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What are the signs of Prerenal AKI?
- Urine sediment: Hyline casts may be normal
- Urinary RBC: None
- Urinary WBC: None
- Urine Na: <20
- FE(Na) %: <1
- Urine serum osmolality: >1+
- Urine Cr/Serum Cr: >40:1
- BUN/SCr: >20
- Urine specific gravity: >1.018
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What are the signs of Intrinsic AKI?
- Urine sediment: Granular casts cellular debris
- Urinary RBC: 2-4+
- Urinary WBC: 2-4+
- Urine Na: >40
- FE(Na) %: >2
- Urine serum osmolality: <1.3
- Urine Cr/Serum Cr: <20:1
- BUN/SCr: ~15
- Urine specific gravity: <1.012
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What are the signs of Postrenal AKI?
- Urine sediment: Cellular debris
- Urinary RBC: Variable
- Urinary WBC: 1+
- Urine Na: >40
- FE(Na) %: Variable
- Urine serum osmolality: <1.5
- Urine Cr/Serum Cr: <20:1
- BUN/SCr: ~15
- Urine specific gravity: Variable
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An FE(Na) of <1% indicates what?
- Prerenal/functional AKI
- Tubular function intact
- Can reabsorb Na and Concentrate
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An Fe(Na) of >1% indicates what?
- Acute Intrinsic AKI
- Tubular damage
- CANNOT reabsorb Na and Concentrate
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What is a normal urine osmolality?
>500
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What urine osmolality indicates that the patient cannot concentrate urine?
<350
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What BUN/Cr ratio indicates pre-renal injury?
>20
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What BUN/Cr indicates non-pre-renal injury?
<20
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What drugs are not useful in AKI?
- Loop diuretics
- Low dose dopamine (arrhythmias)
- Atrial natriuretic peptide
- Fenoldopam (DA agonist)
- Recombinant human insulin-like growth factor
- N-acetylcysteine
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What drugs have a definite/possible benefit in prevention of AKI?
- Normal saline infusion
- Sodium bicarbonate infusion
- Ascorbic acid
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How would you administer Saline to prevent AKI?
- Normal saline IV
- 1 mL/kg/h
- 3-12h before and 6-24h after procedure
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How would you administer a Sodium bicarbonate infusion to prevent AKI?
- NaHCO3 IV drip
- 154 mEq/L infused at 3 mL/kg/h
- 1h before and 1 mL/kg/h for 6h after procedure
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How would you administer Ascorbic acid to prevent AKI?
- 3g PO before
- 2g po BID x2 after the procedure
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What are the indications for renal replacement therapy?
- A= Acid-base abnormalities
- E= Electrolyte imbalance
- I= Intoxications
- O= Fluid Overload
- U= Uremia
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By what modes can substances be removed from blod using dialysis?
- Diffusion
- Convection
- Adsoprtion
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Which removes more drugs, IHD or PD?
IHD
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A patient on dialysis will require anticoagulation to avoid coagulation on the dialysis membrane, tubing or catheter, what is an appropriate anticoagulant?
- Regional anticoagulation
- Intermittent RRT: UFH or LMWH (sometimes saline)
- CRRT: Regional citrate anticoagulant
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What is the MOA of Regional citrate anticoagulant?
Chelates Calcium
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What diuretics can you use in a non-oliguric fluid overloaded Aki patient?
- First try: Furosemide 40-80 mg and assess status after that
- Can also use: Butenamide, Torsemide and ethacrynic acid
- Can give Loop + Thiazide to avoid diuretic resistance (Chlorthizide or Metolazone 5 mg 30 min before loop)
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What is Anuric?
UOP of <50 mL/day
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What is Oliguric?
UOP of 50-500 mL/day
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What is Nonoliguric?
UOP > 500 mL/day
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What are the general definitions of AKI?
- Elevation of SCr > or = to 0.5 mg/dL above normal
- Elevation of SCr > or = to 1 mg/dL above normal for CKD patients
- UOP <0.5 mL/kg/h
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What are AKIN definistions of AKI?
- Increase in SCr > 0.3 mg/dL
- Increase in SCr > 1.5 times baseline
- UOP < 0.5 mL/kg/h for 6 hours
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What are AKIN stages of AKI?
- Stage 1: >/= 0.3 mg/dL increase or 1.5-2x baseline, UOP <0.5 mL/kg/hr 6 or more hours
- Stage 2: 2-3x increase from baseline, UOP <0.5 for 12 hrs
- Stage 3: >3x increase from baseline, SCr >/= 4, HD or acute increase of >/= 0.5 mg/dL, UOP <0.3 for 24 hours or anuria for 12
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Prerenal azotomia general cause:
- Volume depletion
- Functional = hemodynamic changes in the glomeruli
- Hypoperfusion of renal parenchyma
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Intrinsic AKI general cause:
Structural damage
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Post renal AKI general cause:
Obstruction to urine outflow
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What are the causes of Prerenal AKI with Hypotension?
- Intravascular depletion
- Dehydration, Hemorrhage, CHR and HYPOtension
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What are the causes of Prerenal AKI without Hypotension?
- Renal arterial stenosis
- Kidney emboli
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What generally causes functional AKI?
- Decrease in glomerular hydrostatic pressure W/O damage to the kidney
- Due to changes in afferent and efferent arteriolar circumference
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What drugs cause an increase in afferent resitance, and thus Functional AKI?
NSAIDs, CSA
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What drugs cause a decrease in efferent arteriole resistance and thus Functional AKI?
ACEIs and ARBs
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What is the most common cause of intrinsic AKI?
Necrosis due to either tubular toxins or extended prerenal state
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What drugs can cause tubule toxicity (and thus Intrinsic AKI)?
- Contrast Dye
- AGs (-micin)
- Amotericin B
- Myoglobin
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What drugs can cause Postrenal AKI by renal pelvis or tubule obstruction?
- Acyclovir
- Methotrexate
- Sulfonamide
- HCTZ (increase Ca)
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What are normal symptoms of AKI?
- Change in urinary habits
- Weight gain
- Flank pain
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What lab tests would you order for AKI determination?
Urine, blood chemistries, CBC w/ differential, microscopic analysis of urine
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What are the signs of AKI?
- Edema
- Urine discoloration
- Hypotension
- Petechiae
- S3 Heart sounds
- Ascites
- Rales
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