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Renal 07 ARF/AKI

Thomas: Clinical aspects of Acute Renal Failure/Acute Kidney Injury

What is the definition of Acute Renal Failure (ARF)? Sudden decline in the ability of the kidney to maintain fluid and electrolyte homeostasis [Lesser of the following] Increase of serum Creatinine >=0.3 mg/dL in 48 hours Increase in serum creatinine >50% in 48 hours.
What changes in creatinine define ARF? [Lesser of the following] Increase of serum Creatinine >=0.3 mg/dL in 48 hours Increase in serum creatinine >50% in 48 hours.
What might you see clinically in a pt with ARF? Abrupt onset of: edema, hematuria, hyper/hypotension, cardiac dysrhythmias, malaise/fatigue, oliguria, altered mental status
What are the three types of ARF? Prerenal Intrinsic Postrenal
What's up with Prerenal? Secondary to renal hypoperfusion Absolute hypovolumemia Decreased effective arterial blood volume
What can cause Postrenal ARF? Obstructions (stones, masses, blood clot) [After kidney=tubules, so it must be a blockage]
What type of things do you look for in the initial workup of ARF? Recent illness (medications), new prescriptions, chest pain, SoB, orthopnea, Vomiting/diarrhea, decrease urine output
List some potentially nephrotoxic drugs. ACEI/ARBs Aspirin NSAIDs Gentamicin
What co-morbid conditions may contribute to Prerenal ARF? CHF Liver Disease BPH Coronary artery disease
What kind of things might a pt have taken/overdosed? Methanol Ethylene glycol Isopropyl alcohol Blood pressure pills
What physical exam test would you do? Volume status assessment (BP, HR, mucus membranes, Edema/LVD/Crackles) Pericardial rub or knock Signs or otehr predisposing co-morbid conditions.
What is the definition of orthostatic hypotension? Decrease in 20 systolic or 10 diastolic while going from sitting to standing.
What physical exam findings would you expect to see in a pt with chronic liver dz and/or cirrhosis? Jaundice, proteinuria, haptomegaly, gynecomastia, caput medusa, small testicles
What things would you do at the pts bedside? Bladder scan (pre and post-void)[small change or ~300mL post-void may point to obstruction) Insert Foley Cath Strictly record fluid input and output
What labs would you order? Urinalysis, which includes: Specific gravity, Urine osmolaoity, casts, hematuria, and proteinuria
If a pt has high SpGr, what would you expect the Uosm to be? High Usom
How do we calculate FeNa? FeNa= (Una*Serum Cr)/(Serum Na*Una)*100
When do you use FeUr instead of FeNa? If the pt is taking a diuteric
What will you see in FrNa and FeUr for Prerenal dz? FeNa<1% Fe Ur <35%
What will you see in FrNa and FeUr for Intrinsic dz? FeNa>2% Fen > 50%
What are you looking for on renal ultrasound? Size Echogenicity Presence/absence of hydronephrosis Nephrolithiasis Number of Kidneys
True/False ARF cna be defined as an increase in serum creatintine >25% in 48 hours. False, it's an increase >50% in 48 hours.
List some possible causes of Postrenal ARF. BPH Kidney stones/blood clots Pelvic Malignancy Lymphoma (predisposes to retroperitoneal fibrosis) Neurogenic bladder
How do you make the Dx of postrenal ARF? 1. Obtain pre/post-void residuals using bladder scan and place Foley catheter 2. Renal ultrasound 3. Prostate Exam
How do you treat postrenal ARF? 1. Treat the underlying cause 2. Foley cath placement imperitive 3. May require urological intervention
What's the prognosis for postrenal ARF? It's typically favorable as long as the acute obstruction is relieved within ONE WEEK
True/False Postrenal obstruction should be sispected in pts who report recently passing of clots. True
What volume in a post-void bladder makes you suspicious of postrenal ARF? >300 ccs
True/False Postrenal obstruction can be ruled out if <=300 ccs of urine are seen on post-void bladder scan False
What's the etiology of prerenal ARF? Lack of kidney fxn (occurs if MAP <60) Kidney essentially starved of blood
What in a pts Hx would make you suspect prerenal ARF? If they have absolute or effective hypovolemia.
List some causes of Absolute hypovolemia. Dehydration No access to water Excessive diuresis GI bleed or other hemmorrhage
Name some causes of Effective hypovolemia. Decreased circulating volume CHF Advanced Liver Disease Septic Shock Cardiac Tamponade
What are some physical exam findings you'd see with prerenal ARF? Low/low-normal BP Orthostatic hypotension Tachycardia Dry mucus membranes
What lab values would you see in a pt with prerenal ARF? BUN/Cr ratio >=20:1 Increased SpGr on Ua (>1.025) Increased Uosm (>500) FeNa <1% or FrUr <35%
What is the Tx for Prerenal ARF? Treat underlying cause Stop all BP meds, especially ACEI/ARBs Stop diuretics Volume resuscitation with normal saline
What would extended Tx involve? Frequent BP checks Strict monitoring of ins & outs Repeat physical for volume status Daily BMP to trend creatintine
True/False A BUN/Cr ratio of >= 20:1 supports the Dx of prerenal ARF. True
True/False Prerenal ARF can be ruled out in patients who appear to be volume overloaded. False
True/False Uosm and specific gravity should be decreased in pts with prerenal ARF False Sp Gr is increase (>1.025) and Uosm is high (>500)
True/False ARF in a common finding in a hospitalized pt. True
Name some of the initial work-up for a pt with ARF Foley cath bedside bladder scan UA, Uosm, FeNa/FeUr Renal ultrasound
Created by: bcriss