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AKI

Liam Musselbrook Surgery Inglés 35 fichas

AKI criteria: stages

Fichas del conjunto (35)

  1. 1What are the NICE specifications for AKI?- Urine output <0.5ml/kg/hr for 6 hrs
    - >50% rise in creatinine over 7 days
    - >26 micromol rise in creatinine over 48hrs
  2. 2AKI criteria: stagesAKI criteria: stages
  3. 3What might occur, indicating severe AKI?- Uraemia (vomiting, pruritis, pericarditis, encephalitis)
    - Hyperkalaemia
    - Pulmonary oedema (unless pre-renal cause)
  4. 4What are the three categories of AKI and which is the most common in hospital patients?Pre-renal, renal and post-renal
    Pre-renal is most common (75%)
  5. 5What is the basic explanation of pre-renal AKI?When the blood supply to the kidney is interrupted
  6. 6What are the two main causes of pre-renal AKI?- Shock: hypovolaemia, cardiogenic, distributive
    - Renovascular obstruction: embolus, aortic dissection, renal artery stenosis & thrombosis, or ACEIs given in bilateral RAS
  7. 7What can result from prolonged interruption in blood supply?Acute tubular necrosis (ATN)
  8. 8What happens as a result of ANT?Porous tubular membranes -> loss of concentrating power as ATN develops
    Blockage of tubules by necrosed cells
  9. 9How does the urine change as ATN develops?Initially urine osmolality is high (>500mosmol/kg), and urine sodium is low
    As it develops, urine is isotonic with plasma (<400mosmol/kg) and has high sodium
  10. 10What is the basic explanation for post-renal AKI?Obstruction to the outflow of the urinary tract
  11. 11Name causes of post-renal AKIRenal calculi
    Ureteric/urethral strictures
    Clots
    External/internal malignancy
    Prostatic enlargement
    Phimosis/paraphimosis
  12. 12What are the three separate mechanisms/pathologies by which renal AKI can occur?- Acute tubular necrosis (85%)
    - Interstitial nephritis (10%)
    - Glomerular disease (5%)
  13. 13What are the renal causes of ATN?Drugs: aminoglycosides, cephalosporins, radiological contrast, NSAIDs
    Toxins: heavy metals, myoglobinuria or HUS
  14. 14How does myoglobinuria occur and how does it classically present?Follows rhabdomyolysis
    Dark urine
  15. 15What is the cause of HUS?Occurs in children following diarrhoeal illness from E.Coli O157
    or
    following an URTI in adults
  16. 16What is the triad for HUS?Thrombocytopenia
    Haemolysis
    ATN
  17. 17How does interstitial nephritis differ from ANT?Damage is not limited to the tubular cells and bypasses the basement membrane to cause damage to the interstitium
  18. 18What is the most common cause of interstitial nephritis and how do you manage it?Antibiotics (also diuretics, allopurinol and PPIs)
    Withdraw drugs and start short course of oral steroids
  19. 19What are your general 1st line examinations and investigations for AKI?Obs
    Abdominal examination
    Bloods: FBC, U&Es, bicarbonate, phosphate, CRP, clotting, creatinine kinase (myoglobinuria), nephritic screen
    ABG
    Urine dip and MCS
    ECG
    Renal USS
  20. 20What is included in a nephritic screen?-ANCA & anti-GBM (RPGN)
    -ANA, dsDNA and complement (SLE)
    -Immunoglobulins, serum electrophoresis (myeloma)
    -Rheumatoid factor
    -Hep B/C (MCGN)
    -ASO (post-strep)
  21. 21How might you approach assessing whether an AKI is pre-renal?- Look for signs of shock
    - Listen for renal bruits and take a vascular history (AF/IC) if suspecting arterial pathology
  22. 22How might you approach assessing whether an AKI is post-renal?- Order an abdominal USS to show distended bladder/hydronephrosis
    - Examine the prostate in older males
  23. 23How might you approach assessing whether an AKI is renal?- Take a meticulous drug Hx and enquire about recent infections, joint pains, rashes
    - Order a urine dip to look for +ve blood/protein
    - Red cell casts on microscopy (diagnostic for glomerulonephritis)
  24. 24What is included in your general AKI management?A-E assessment
    Halt any potentially damaging drugs
    Restrict potassium intake
  25. 25What is must be included in your management of post-renal?Referral to urology for appropriate treatment
  26. 26What must be included in your management of renal AKI?- Assess fluid status, with volume replacement
    - CVP measurement may be necessary
    - If there is urine output following fluid, continue large quantities of fluid +/- diuretics (furosemide stress test)
    *If no urine output or if complications, nephrologist input is necessary
  27. 27Furosemide stress testFurosemide 1mg/kg given after fluid resuscitation, and urine output measured and replaced at 2 hrs
    Volume of fluid output at 2 hrs can be used to demonstrate likelihood of progression to AKIN stage III
  28. 28What are the indications for acute dialysis?- Refractory hyperkalaemia
    - Pulmonary oedema
    - Acidosis
    - Uraemic pericarditis/encephalopathy
    - Complete anuria
    - Drug OD
  29. 29What is the general pattern of urine output if the AKI is improving?After one week of oliguria, there will be one week of polyuria before return to normal kidney function
  30. 30What are the common electrolyte abnormalities in AKI?- Rapidly progressive uraemia
    - Hyperkalaemia
    - Hypernatraemia (unless pre-renal)
    - Metabolic acidosis
    - Hypocalcaemia/hypophosphataemia (more common in CKD)
  31. 31What symptoms can uraemia give?Symptoms progress from:
    - anorexia
    - vomiting
    - pruritis
    to:
    - encephalopathy (confusion, drowsiness, fitting)
    - haemorrhagic episodes
  32. 32What, other than AKI, might cause hyperkalaemia?- Pseudohyperkalaemia
    - Drugs: supplements, K sparing diuretics, ACEIs, NSAIDs
    - Acidosis e.g. DKA
    - Addison's/Tumour Lysis Syndrome/burns
  33. 33How does hyperkalaemia present on an ECG?- Tall, tented T-waves
    - Widened QRS complex
    - Flattened P waves / prolonged PR interval
  34. 34When do you initiate emergency management of hyperkalaemia?Potassium >6.5mmol/L
    or
    ECG changes
  35. 35What is the emergency managment of hyperkalaemia?1. Continuous ECG monitoring
    2. 10ml of 10% calcium gluconate IV (repeat at 5 min intervals (mx. 3 doses) until ECG normal)
    3. 50ml of 50% glucose with 10U ACTRAPID insulin over 30 mins (large vein)
    4. Consider 10mg salbutamol nebs
    5. If pH <7.2, consider sodium bicarbonate IV if advised by renal registrar
    6. Recheck K after 2 hrs
    7. Can give calcium resonium (long term)
    8. Ensure underlying cause is treated

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(Urology) Surgery Fichas sobre AKI, creado por Liam Musselbrook el 18/07/2017.
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