What key parts should we ask about in HPC section of a history taken from the patient with AKI? (key symptoms)
HPC:
- Events preceding illness
- Hydration status
- Urine output
- Obstructive symptoms
- Possible focus of infection
What to ask in Symptoms of vasculitis/**autoimmune disease in Hx of AKI patient?
Symptoms of vasculitis/autoimmune disease
- uveitis
- epistaxis
- hearing loss
- sinusitis
- mouth ulcers
- haemoptysis
- bloody diarrhoea
- joint pain
- rash
- anorexia
- weight loss
Hx taking from pt presenting with AKI. What to ask for in PMH?
- Risk factors for AKI
- Renal disease
What elements of examination of pt with AKI to focus on?
- Pulse / BP / SaO2
- Urine output
- Hydration status
- Palpable bladder
- loin tenderness
- Evidence of systemic illness
- Infective focus
The general approach to finding the cause of AKI
Indications for renal biopsy (3)
Renal biopsy
- suspicion of vasculitis
- likely intrinsic disease
- unexplained / not recovering
What bloods to perform in AKI Ix?
- U&E
- HCO3, Ca2+ profile
- LFTs
- FBC
- Clotting
- ESR
- Immunoglobulins / electrophoresis
What (other then bloods) Ix to do in AKI?
- MSSU (mid stream specimen urine)
- PCR/ ACR
- ECG
- CXR
- USS kidney/ bladder
What ‘renal screen’ in investigations consist of?
Renal Screen
- ANCA, Anti GBM, ANA, dsDNA, Complement
- CK Blood cultures
- blood film
- cryoglobulins (specific immunoglobulins)
- PSA
Risk factors for AKI
Risk factors for AKI include:
- chronic kidney disease
- other organ failure/chronic disease e.g. heart failure, liver disease, diabetes mellitus
- history of AKI
- use of drugs with nephrotoxic potential (e.g. NSAIDs, aminoglycosides, ACE inhibitors, angiotensin II receptor antagonists [ARBs] and diuretics) within the past week
- use of iodinated contrast agents within the past week
- age 65 years or over
- oliguria (urine output less than 0.5 ml/kg/hour)
- neurological or cognitive impairment or disability, which may mean limited access to fluids because of reliance on a carer
Signs and symptoms of AKI
Many patients with early AKI may experience no symptoms
As renal failure progresses the following may be seen:
- reduced urine output
- pulmonary and peripheral oedema
- arrhythmias (secondary to changes in potassium and acid-base balance)
- features of uraemia (for example, pericarditis or encephalopathy)
Management of AKI
- adequate hydration
- correction of hypotension – fluid -> Inotropic support
- aAppropriate level of care
- Exclude obstruction
- treat underlying causes e.g. sepsis
- stop / avoid nephrotoxins
- monitor input/output
- treat complications
- renal referral
What are indications for dialysis in AKI?
Indications for dialysis:
- hyperkalaemia
- pulmonary oedema
- uraemic encephalopathy
- uraemic pericarditis
- severe metabolic acidosis
What’s hyperkalaemia?
Serum Potassium > 5.5mmol/L
What’s hyperkalaemia?
Serum Potassium > 5.5mmol/L
What is the cause of hyperkalaemia in AKI?
Result of either
- increased release from cells
- decreased excretion – 90% excreted by kidneys
What are (2) major consequences of hyperkalaemia?
- lower cell-resting action potential -> delays conduction
- muscle weakness -> paralysis
- cardiac conduction abnormalities -> arrhythmias and cardiac arrest
ECG changes in hyperkalaemia: with potassium level of 6-7
ECG changes in hyperkalaemia, with a potassium level of 7-8
ECG changes in hyperkalaemia with a potassium level of 8-9
ECG changes in hyperkalaemia with potassium level of 9 or above
Sine wave pattern
(3) treatment strategies of hyperkalaemia
Treatment strategies
1. Stabilising cardiac cell membrane -> calcium gluconate
2. Driving extracellular K+ into cells -> combined insulin/dextrose infusion & Nebulised salbutamol
3. Removing excess K+ from the body:
- Calcium resonium (orally or enema)
- Loop diuretics
- Dialysis
Treatment of Pulmonary Oedema
- IV Furosemide
- IV GTN
- CPAP
*all may buy time until dialysis possible
F L U I D (mnemonic in Mx of AKI)
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ADR39
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Glomerulonephritis (1)38
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Glomerulonephritis (2)27
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Imaging of renal tract45
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Renal pathology30
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Genetics: Renal Disease41
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Assessment of patient with reduced consciousness55
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High risk medications and never events14
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Renal Disease and Pregnancy (1)40
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Renal Disease and Pregnancy (2)22
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SIM session 420
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Lab 5: Biochemistry in renal disase (1)40
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Lab5: Biochemistry in renal disase (2)37
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IV fluids36
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Microbiology Lab Investigations23
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Yellow Card Scheme20
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CAT (PP) lecture43
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AKI lecture28
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Paediatric renal problems55
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Biologics48
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Patient with renal tumors42
