What we will cover AKI CKD Hyperkalaemia Dialysis UTI Pyelonephritis Case 1 92 year old lady with poor oral intake having routine bloods done Her urea and creatinine come back raised compared to bloods yesterday ID: 1032970
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1. Renal Dr Anna Hoogkamer, FY1
2. What we will cover:AKICKDHyperkalaemiaDialysisUTIPyelonephritis
3. Case 1. 92 year old lady with poor oral intake having routine bloods done. Her urea and creatinine come back raised compared to bloods yesterday. Likely diagnosis?
4. Acute Kidney Injury
5. Acute Kidney InjuryNICE Guidelines:Rise in creatinine of >/= 26 micromole/L in 48 hoursRise in creatinine of >/= 50% in 7 daysUrine output of <0.5 ml/kg/hour for >6 hours
6. Defining AKIStageUrine OutputRelative Creatinine RiseAbsolute creatinine/creatinine riseAKI Stage 1Less than 0.5 ml/kg/hour for 6 hours1.5 to 2 fold riseGreater than 26 umol/LAKI Stage 2Less than 0.5 mg/kg/hour for 12 hours2 – 3 fold riseAKI Stage 3Less than 0.5 mg/kg/hour or anuria >12 hours>3 fold riseGreater than 350 umol/L (with more than 44 umol/L acute increase)
7. Causes of AKIPre-RenalRenalPost-Renal
8. Pre-Renal CausesHypovolaemiaSepsisDrugsDiureticsACE inhibitorsHeart failureLiver failureRenal artery occlusion
9. Renal CausesChronic kidney diseaseNephrotoxic drugsMalignant hypertensionRhabdomyolysisMyelomaHypercalcaemiaGlomerulonephritisAutoimmune diseaseHaemolytic uraemic syndrome
10. Post-RenalMechanical:Blocked catheterCalculusClotLuminal strictureExtrinsic compressionNeurological:Post-op retentionCauda equina/spinal cord diseaseDiabetic neuropathyMultiple sclerosisDrugs
11. History for AKIHypovolaemia screen i.e. thirst, diarrhoeaSeptic screen BleedingAbdominal painDizzinessBreathlessnessChest painPalpitationsConstipationUrinary symptoms
12. Uraemia screenNauseaVomitingFatigueAnorexiaMuscle crampsPruritisVisual disturbanceMental state changeIncreased thirst
13. AKI examinationABCDE assessmentFluid status
14. Management of AKIStabilise haemodynamicallyTreat life threatening hyperkalaemiaInput/output monitoringIV fluidsUrinalysisUltrasoundBloods – renal profile (bone chemistry and bicarb), FBC, CRP
15. AKI medications reviewNephrotoxics:NSAIDsAminoglycosides (antibiotics i.e. gentamicin)Renally excreted medications:MetforminLMWH in stage 2&3Antihypertensives:ACE-I/ARBs stopStop diuretics in dehydration/euvolaemiaContinue diuretics in fluid overload
16. Case 2. 84 year old gentleman admitted with LRTI. Routine bloods are sent and his eGFR comes back at 41. Likely diagnosis?
17. Chronic Kidney Disease
18. CKDGradual decline in renal function over yearsBegins to decline about age 405 stages
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20. Basic CKD ManagementLifestyle advice i.e. smoking cessation, weight management, exerciseManage cardiovascular risk – BP control Check for aneamia in CKD 3B, 4 and 5Monitor calcium phosphate and PTH levels in CKD stage 5
21. CKD Refer to NephrologyeGFR <30 mls/min (CKD stages 4 and 5)ACR more than 70 mg/mmolDecrease in GFR of 25% or more and change in CKD category within 12 monthsPoorly controlled hypertension despite at least 4 antihypertensivesRare or genetic causes of CKDSuspected renal artery stenosis
22. Case 3. You are asked to chase an ECG for a 54 year old gentleman who has some chest pain and nausea. Likely diagnosis?
23. Hyperkalaemia
24. Hyperkalaemia InvestigationsECGABG to confirm result if you suspect is inaccurateBloods – UE, Magnesium, VGB
25. ECG Hyperkalaemia Changes
26. Hyperkalaemia ECG ChangesArrhythmiasProlonged PR with flattened P wavesWide QRS with slurry ST segmentTall tented T waves
27. Medication ReviewHold K+ sparing diuretics i.e. spironolactone, amilorideHold ACE/A2RB inhibitors i.e. Ramipril, losartanReview NSAIDsIV fluidsPotassium supplements i.e. SandoKNutritional drinks
28. Plan and Treatment (follow local guidelines)If <6.5 and NO ECG CHANGESIf >6.5 OR ECG CHANGESInsulin and dextrose IVI (refer to guidelines but i.e. 10 units short-acting insulin in 100ml of 10% dextrose IV over 15-30 mins)Monitor closely for clinical and ECG changesCalcium Gluconate 10ml of 10% IV over 5 mins for cardiac protection (more slowly if on digoxin). Cardiac monitoring needed.Insulin and dextrose IV Salbutamol 5-10mg NebHold medications as appropriateRepeat bloods after treatmentMay require haemodyalisis in persistent hyperkalaemia >7, metabolic acidosis, encephalopathyGet senior help early!!!
29. Dialysis
30. Indications for Acute Dialysis (AEIOU)A – Acidosis (severe and not responding to treatment)E – Electrolyte disturbance (severe and unresponsive hyperkalaemia)I – Intoxication (overdose of certain medications)O – Oedema (severe and unresponsive pulmonary oedema)U – Uraemia symptoms i.e. seizures or decreased conciousness
31. Indications for Long Term DialysisAny of the acute indications that continue long termEnd stage renal failure (CKD stage 5)
32. Types of Dialysis1. Continuous ambulatory peritoneal dialysis2. Automated peritoneal dialysis3. HaemodialysisDepends on:Patient preferenceLifestyle factorsCo-morbiditiesIndividual patient risks
33. Case 4. 24 year old lady with urinary frequency and some pain on micturition. No abdominal pain, fevers etc. Likely diagnsosis?
34. UTI
35. Uncomplicated UTI 1st Line Treatment:Nitrofurantoin PO every 6 hoursWomen: 3 daysMen or complicated: 5-7 days
36. Case 5. 78 year old lady with increased frequency of urination, non-specific abdominal pain, fever. Likely diagnosis?
37. Pyelonephritis
38. PyelonephritisPatient <65 years:Co-amoxiclav IVPatient >65 years:Co-amoxiclav IV every 8 hoursRemember to check penicillin allergy!Think Sepsis!!BUFALO
39. Things I haven’t covered..Renal transplantGlomerulonephritisDiabetic neuropathyAcute tubular necrosisRenal tubular necrosisInterstitial kidney diseaseHaemolytic uraemic syndromePolycystic kidney disease
40. SummaryAKI – treat with IV fluids (unless in overload), stop nephrotoxics, identify causeCKD – control BP and lifestyle modificationsHyperkalaemia – emergency!! Get senior support and follow protocolUTI – start with oral antibiotics where possiblePyelonephritis – IV antibiotics might be needed, think sepsis!
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