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What is the definition of anuric?
urine output < 50mL/d
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What is the definition of oliguric?
urine output < 500mL/d
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What is the definition of nonoliguric?
urine output >500mL/d
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What are the characteristics of RIFLE?
- R = risk of dysfunction; SrCr up 50%; GFR down 25%, UO < 0.5mL/kg/h for 6h
- I = injury to kidney; SrCr up 100%; GFR down 50%; UO < 0.5mL/kg/h for 12h
- F = failure of kidney; SrCr up 200%; GFR down 75%; UO < 0.3mL/kg/h for 24h or anuria for 12h
- L = Loss of function; persistent ARF > 4wks
- E = End-stage renal disease; ESRD > 3mo
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What is the definition of prerenal ARF?
- decreased renal perfusion in the setting of undamaged parenchymal tissue
- NSAIDS, ACE, ARB, dehydration, B-blockers
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What is the definition of intrinsic ARF?
- result of structural damage to the kidney - most commonly the tubule from ischemic or toxic insult
- nafcillin
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What is the definition of postrenal ARF?
- caused by obstruction of urine flow downstream from the kidney
- obstruction d/t prostatic process (enlarged prostate)
- improperly placed urinary catheter
- neurogenic bladder
- too many anticholinergics
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What are the causes of decline in IV blood volume leading to prerenal azotemia?
- acute blood loss
- dehydration
- hypoalbuminemia
- diuretic therapy
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How is renal vascular damage usually caused?
atherothrombi dislodged during a procedure or thromboemboli from pts with severe heart failure or atrial fibrillation
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What is the cause of glomerular damage?
- severe inflammatory processes as seen in SLE and poststreptococcal glomerulonephritis
- emboli
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What is the cause of 85% of ARF?
tubule damage (acute tubular necrosis)
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What is the cause of 50% of ARF?
renal ischemia
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What is the cause of 35% of ARF?
- exposure to direct tubule toxins:
- myoglobin
- hemoglobin
- uric acid
- contrast dyes
- heavy metals
- aminoglycosides
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What are the effects of tubular injury?
- inability to concentrate urine
- defective distal sodium reabsorption
- decrease in GFR
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What is the time frame for the maintenance and recovery phases of acute tubular necrosis (ATN)?
2-3 wks per phase
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What are the most common causes of interstitial damage?
- medications
- bacterial or viral infections
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What type of dialysis should be used to treat hypokalemia?
hemodialysis
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What is the mechanism for renal failure d/t concomittant use of NSAIDs and ACE/ARBs?
constriction of afferent arterioles (NSAIDs) and dilation of efferent arterioles (ACEI)
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What is urine sodium in prerenal?
< 20
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What is urine sodium in intrinsic and postrenal?
> 40
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What is FENa % in prerenal?
<1
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What is FENa % in intrinsic?
>2
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What is FENa % in postrenal?
variable
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What is osmolality in prerenal?
> 1.5
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What is osmolality in intrinsic?
< 1.3
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What is osmolality in postrenal?
< 1.5
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What is urine/SCr in prerenal?
> 40:1
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What is urine/SCr in intrinsic and postrenal?
< 20:1
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What is BUN/SCr in prerenal?
> 20
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What is BUN/SCr in intrinsic and postrenal?
about 15
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What is the FENa equation?
FENa = (UNa x SCr x 100)/(UCr x SNa)
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What meds disrupt the usefulness of FENa?
diuretics
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At what [K] is immediate tx of hyperkalemia required?
- > 7.0
- b/w 6.1-6.9 if ECG changes present
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How do you treat hyperkalemia?
- lasix
- kayexelate (cation exchange for Na)
- Calcium gluconate or chloride (stabilizes the heart)
- sodium bicarb (pushes intracellular)
- insulin and glucose (pushes intracellular
- beta agonists (pushes intracellular)
- dialysis
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What should be remembered about Metformin and ARF?
Metformin doesn't cause ARF, but it does need to be stopped in ARF
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What is the Ca x Phosphorus product goal value?
< 55 mg/dL
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At what Ca x Phosphorus product value does mortality increase?
72 mg/dL
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What are the medical issues associated with hyperphosphatemia/hyperparthyroidism?
- alterations in lipid metabolism and insulin secretion
- resistance to erythropoieten tx
- myocardial, skeletal muscle, neurologic and immune dysfunction
- vascular calcification, renal osteodystrophy
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What drugs are used to treat hyperphosphatemia?
- calcium acetate or carbonate (Phoslo)
- Sevelamer
- Lanthanum
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What is first line tx for hyperphoshpatemia?
- sevelamer
- calcium acetate/carbonate (Phoslo) if no insurance or if Ca < 8.2
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What drugs are used to tx hyperparathyroidism?
- vitamin D3 (Calcitriol, Rocaltrol)
- vitamin D2 (Zemplar)
- Cinacalcet
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Why do pts with chronic renal failure have anemia?
- blood draws
- hemodialysis
- iron deficiency
- decreased erythropoietin production
- uremia build-up
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When does work-up start for anemia?
- Hgb < 12 premenopausal
- Hgb < 13.5 postmenopausal and men
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What is the goal for CKD?
- 11-12g/dL
- begin tx at about 9g/dL
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What is the goal for transferrin saturation?
> 20%
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What is the goal for serum ferritin?
> 100ng/mL
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What is the goal for serum iron?
65-185mcg/dL
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What drugs are used to tx anemia secondary to renal failure?
- epoetin alfa/darbepoetin alfa (Epogen, Procrit, Eprex)
- Iron (Slow Fe, Ferrin-Sol, Feratab, Mol-Iron, Feosol)
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How should iron be taken?
on an empty stomach to increase absorption
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What is SCUF (slow continuous ultrafiltration) used for?
- only for fluid control
- no dialysate
- no replacement fluid
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What is CVVH (continuous venovenous hemofiltration) used for?
- fluid and some solute removal
- replacement fluid
- no dialysate
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What is CVVHD (continuous venovenous hemodialysis) used for?
- greater solute removal, less fluid removal
- dialysate
- no replacement fluid
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What is CVVHDF (continuous venovenous hemodiafiltration) used for?
- fluid removal plus solute removal (small and large particles)
- dialysate
- replacement fluid
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What is the MW cutoff to get through the peritoneum in or out?
5200 Dalton
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What is the MW cutoff for low efficiency, conventional dialysis?
> 500 Dalton
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What is the MW cutoff for high efficiency, conventional dialysis?
> 2,000 Dalton
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What is the MW cutoff for high efficiency, high flux dialysis?
> 12,000 Dalton
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