Renal: 21. Thomas : Acute Kidney Injury/acute Renal Failure

Front 1

The kidney is involved in which of the following:

clearance of Nitrogenous wastes

reg of electrolytes and pH

maintenance of BP

regulation of volume

production of cholesterol

Synthesis of active vitamin D

synthesis of erythropoietin

Back 1

Does all but E (production of cholesterol)

Front 2

what is the role of the kidney with Vit D?

Back 2

converts vit D2 to the active D3

Front 3

Serological tests for evaluating renal insufficiency which may aide in the diagnosis include:

Antinuclear antibody (ANA)

Anti-Glomerular Basement membrane antibody

Antinuetrophil cytoplasmic antibody (ANCA)

B-type natriuretic peptide (BNP)

Complement

Cryoglubulins

Back 3

ANA- evaluates acute renal failure

Anti-Glomerular Basement membrane antibody (seen in goodpastures)

Antinuetrophil cytoplasmic antibody (ANCA)- wegeners gramulatosis

BNP you MIGHT order, but that is for HF, so this is probably not right

Complement levels are helpful (autoimmune processes)

Cryoglobulins

Front 4

when do you order B-type natriuretic peptide (BNP)

Back 4

heart failure

Front 5

Urinalysis in a patient with renal dysfunction may include measuring/evaluating:

Microalbumin levels

Fractional excretion of sodium

Fractional excretion of urea

Specific gravity

Urine sediment

Back 5

Microalbumin- especially in HT/diabetic nephro

Fractional excretion of Na- can see if the body can hold Na adequately

Specific gravity- can tell if person is volume depleted (will have high)

Fractional excretion of urea

Urine sed

Front 6

sudden decline in the ability of the kidneys to maintain fluid and electrolyte homeostasis =?

Back 6

ARF

Front 7

numerically, what increase in creatinine in 48 hours represents ARF?

Back 7

creatinine ≥ 0.3

or

creatinine >50%

Front 8

pt has an abrupt onset of edema, hematuria, abnormal BP, and cardiac dsrhythmias... what do they have?

Back 8

ARF

Front 9

What ion is responsible for the cardiac dysrhthmias associated with ARF?

Back 9

potassium

Front 10

what is the definition of oliguria?

**

Back 10

<500 ccs of urine in 24 hours

or

<0.5 cc/kg/h for >6 hours

Front 11

What are the 3 types of ARF? basic causes?

Back 11

Prerenal: secondary to hypoperfusion

Intrinsic: something primarily with the kidney

Post renal: obstuction

Front 12

what class of drugs especially on initiation can lead to ARF?

***

Back 12

ACEi/ARB

Front 13

Why do NSAIDs cause ARF?

Back 13

NSAIDs cause prerenal acute renal failure by blocking prostaglandin production, which also alters local glomerular arteriolar perfusion

remember, prostaglandins help vasodilate the afferent arteriole

Front 14

how does liver disease contribute to ARF?

Back 14

liver synthesizes albumin, which is needed for oncotic pressure to keep fluid in the vascular space

so if you aren't making it, your COP is low and fluid will leak out and your perfusion will be low

Front 15

how does BPH cause ARF?

Back 15

obstruction

Front 16

What is the definition of orthostatic hypotension?

Back 16

decrease in systolic pressure by 20 when standing

decrease HR of 10

Front 17

What physical exam findings would you expect in someone with chronic liver disease and/or cirrhosis? (random...dont worry)

Back 17

gynocomastia
hemoriods
JVD

Front 18

what 2 things can you do as an initial workup of ARF at the bedside?

Back 18

Bladder scan (pre- and post-void)
Insert Foley catheter

also Strictly record input and output data (what you put in and what they pee out)

Front 19

in a pt with volume depletion, what would the specific gravity and Uosm be?

Back 19

Specific gravity:High

Uosm: high

wehen you are volume depleted, kidney is going to hold on to all the water it can so it concentrates the urine

Front 20

What does your Fractional Excretion of Sodium tell you

Back 20

will tell you if you have a pre-renal failure or intrinsic

in pre-renal the kidney will try to hold on to as much salt and water as possible... so your FeNa will be low

Front 21

Why use the FeUr if the patient is taking a diuretic?

Back 21

Diuretics cause Na excretion and the FeNa would be higher than expected

Front 22

Initial workup of ARF includes which of the following:

Urinalysis for casts, specific gravity, blood
FeNa/FeUr to differentiate prerenal from intrinsic
CT abdomen/pelvis to look for renal size, hydronephrosis, kidney stone(s)
Renal Ultrasound to look for renal size, hydronephrosis, kidney stone(s)

Back 22

all except ordering the CT

Front 23

TRUE/FALSE

Acute renal failure can be defined as an increase in serum creatinine >25% in 48 hours.

Back 23

FALSE

must be greater than 50%

Front 24

How does an obstruction to urine outflow cause a decline in glomerular filtration or GFR?

Back 24

Urine 'backs up' causing an increase in tubular hydrostatic pressure which exceeds the transcapillary hydrostatic pressure

Front 25

how can you diagnose a postrenal cause of ARF? 3

Back 25

1. Obtain pre- and post-void residuals using bladder scan (suspect bladder outlet obstruction if >300 ccs urine remain in bladder postvoid) and place Foley catheter

2. Renal Ultrasound
-hydronephrosis?, obstructing stone?

3. Prostate Exam
-BPH? , prostate mass?

Front 26

Tx for postrenal ARF?

Back 26

treat underlying cause! Such as removing the obstruction

Front 27

TRUE/FALSE

Post-renal obstruction should be suspected in patients who report recently passing clots of blood.

Back 27

True

Front 28

Can you rule out post renal if less than 300ccs urine remain in bladder ?

Back 28

Yes

you should see greater than >300 ccs for obstruction aka post renal

Front 29

TRUE/FALSE

Patients with postrenal ARF are typically oliguric or anuric.

Back 29

True

Front 30

MAP must be what in order to perfuse a kidney?

Back 30

MAP>60

Front 31

if a pt has absolute hypovolemia or effective hypovolemia what type of ARF do they have?

Back 31

Prerenal

Front 32

A 70-year-old male with Stage C heart failure is placed on ramipril. His serum creatinine jumps up from 1.5 mg/dL to 2.7 mg/dL. How did ramipril precipitated this decline in kidney function?

Back 32

efferent arteriole dilation and a reduction in intraglomerular hydrostatic pressure

Front 33

With dehydration or heart failure or sepsis, the patient can develop renal failure because the kidney is hypoperfused. What is the kidney’s response with regards to Na and water?

Back 33

Reabsorb more sodium and water

Front 34

What will happen to the FeNa, urine osmolality and urine specific gravity in a dehydrated pt?

Back 34

Urine osmolality will be high (hanging on to water, more solute in urine)

Specific gravity would increase

FeNa will be low (0.5%)

Front 35

what will your BUN/Cr ratio be in pre renal ARF?

Back 35

BUN/Cr ratio ≥20:1

Front 36

tx for pre-renal ARF?

Back 36

underlying cause

Front 37

TRUE/FALSE

A BUN/Cr ratio of ≥20:1 supports the diagnosis of prerenal ARF.

Back 37

True

Front 38

TRUE/FALSE

Prerenal ARF can be ruled out in patients who appear to be volume overloaded.

Back 38

False

Front 39

TRUE/FALSE

Uosm and specific gravity should be decreased in patients with prerenal ARF.

Back 39

False

should both be up

Front 40

What happens if either prerenal azotemia or postrenal azotemia is not corrected?

Back 40

Acute tubular necrosis

if you are volume depleted, you are not filtering much, you plug up the tubules leading to ATN

Front 41

Compare the urinary indices of prerenal azotemia and acute tubular necrosis
BUN/Cr ratio
Specific gravity
Urine osmolality
Urine Na
FeNa
Sediment

Back 41

**** that bull ****. like we don't have enough to do

Front 42

An 80 year old female is sent to the ED from the nursing home because of altered mental status. CT head, CXR, UA, and troponin in the ED have ruled out acute stroke, pneumonia, UTI and MI, respectively. Vital signs are:

T 97.8 P 108 R 20 BP 92/50
96%RA

Review of NH records show that the patient has a PMH of HTN, hypothyroidism, and GERD, and takes HCTZ, Lisinopril, Levothyroxine, and Omeprazole. A Foley catheter is inserted and returns 50 ccs dark urine. Renal US is negative for hydronephrosis.

Initial labs reveal:
Serum Na 134
Serum K 5.0
BUN 34
Serum Creatinine 1.4 (nml 0.6-1.2 mg/dL)
UA negative for protein, blood, casts
Urine sp gr 1.030
Uosm 550
FeUr is calculated as 20%.

what are you thinking and why?

Back 42

tachy, low bp...start thinking hypovolemia

she likely has prerenal ARF

specific grav increased, low FeUr (cut off is 35%)

Front 43

you have a pre-renal cause of problem, Your initial management will include which of the following:

Stop all BP meds
Volume resuscitation with ½ NS
Strict I/O
Volume resuscitation with NS

Back 43

Stop all BP meds

Strict ins and outs

Volume resuscitation with normal saline

Front 44

Differential diagnosis in a patient who is old from a nursing home with hypovolemia and pre-renal cause on thiazides includes which of the following:

No access to free water
Excessive diuresis
Pelvic Malignancy
Overly-aggressive BP control

Back 44

No access to free water
Excessive diuresis
Overly-aggressive BP control

Front 45

27 year old male. The consult note simply states, “Patient developed ARF. Please assist with management.” Chart review shows that the patient was admitted 10 days ago after suffering multiple pelvis fractures as a result of being a restrained passenger in a motor vehicle accident.
Labs on admission were BUN 15 and Cr 0.8, and now are BUN 20 and Cr 2.0. Patient is normotensive, participating in PT (Foley removed 3 days ago), and otherwise is without complaints. Urine output for the past 24 hours is documented as 750 ccs. Physical exam is unremarkable except for some mild hypogastric tenderness and fullness.

Your initial first step in the management of this patient should include:

UA
Bladder scan with post-void residual
500 cc NS bolus

Back 45

UA (urinary analysis)
Bladder scan with post-void residual