M2-C6-L16 --> Acute Renal Failure

Front 1

ACUTE RENAL FAILURE BASICS

- what is a newer term for ARF?

Back 1

- Acute Kidney Injury (AKI)

Front 2

ACUTE RENAL FAILURE BASICS

- what 5 events occur with ARF?

Back 2

- Rapid (hrs - wks) decrease in GFR

- Retention of Nitrogenous Waste Products

- Perturbation of Electrolyte Homeostasis

- Perturbation of Acid/Base Homeostasis

- Perturbation of ECF Volume Homeostasis

Front 3

ARF EPIDEMIOLOGY

- Occurs in what % of hospitalized patients?

- Mortality risk increases how much with ARF?

- Mortality risk can increase as high as what %?

Back 3

- 5%

- 5 fold

- 50%

Front 4

ARF EPIDEMIOLOGY

- describe the prevalence of ARF in 2 hospital settings.

Back 4

- 30% of patients in ICU

- 40% of patients After CV Surgery

Front 5

ARF EPIDEMIOLOGY

- approximately 30% of patients who experience ARF will require what therapy?

Back 5

- Renal Replacement Therapy

Front 6

DEFINING ARF

T/F : ARF is usually Asymptomatic

Back 6

- True

Front 7

DEFINING ARF

- ARF is usually DX'd when?

- DX'd with what evidence?

Back 7

- Routine BCHM SCREENING of hospitalized patients

- RECENT increase in BUN & serum Creatinine concentrations

Front 8

DEFINING ARF

- ARF can be defined by what compound

Back 8

- Serum Creatinine

Front 9

DEFINING ARF

- what are the 3 conditions of ARF defined by Serum Creatinine?

Back 9

Increased Serum Creatinine of:

0.5 mg/dL with baseline Creatinine < 2 mg/dL

1.0 mg/dL with baseline Creatinine 2.0 to 4.9 mg/dL

1.5 mg/dL with baseline Creatinine >= 5 mg/dL

Front 10

DEFINING ARF

- list 2 diagnostic criteria for ARF

Back 10

- RIFLE criteria

- AKIN criteria

Front 11

DEFINING ARF

- RIFLE criteria is based on what 3 things?

Back 11

- increase Creatinine

- decrease in GFR

- decrease in Urine Output (UOP)

Front 12

DEFINING ARF

- RIFLE criteria has what 5 categories?

Back 12

(RIFLE)

- Risk
- Injury
- Failure
- Loss
- ESRD

Front 13

DEFINING ARF

- AKIN criteria compared to RIFLE criteria

- how many Stages are in the AKIN criteria?

Back 13

- AKIN Criteria is a modification of RIFLE

- 3 stages

Front 14

ARF ETIOLOGY

- Pre-Renal ARF etiology?

- Renal ARF etiology?

- Post-Renal etiology?

Back 14

- Decreased RBF

- Renal Parenchyma affected
(GAIT from L14)

- Urinary Tract Obstruction

Front 15

ARF ETIOLOGY

- Renal Causes of ARF can come from what 4 anatomical structures?

Back 15

(GAIT)

- Glomerulus
- Arteries
- Interstitium of tubules
- Tubules

Front 16

ARF ETIOLOGY

- based on anatomy what 4 pathological conditions cause Renal ARF

Back 16

- Glomerulonephritis

- Vasuclar disorders

- Interstitial Nephritis (AIN)

- Tubular Necrosis

Front 17

ARF ETIOLOGY

- Renal causes of ARF involving Vascular Disorders affect what vessels? x2

- Vascular disorders can be what 2 types

Back 17

- Arteries
- Arterioles

- Vasculitis
- Obstruction of vascular lumen

Front 18

ARF ETIOLOGY

- Renal causes of ARF involving Vascular disorders that Obstruct the vascular lumen as seen in? x2

Back 18

- TTP

- HUS

Front 19

ARF ETIOLOGY

- Renal causes of ARF involving the Glomerulus such as?

Back 19

- RPGN

(Rapidly Progressive GlomeruloNephritis)

Front 20

ARF ETIOLOGY

- Renal causes of ARF involving Tubular lesions are of what 2 TYPES?

Back 20

- ATN

- Tubular Lumen Occlusion

Front 21

ARF ETIOLOGY

- Renal causes of ARF caused by Tubular lesions involving ATN can be due to what? x2

- also associated with?

Back 21

- Ischemia

- Nephrotoxins

- Pigments

Front 22

ARF ETIOLOGY

- Renal causes of ARF caused by Tubular lesions involving Tubular Lumen Occlusion can be due to what? x2

Back 22

- Urate Nephropathy

- Plasma Cell Dyscrasia

Front 23

ARF ETIOLOGY

- Renal causes of ARF involving the Interstitium is called what?

- above Dz is aka?

Back 23

- Interstitial Nephritis

- AIN
(Acute Interstitial Nephritis)

Front 24

ARF DIAGNOSTIC

- what is the 5 step diagnostic approach to patients with ARF?

Back 24

1.) Review of available records
2.) PE
3.) Labs
4.) Imaging
5.) Biopsy

Front 25

ARF DIAGNOSTIC

- when reviewing available records, you are looking for a Personal History of what 4 things?

- what other 2 things would you look for?

Back 25

(PHx of HUNK)
- HYPOTension
- Urinary outflow problems
- Nephotoxin exposure
- Kidney stones (nephrolithiasis)

- Family Hx of Renal Dz

- Predisposing conditions (HTN & DM)

Front 26

ARF DIAGNOSTIC

- when reviewing available records, what are 2 predisposing conditions of Renal Dz that you look for?

Back 26

(PHD)
Predisposing HTN & DM

Front 27

ARF DIAGNOSTIC

- what is another name for nephrolithiasis?

Back 27

- kidney stones

Front 28

ARF PHYSICAL EXAM

- what is the most significant thing to assess for?

- above can involve what 2 things?

Back 28

- Volume status

- Orthostasis (postural hypotension)
- Tachycardia

(L14: IVVD involves hypotension, postural hypotension, tachy, & postural tachy)

Front 29

BUN:CREATININE RATIO

- what metabolic state would increase the BUN:Cr ratio?

- give examples x6

Back 29

(Cats have FISTS x4)

- Catabolic states

- Fever
- Injury/Trauma
- Sepsis
- Tissue necrosis
- Steroids
- Tetracycline

Front 30

BUN:CREATININE RATIO

- what dietary state would increase the BUN:Cr ratio?

- what dietary state would decrease the BUN:Cr ratio?

Back 30

- High protein diet

- Starvation
(or low protein diet - L14)

Front 31

BUN:CREATININE RATIO

- how does urine flow affect BUN:Cr ratio?

Back 31

- Diminished Urine Outflow

increases BUN:Cr ratio

(L14: Obstruction of Urinary Outflow Tract increases the ratio)

Front 32

BUN:CREATININE RATIO

- Diminished (or obstruction : L14) of Urine Flow would affect BUN:Cr ratio how?

- what 2 states of ARF involve a diminished urine flow?

Back 32

- Increases BUN:Cr ratio

- Pre-renal
- Post-renal

Front 33

BUN:CREATININE RATIO

- what conditions would decrease the ratio of BUN:Cr? x5

Back 33

(Down RAMPS)

- Rhabdomyolysis
- Advanced Liver Dz
- MEDS impairing tubular secretion
- Post-dialysis states
- Starvation

Front 34

RENAL FAILURE ABSENCE

- in the absence of renal failure, what would increase the BUN compound? x6

Back 34

(VC OG CAPS)

- Volume depletion w/o RF
- GI bleed

- Catabolic states (burns, injuries)
- Amino acid infusion
- Protein intake increase
- Steroids

Front 35

ARF URINALYSIS

- Abnormal UA in ARF with RBC, RBC casts, and Proteinuria would be indicative of what condtions? x3

Back 35

(GTV)

- Glomerulopathy
- Thrombotic microangiopathy
- Vasculitis

Front 36

ARF URINALYSIS

- Abnormal UA in ARF with WBC & WBC casts would be indicative of what conditions? x2

Back 36

- Pyelonephritis
(in the presence of infection)

- Interstitial Nephritis (AIN)

Front 37

ARF URINALYSIS

- Abnormal UA in ARF with Eosinophils would be indicative of what conditions? x3

Back 37

- Allergic Interstitial Nephritis

- Glomerulopathy

- Atheroemboli

Front 38

ARF URINALYSIS

- Abnormal UA in ARF with Crystalluria would be indicative of what conditions?

Back 38

(Crystal MUT)

- Meds/drugs

- Uric acid

- Toxins

Front 39

ARF URINALYSIS

- Abnormal UA in ARF with Pigmented cells and RTE (renal tubular epithelium) cells would be indicative of what conditions? x3

Back 39

(Pigs give us HAM)

- Hemoglobinuria

- ATN

- Myoglobinuria

Front 40

ARF URINALYSIS

- Abnormal UA in ARF with Low grade Proteinuria would be indicative of what conditions?

Back 40

- Plasma Cell Dyscrasia

Front 41

ARF URINALYSIS

- what 2 stains can give you evidence of eosinophils in the urine?

Back 41

- Hansel stain

- Wright stain

Front 42

Back 42

Front 43

FRACTIONAL EXCRETION of SODIUM

- what is equation for FENa = ?

Back 43

( [U] / [P] ) Na+ / ( [U] / [P] ) Cr x 100

Front 44

URINE PATTERNS

- 3 Renal Diseases associated with Dysmorphic RBCs and RBC Casts w/
Hematuria
Proteinuria
Lipiduria
Casts of RBCs

Back 44

(VG-Tm)

- Vasculitis
- Glomerular Dz

- Thrombotic Microangiopathy

Front 45

URINE PATTERNS

- 3 Renal Diseases associated with Granular Casts (Pigmented cells), Epithelial Casts, & Free epithelial cells

Back 45

(Pig = HAM)

- Hemoglobinuria

- ATN

- Myoglobinuria

Front 46

URINE PATTERNS

- 2 Renal Diseases associated with WBCs (pyruia), WBC casts, Waxy or granular casts
(little or no proteinuria)

Back 46

(WWW = TO somewhere)

- Tubulointerstitial Dz

- Obstruction of UT

Front 47

URINE PATTERNS

- 5 Renal Diseases associated with Pyruia, Hematuria, and with none/variable casts (excluding RBC casts)

Back 47

(VGA-OI)
- Vasculitis
- Glomerular Dz
- AIN

- Obstruction of UT
- Infarction of UT

Front 48

URINE PATTERNS

- Renal Diseases associated with Pyuria only?

- Renal Diseases associated with sterile pyruia? x5

Back 48

- Infection

- Tubulointerstitial Dz
- TB of UT
(L14: Prostatitis, Chronic urethritis, Interstitial Nephritis)

Front 49

URINE PATTERNS

- Renal Diseases associated with Hematuria alone

Back 49

- varies with clinical setting

Front 50

URINE PATTERNS

- Renal Diseases associated with Few cells and little or no casts/proteinuria.
(normal or near normal UA)

Back 50

- all EXCEPT infection

(Scleroderma, Atheroemboli)

Front 51

URINE PATTERNS & PYURIA

- Pyuria alone?

- Sterile pyuria? x5

Back 51

- Infection

- (Prostatitis - L15)
- (Chronic Urethritis - L15)
- Tubulointerstitial Dz
- (Interstital Nephritis - L15)
- TB of UT

Front 52

URINE PATTERNS & PYURIA

- Pyuria & Hematuria & RBC casts? x5

- Pyuria & Free cells & WBC casts? x2

Back 52

- Vasculitis
- Glomerular Dz
- AIN
- Obstruction
- Infection

- Tubulointerstital Dz
- Obstruction of UT

Front 53

PRE-RENAL DISEASE

- usually involves some kind of what?

Back 53

- IntraVascular Volume Depletion (IVVD)

Front 54

PRE-RENAL DISEASE

- IVVD due to renal fluid loss can occur from?

- IVVD due to cutaneous loss can occur from?

- IVVD due 3rd space fluid loss

Back 54

- Diuretics

- Burnas

- Pancreatitis

Front 55

PRE-RENAL DISEASE

- Pre-renal (IVVD) can also be associated with decreased "effective" circulating volume in what 3 conditions?

Back 55

- CHF

- Cirrhosis

- Nephrotic syndrome

Front 56

PRE-RENAL DISEASE

- how is GFR affected?

- why?

Back 56

- Decreases

- Hemodynamic disturbances
(that decrease glomerular perfusion)

Front 57

PRE-RENAL DISEASE

- usually with an Absence of?

- can renal function be normalized?

Back 57

- Cellular injury

- Yes with the reversal of hemodynamic factors

Front 58

PRE-RENAL DISEASE

- Pre-renal Dz or IVVD is usually characterized by what 2 things?

Back 58

- Oliguria (decreased urine)

- Sodium Retention

Front 59

PRE-RENAL DISEASE

- levels for Oliguria

- levels for Urine Na+

- levels for FENa+

Back 59

< 400 mL (UOP per 24 hours)

< 20 mmol/L

< 1%

Front 60

PRE-RENAL DISEASE

- Altered Renal Hemodynamics @ Afferent end

- Altered Renal Hemodynamics @ Efferent end

Back 60

- VasoConstriction

- VasoDilation

Front 61

PRE-RENAL DISEASE

- what drugs would VasoContrict the Afferent end? x2

- what drugs would VasoDilate the Efferent end? x2

Back 61

- NSAIDs
- Cyclosporines

- ACE-Inhibitors
- ARBs

Front 62

NSAIDs

- MOA?

- Renal Hemodynamic effects

Back 62

- Inhibits PG synthesis

- Vasoconstricts afferent arteriole

Front 63

NSAIDs

- with NSAIDs, the most frequent pattern of injury is?

Back 63

- Pre-renal Azotemia in susceptible patients

Front 64

NSAIDs

- with NSAIDs, the most frequent pattern of injury is Pre-renal Azotemia in which susceptible patients? x5

Back 64

(these pts severely LACK Volume)

- Advanced Liver Dz
- Severe Atherosclerotic Vascular Dz
- Severe CHF
- Chronic Kidney Dz

- Volume depletion

Front 65

NSAIDs

- NSAIDs associated with what NON-Pre-renal Dz?

- Prolonged damage from NSAID usage can result in what?

- how would you distinguish the above dz from prolonged use?

Back 65

- AIN

- ATN

- Urinary indices

Front 66

POST-RENAL ARF

- can be separated into what 2 categories?

Back 66

- Upper Tract obstruction

- Lower Tract obstruction

Front 67

POST-RENAL ARF

- Upper Tract obstruction can be separated into what 2 categories?

Back 67

- Intrinsic

- Extrinsic

Front 68

POST-RENAL ARF

- List pathologies associated with the INSTINSIC Upper Tract Obstruction? x4

- List pathologies associated with the EXTRINSIC Upper Tract Obstruction? 3

Back 68

(Tcc & PBS)
- Transitional Cell Carcinoma
- Papillary necrosis
- Blood clots
- Stones

(RAM)
- Retroperitoneal Fibrosis
- Aortic aneurysm
- Malignancy (retro or pelvic)

Front 69

POST-RENAL ARF

- List pathologies associated with the Lower Tract Obstruction. x5

Back 69

(bnp-C U B)

- Bladder CA
- Neurogenic CA
- Prostate CA

- Ureteral constricture
- BPH
(Benign Prostatic Hyperplasia)

Front 70

POST-RENAL ARF

- Symptoms x4

Back 70

("IF U Hesitate)

- Incontinence
- Frequency

- Urgency

- Hesitancy

Front 71

POST-RENAL ARF

- Diagnosis how? x3

(include tests used for each)

Back 71

(HIP)

- Hydronephroses (US)

- Increased BUN & Creatinine
(if bilateral kidney involvement, eg - prostatic hypertrophy)

- Post void residual > 100 to 200 cc

Front 72

POST-RENAL ARF

- in post-renal ARF, under what conditions would BOTH the BUN and Creatinine go up?

- example of the condition stated above

Back 72

- obstruction involving both kidneys

- Prostatic Hypertrophy

Front 73

POST-RENAL ARF

- after relieving the obstruction, what is the prognosis?

Back 73

- improved renal function

Front 74

ARF ETIOLOGY

- what are the 4 basic ARF etiologies?

- which is the MCC of intrinsic ARF?

Back 74

(GAIT)
- Acute Glomerulonephritis
- Acute Vascular syndromes
- AIN
- ATN

- ATN

Front 75

ARF ETIOLOGY:
ACUTE TUBULAR NECROSIS

- Etiology of ATN x3

Back 75

(ATN is from MINnesota)

- Multifactorial

- Ischemic

- Nephrotoxic

Front 76

ARF ETIOLOGY:
ACUTE TUBULAR NECROSIS

- Pathogenesis of ATN x5

Back 76

(ATN found the path after VD OIL)

- Vasoconstriction (intrarenal)
- Direct tubular cell injury

- Oxygen reactive species generation
- Inflammatory pathway activation
- Leukocyte infiltration

Front 77

ARF ETIOLOGY:
ACUTE TUBULAR NECROSIS

- in patients with ARF, a ATN etiology can be highly indicated by what pathology?

Back 77

- brown muddy Granular Casts

Front 78

NEPHROTOXIN
ACUTE TUBULAR NECROSIS

- results from toxins where?

Back 78

- either Endogenous or Exogenous

Front 79

NEPHROTOXIN
ACUTE TUBULAR NECROSIS

- give an example of an endogenous nephrotoxin

- above example can result from what 2 conditions/events?

Back 79

- heme-pigment induced tubular toxicity

- Rhabdomyolysis
- Intravascular Hemolysis

Front 80

NEPHROTOXIN
ACUTE TUBULAR NECROSIS

- give 2 examples of Exogenous toxins

Back 80

- Aminoglycosides

- RadioContrast agents

Front 81

ACUTE TUBULAR NECROSIS

- what are the 3 phases of ATN in the clinical course?

Back 81

- Initiation

- Maintenance

- Recovery

Front 82

ATN : INITIATION PHASE

- this period is when patients are subjected to what?

- give examples x4

- describe the parenchymal damage seen

Back 82

- factors known to cause ATN

(SHIN)
- Sepsis
- HYPOTension
- Ischemia
- Nephrotoxins

- None. not yet developed

Front 83

ATN : INITIATION PHASE

- describe the hemodynamics of this phase?

Back 83

There is a Reduction in renal perfusion

exceeding critical threshold

(required to maintain O2 delivery and sustain normal cellular metabolism)

Front 84

ATN : INITIATION PHASE

- why is this phase so important clinically?

Back 84

- ARF is potentially reversible here

Front 85

ATN : MAINTENANCE PHASE

- duration?

- what is going on hemodynamically?

Back 85

- highly variable, but usually 1 to 2 wks

- GFR is markedly decreased

Front 86

ATN : MAINTENANCE PHASE

- what is the major pathogenesis seen here? x2

- does resolution of Inciting Ischemic event correct this?

Back 86

- Persistent Tissue Hypoxia

- Ongoing Cellular Injury

- NO!!

Front 87

ATN : MAINTENANCE PHASE

- describe the urine volume in this phase

Back 87

- Variable

(but many are oliguric)

Front 88

ATN : RECOVERY PHASE

- what are the characters of this phase? x2

- how does the above happen?

Back 88

- Cellular regeneration
- Repair/Restore Tubular Integrity

- Remaining Viable cells Dedifferentiate, Proliferate, and Migrate across BM to establish epithelial continuity

Front 89

ATN : RECOVERY PHASE

- describe the hemodynamics x2

Back 89

- Restoration of normal (or near nml) RBF

- Improved GFR