydration Use liposomal product in high risk patients |
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Hemodynamically mediated kidney failure causes
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Results from a decrease in intraglomerular pressure through the vasoconstriction of afferent arterioles or the vasodilation of efferent arterioles
1) ACEI 2) NSAIDS 3) Cyclosporine/tacrolimus |
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What NSAIDS can you use that causes less prostaglandin synthesis in the kidney
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Sulindac
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What is tubulointerstitial disease
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Involves the renal tubules and surrounding interstitium
Acute allergic interstitial nephritis (penicillins, NSAIDS,) Chronic interstitial nephritis (lithium, cyclosporine) |
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What is obstructive nephropathy
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Obstruction of the flow of urine
Renal tubular obstruction causes by precipitation of drugs: sulfonamides, methotexate, acyclovir, uric acid after tumor lysis Extrarenal urinary tract obstruction caused by anticholinergics worsened BPH or cyclophosphamide caused hemorrhagic cystitis Nephrolithiasis: triamterene, sulfadiazine, indiniavir` |
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how do you manage diabetic nephropathy
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1) Aggressive BP management, in patients with diabetes and CKD BP target 130/80
ACEI or ARBs are preferred Most patients need diuretic in combination CCB (nonDHP) are considered second line to ACEI/ARB 2) Intensive blood glucose control 3) Protein restriction |
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What are the indications for RRT
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A - acidosis
E - electrolyte abnormality I - intoxication O - fluid overload U - uremia |
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How do you treat anemia in CKD
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Do not treat Hgb to >13
Erythropoiesis stimulating agents (REMS program) - Epoetin, darbepoetin - goal to 11-12 - dose adjustments made every 4 weeks, 25% intervals - most common cause of inadequate response is iron deficiency |
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What are the target levels of ferritin and transferrin in CKD
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ferritin - 200 to 500
transferrin is >20% |
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How do you treat iron deficiency in CKD
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Do not use oral agents, use parenteral
Iron Dextran (need test dose) Ferric gluconate (125mg IV TID during HD) Iron sucrose Ferumoxytol |
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How do you treat hyperphosphatemia
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1) Phosphate binders - take with meals
- aluminum binders (aluminum hydroxide, sucrulfate). In general not used - calcium containing binders (calcium carbonate, acetate). Initial binder of choice for stage 3 and 4 CKD - Sevelamer. Considered primary therapy in stage 5. Use is calcium levels very high - lanthasum. Not widely used, can use if high calcium |
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What are the vitamin D analogs
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Suppress PTH synthesis and reduce PTH concentrations
Calcitriol - approved for use in hypocalcemia and prevention of secondary hyperparathyroidism. Dose adjust every 4 weeks. High incidence of hypercalcemia Paracalcitol - lower incidence of hypercalcemia Doxercalciferol - vitamin D analog - lower incidence of hypercalcemia |
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What is cinacalcet
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calcimimetic that attaches to the calcium receptor on the parathyroid gland and increased sensitivity to serum calcium levels reducing PTH
Especially useful in patients with high PTH, high calcium levels and vitamin D analogs cant be used Caution in seizure disorder Metabolized by Cyp3A Can be used whether or not patient on phosphate binders of vitamin D analogs |
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How do you generally calculate renal adjusted doses
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Rowland-Tozer
Q=1-[Fe(1-KF)] Q= kinetic parameter or drug dose adjustment factor Fe=fraction of drug excreted unchanged in urine KF=ratio of patients ClCr to normal (120ml/min) |
