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AKI - Coggle Diagram
AKI
Therapeutic Goal Monitoring
daily pt weight
Pt Fluid ins & outs, urinalysis
Hourly BP, HR, MAP
Daily BMP, BUN, SCr (for CrCl), BG
Therapeutic monitoring of renal cleared drugs to assess dosing regimens prn
Therapeutic Goals
Maintenance of BP/fluid/electrolyte homeostasis
Minimizing degree of injury to the kidney
Reducing extrarental complications
Expediting recovery of renal function
Diagnostic Criteria
Differentiating factors
Urinary sediment, urinary RBC, urinary WBC, Urine Na, FENa, urine specific gravity
Signs/Symptoms
(highly variable and depend largely on etiology); abrupt rise in SCr, decreased urine output, change in urine color, edema, electrolyte disturbances, sudden weight gain, flank/abdominal pain
Baseline kidney function important to obtain; use average CrCl of 75 mL/min if unknown
TIMP-2 & IGFBP7 - biomarkers used to detect early signs of AKI
Non-Pharm/CAM
Treatment
Remove nephrotoxin sources; hydration; maintenance of renal perfusion; nutritional control
Prevention
IV fluids (in setting of volume depletion); remote ischemic preconditioning (period of hypoperfusion followed by hyperperfusion, cytoprotective molecules released; Ascorbic acid (relieves oxidative stress caused by ischemia); NAC (up for debate); statins (protective effects); glycemic control
Treatment
Fluids
Crystalloid
: smaller molecules
2012 KDIGO guidelines recommend isotonic crystalloids > colloids for intravascular volume expansion In patients at risk for AKI
Balanced solutions
Lactated Ringers
Can be problematic In hepatic disease (requires metabolism); K+ content can be a problem
Isotonic saline
NS (0.9%)
Remains most common resuscitation fluid
Issues arise when large volume of replacement Is needed (5-10L) > dumping a lot of Na and Cl, contributing to metabolic acidosis
Isotonic solutions remain In ECF space
Lactated Ringers
Plasmalyte
isotonic 250-375 mOsm/L
Hypotonic
D5W
1/2 NS (0.45%)
Hypertonic
3% Saline
D5W In 1/2 NS
D10W
Colloid
: large organic molecules (proteins, blood products); remain In Intravacular space
Albumin
Dextran
Free Frozen Plasma (FFP)
Packed Red Blood Cells (PRBC)
Although effective for resuscitation, routine use Is not warranted; no benefit over crystalloids In mortality
Use associated with coagulopathy and analphylaxis
More expensive
Indication
: resuscitation > acutely expand Intravascular volume In hypovolemic states and replace extracellular losses
Maintenance
: daily needs ~ 25-30 mL/kg/day In adults
Water: 25-30 mL/kg/day
Na and K: 1 mEq/kg/day
Glucose: 50-100 g/day
Rate of replacement
: depends on severity of fluid loss
Severe volume depletion: at least 1-2 L isotonic fluids given ASAP
Mild/moderate volume depletion: greater than the rate of continued fluid losses, which is equal to the urine output plus estimated insensible losses (usually 30 to 50 mL/hour) plus any other fluid losses
Monitoring
: fluid Intake and urine output, pulmonary/peripheral edema, BP (target MAP >/= 65), serum electrolytes
Urine output >/= 0.5 mL/kg/hr targeted during Initial fluid resuscitation phase
Renal Replacement Therapy (RRT)
Severe AKI
Indications for RRT:
A: acid- base abnormalities (metabolic acidosis (especially If pH < 7.2)
E: electrolyte Imbalance (severe hyperkalemia and/or hypermagesemia)
I: Intoxications: salicylates, lithium, methanol, ethylene glycol, theophylline, phenobarbital)
O: fluid overload (especially pulmonary edema unresponsive to diuretics)
U: uremia (or associated complications - neuropathy, encephalopathy, pericarditis)
Risk Factors
presence of CKD, decreasing eGFR, diabetes, heart.liver disease, albuminuria, major surgery, sepsis, acute decompensated heart failure, hypotension, volume depletion, medications, male gender, old age, AA race
Nephrotoxic drugs
Causes
Prerenal (decreased renal perfusion), intrinsic (structural damage), post renal (obstruction of urine flow)