AKI

Question 1

AKI

Answer 1

An abrupt (within 48 hours) reduction in kidney function currently defined as:
◦ Absolute increase in Scr of ≥ 0.3mg/dL OR
◦ Increase in Scr ≥ 50%(≥ 1.5 x baseline), within the prior 7 days OR
◦ A reduction in urine output (documented oliguria of< 0.5 ml/kg/hr for > 6 hours)

Question 2

Drug Induced Hemodynamic AKI

Answer 2

-ACEI/ARB
-Cyclosporine/Tacrolimus
-Diuretics
-NSAIDS/COX II INH

Question 3

Acute Tubular Necrosis - Nephrotoxins

Answer 3

-Aminoglycosides
-Amph B
-Cisplatin, carboplatin
-Cyclophosphamide
-Ifosfamide
-Pentamidine
-Radiocontrast media
-Vancomycin

PRIV CACA

Question 4

Acute Interstitial Nephritis - Nephrotoxins

Answer 4

-NSAIDS
-Quinolones
-Penicillins
-Sulfonamides
-Rifampin, vanco

Question 5

Obstructive Nephropathy

Answer 5

• Acyclovir
• Allopurinol
• Indinavir
• Nelfinavir
• Methotrexate
• Quinolones
• Sulfonamides
• Triamterene

Question 6

Goals of Therapy

Answer 6

• Prevent AKI if possible
• Reduce morbidity (progression to ESRD) and mortality
• Avoid or minimize further insults
• Provide supportive treatment of AKI
• Return of kidney function to baseline

Question 7

Volume Status

Answer 7

• Hydration
  -Sodium chloride or sodium bicarbonate preferred (help renal blood flow)
  -Sodium loading beneficial
  -Prevent overload

NaCl 0.9% 1L over 2 hr

Question 8

Vasopressors

Answer 8

For hemodynamic AKI
-only if pt is resuscitated
-norepinephrine, dopamine, vasopressin
-low dose dopamine <= 2 mcg/kg/min

Question 9

Loop Diuretics

Answer 9

Reserved for volume overload
-convert oliguric AKI to non-oliguric AKI
-patients who are volume overloaded and respond to initial dose of loop diuretic
-but increased mortality in ICU pts with AKI

Question 10

Indications for Acute Dialysis

Answer 10

-Acidosis (ph<7.1)
-Electrolytes (K>6.5)
-Intoxication (overdose)
-Overload (edema, weight gain, pulmonary congestion)
-Uremia (pericarditis, mental status, neuropathy)

Question 11

Intermittent Hemodialysis (IHD)

Answer 11

• Patients with hemodynamic stability
• Overdose cases
• Hyperkalemia

Question 12

Continuous Renal Replacement Therapies (CRRT)

Answer 12

• Hemodynamic instability
• ICU patients are catabolic, better control of uremia
• Excessive volume overload
• Sepsis, SIRS (?)

Question 13

Dialysis Prescription: IHD

Answer 13

Question 14

Dialysis Prescription: CRRT

Answer 14

Question 15

Types of CRRT: CVVH

Answer 15

• Continuous venovenous hemodiafiltration
• Convective and diffusive clearance
• Dialysate and replacement solutions (20 L)
• Blood flow maintained by pump

Question 16

Determinants of Drug Removal by Dialysis

Answer 16

• Protein Binding
• Volume of Distribution
• Molecular Weight
• Drug Charge?
• Type of modality
• Effluent flow rate
• Blood flow rate
• Fluid replacement (pre/post)
• Hemofilter

Question 17

Protein Binding

Answer 17

Drugs with a high degree of protein binding (>90%) are less likely to be removed by dialysis
-most important determinant of drug removal by hemodialysis or CRRT

Question 18

Volume of Distribution

Answer 18

Drugs with small Vd
(< 0.3 L/kg)are located in the intravascular space and more
likely to be removed by dialysis

Drugs with large Vd (> 1 L/kg) are likely distributed at other tissue sites

Question 19

Molecular Weight

Answer 19

• Most drugs have a MW < 1500 daltons (1 Da=1 g/mol)
• MW is not a major determinant of removal since new hemofilters have large pore size

Question 20

____ Doses of Fluconazole are Needed in CRRT

Answer 20

HIGHER

Question 21

Dose Adjustments for Patients with AKI

Answer 21

-IV drugs to bypass absorption issues

Adjust the loading dose of hydrophilic drugs to account for increased Vd
-If Vd doubles, double loading dose
-but reduce once Vd decreases

Question 22

Etiology

Answer 22

HEMO
-Volume depletion, decreased circulating volume, hypotension, shock, renal vascular occlusion, AA constrictors, EA dilators

INTRINSIC
-Glomerular disorders, acute tubular necrosis, interstitial nephritis (GIT)

OBS
-Nephrolithiasis, BPH, pregnancy, cancer (PBNC)