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50 Cards in this Set
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- Back
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diagnostic criteria for acute kidney injury (AKI) (or acute renal failure (ARF))
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-an abrupt (within 48hrs) absolute increases in the serum creatinine concentraiton of >/= 3mg/dL from baseline, a percantage inc in the serum creatinine concentration of >/= 50%
-or oligouria of <.5 mL/kg /hr for > 6 hrs -criteria can only be applied after vol status had been optimized (PRE RENAL) -UTI has been excluded if oligouria was used as the sole diagnostic criteria (POST RENAL) |
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AKI- Stage 1
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-inc in serum creatinine of >/= 0.3 mg/dL or
-inc to more than or equal to 150 to 200% from baseline or -urine output < 0.5 mL/kg/hr for >6 hrs |
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AKI- Stage 2
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-inc in serum creat >200-300 % from baseline or
-urine output < 0.5 mL/kg/hr for >12 hrs |
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AKI- stage 3
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-inc in serum creat to > 300% from baseline or
-serum creat of >/= 4.0 mh/dL with an acute inc of at least 0.5 mg/dL or -urine output < 0.3 mL/kg/hr for 24 hrs or anuria for 12 hrs |
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outcome of AKI/ARF
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1. reversible: complete recovery
2. Reversible- partial: chronic kidney dz 3. Irreversible: end stage renal dz |
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post renal
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-anything blocking the urine flow after the calices
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pre renal
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-problem before the renal artery
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acute renal failure
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-usually in the hospital setting
-mainly in the ICU reason for consult: -oliguria/anuria: urine output </= 20 ml/hr -elevated BUN or Cr with or without oliguria -vol overload: pul edema -hyperkalemia -metabolic acidosis |
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ARF: pre-renal:
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-absolute dec in effective blood vol: bleeding, skin loss, GI loss, renal loss
-relative dec in effective blood vol: CHF, sepsis, liver failure -renal arterial occlusion |
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ARF: renal
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-acute tubular necrosis: kidney not getting enough bl
-vascular: vasculitis, eclampsia, NSAIDs, malignant HTN -glomerular: acute glomerulonephritis -acute pyelonephritis -acute intersitial nephritis- drugs -acute tubular injury |
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ACF: post-renal
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-obstructive uropathy: kidney, ureters, bladder or urethra
-kidney stones -malignancy -retroperitoneal fibrosis -enlarged prostate particularly in an elderly male pt |
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ARF clinical features
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1. urine output (nonoliguric/oliguria/anuria)
2. elveated BUN and serum creat 3. fluid overload: pul edema 4. hyperkalemia, metabolic acidosis 5. depending on etiology there can be hematuria, pyuria, flank pain |
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ARF: diagnosis
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1. H&P
2. labs: UA, urine and serum chemistry panel, C3, C4, ANA. anti-dzDNA, ANCA, SPEP, UPEP 3. sonogram, isotope DTPA scan, CT/MRI 4. kidney biopsy (not for acute tubular necrosis) |
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ARF: H &P
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1. vomiting
2. diarrhea 3. hypotension 4. nephrotoxic drugs (NSAIDs. gentamicin, contrast use) 5. hypertensive-retinopathy 6. cardiomegaly 7. renal bruit or mass 8 . signs of fluid overload |
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ARF: Lab data
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1. urine: sediments
2. muddy brown casts: ATN 3. RBC: acute glomerulonephritis 4. WBC casts: acute pyelonehpritis 5. granular casts: acute intersitial nephritis 6. urine electrolytes: Fr exec Na: {U Na/S Na/U Cr/S cr} * 100 |
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Red urine
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-myoglobinuria
-hemoglobinuria -slide 31 |
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slide 32
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32
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ARF: radiological
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1. plain xray abdomen: kidney stones
2. sonogram of kidney: size and obstruction 3. renal isotope scan: perfusion 4. CT/MRA: obstruction, mass, renal a. stenosis |
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ACF: post-renal
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-obstructive uropathy: kidney, ureters, bladder or urethra
-kidney stones -malignancy -retroperitoneal fibrosis -enlarged prostate particularly in an elderly male pt |
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ARF: kidney biopsy
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-rapidly progressive glomerulonephritis or other unexplained cause
-ATN: biopsy not done |
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ARF clinical features
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1. urine output (nonoliguric/oliguria/anuria)
2. elveated BUN and serum creat 3. fluid overload: pul edema 4. hyperkalemia, metabolic acidosis 5. depending on etiology there can be hematuria, pyuria, flank pain |
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ARF: treatment
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-depends on etiology
-Pre-renal: fluid; diuretics to convert to non-oliguric, F&E mgmt -Acute GN: steroids/cytotoxic drugs, plasmapharesis -AIN: stop the causative agent -dialysis: to tx vol overload, hyperkalemia, metabolic acidosis |
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ARF: diagnosis
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1. H&P
2. labs: UA, urine and serum chemistry panel, C3, C4, ANA. anti-dzDNA, ANCA, SPEP, UPEP 3. sonogram, isotope DTPA scan, CT/MRI 4. kidney biopsy (not for acute tubular necrosis) |
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ARF: H &P
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1. vomiting
2. diarrhea 3. hypotension 4. nephrotoxic drugs (NSAIDs. gentamicin, contrast use) 5. hypertensive-retinopathy 6. cardiomegaly 7. renal bruit or mass 8 . signs of fluid overload |
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ARF: Lab data
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1. urine: sediments
2. muddy brown casts: ATN 3. RBC: acute glomerulonephritis 4. WBC casts: acute pyelonehpritis 5. granular casts: acute intersitial nephritis 6. urine electrolytes: Fr exec Na: {U Na/S Na/U Cr/S cr} * 100 |
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Red urine
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-myoglobinuria
-hemoglobinuria -slide 31 |
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slide 32
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32
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ARF: radiological
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1. plain xray abdomen: kidney stones
2. sonogram of kidney: size and obstruction 3. renal isotope scan: perfusion 4. CT/MRA: obstruction, mass, renal a. stenosis |
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ARF: kidney biopsy
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-rapidly progressive glomerulonephritis or other unexplained cause
-ATN: biopsy not done |
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ARF: treatment
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-depends on etiology
-Pre-renal: fluid; diuretics to convert to non-oliguric, F&E mgmt -Acute GN: steroids/cytotoxic drugs, plasmapharesis -AIN: stop the causative agent -dialysis: to tx vol overload, hyperkalemia, metabolic acidosis |
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ATN: outcome
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1. highly variable; recovery in 7-21 days
2. delayed partial recovery 3. no recovery |
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cockcroft- gault equation
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CCr =
(140-age) x wt in kg / Cr x 72 x.85 in women |
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modification of diet in renal dz (MDRD)
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-to estimate GFR, you need
1. serum creatinine 2. age 3. gender 4. race |
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definition of CKD
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1. kidney damage for >/= 3 mo, either structural or functional
2. GFR <60 mL/min/1.73 m^2 for >/= 3 months with or without kidney damage |
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CKD stages
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1. kidney damage with nml or inc GFR: GFR >/=90
2. kidney damage with mild dec GFR: 60-89 3. mod dec GFR: 30-59 4. severe dec GFR: 15-29 5. kidney failure: <15 (or dialysis) |
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CKD causes
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1. diabetic gomerulonephritis: 30%**
2. HTN glomerulosclerosis: 30%** 3. chronic glomerulonehpritis: 16% 4. chronic interstitial nephritis: 6% 5. polycystic kidney dz: 6% 6/ others and unknown etiology |
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CKD pathogenesis
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-uremic toxins
-overproduction of counter-regulatory hormones: PTH -underproduction of renal hormones: erythropoietin and 1 hydroxylation of vit D3 |
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CKD pathophys
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-inc in GFR in remaining nml nephrons-adoptive hyperfiltration
-this hyperfiltration permits sodium, K, Ca, phos, total body water to near nml in mild to mod renal failure -loss of flexibility to handle sudden load of solutes- water, sodium or potassium |
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CKD- solute handling - Cr and Urea
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-Tubular creatinine secretion is increased to 30% (normal 10%) in CRF
-Tubular urea absorption falls to 30% (normal-50-60% of filtered urea) as GFR decreases |
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CKD-solute handling- potassium
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-90% of K is excreted in urine and 10% in stool in a nml subject
-distal tubular secretion increases: : (1) increased tubular flow rate (2) increased distal Na delivery (3) increased luminal negative charge -in CKD/CRF, fecal excretion of K is inc to 35% of K intake |
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hyperkalemia
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Increased dietary intake
Potassium sparing diuretics ACE inhibitors and ARBs NSAID use Constipation Protein catabolism Metabolic acidosis Hemolysis, hemorrhage Blood transfusion Type IV RTA |
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hypokalemia
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Diarrhea
Vomiting Excessive diuretic use Metabolic alkalosis Type I RTA Type II RTA |
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CKD- solute handling- water
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-Nocturia-decreased urine concentrating ability of kidney during sleep
- Urine concentrating ability of kidney becomes fixed at 300 mosm/kg of water |
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CKD- solute handling: Hydrogen
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-Positive balance of hydrogen ions- decreased tubular NH3 production
-Flexibility of handling hydrogen load by kidney is impaired in CRF |
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CKD: progression: secondary factors
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1. systemic HTN
2. intraglomerular HTN 3. glomerular hypertrophy 4. intra-renal deposition of CaPO4 5. hyperlipidemia 6. proteinuria |
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acute on chronic kidney dz: acute aggravating factors
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Volume depletion
Urinary obstruction Nephrotoxic drugs Congestive heart failure Accelerated hypertension Renal or systemic infection Hypercalcemia Exacerbation of underlying disease |
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CKD: ssx
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Asymptomatic
Symptomatic: variable – volume overload, hyperkalemia, metabolic acidosis, hypertension, anemia and bone disease The constellation of signs and symptoms of ESRD (end stage renal disease) referred to as uremia |
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Chronic kidney disease-uremia signs & symptoms
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Anorexia, nausea and vomiting
Pericarditis, hypertension Anemia Peripheral neuropathy, loss of concentration, lethargy, seizures, coma No direct correlation between BUN or Cr and symptoms One patient-symptomatic at BUN 60 while other asymptomatic at BUN 140 mg/dl |
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cardiovascular and pul ssx
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Arterial hypertension
CHF and pulmonary edema Pericarditis Cardiomyopathy Uremic lung Accelerated atherosclerosis Hypotension and Arrhythmias Vascular calcification |
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GI disorders
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-Nausea and Vomiting
Anorexia Uremic fetor Peptic Ulcers Gastroenteritis Hepatitis Idiopathic ascites Peritonitis |
