9. AKI.pdf - ACUTE KIDNEY INJURY Megan Dunning, MD UW...

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ACUTE KIDNEY INJURYMegan Dunning, MDUW Global and Rural Health FellowEgerton University, October 2018
What is AKI?OROR
Basic Kidney Function¨When we understand normal renal function, we also understand whathappens to the kidney when it is injured.NORMALCOMPLICATIONMaintain EuvolemiaàVolume OverloadMaintain Blood PressureàHypertensionMaintain Electrolyte BalanceàHyperkalemiaExcrete UreaàUremia
AKI FrameworkPre-Renal AKIPost-Renal AKIIntra-Renal AKI
AKI FrameworkPre-Renal AKIHypovolemia / DehydrationHemorrhage, Vomiting, Diarrhea, BurnsSepsisCCFCirrhosisDrugsNSAIDS, Contrast, Amphotericin, ACE/ARBsPost-Renal AKI / ObstructionLower Tract ObstructionBPH, Urethral Stricture, Tumor, Neurogenic BladderUpper Tract ObstructionRenal Stone, TumorIntra-Renal AKIDrugsAntibiotics, NSAIDS, Contrast, Amphotericin,Tenofovir, Abacavir, Rifampin, Proton Pump InhibitorsGlomerulonephritisANCA Vasculitis, anti-GBM, Immune Complex DepositsRenal Artery Stenosis / Vein ThrombosisRhabdomyolysisMultiple MyelomaToxinsEthylene GlycolLupus NephritisPyelonephritisTumor Lysis Syndrome
Diagnosis¨Order urinalysis with microscopy to check for cells, casts, and protein.¨In patients with oliguria, the fractional excretion of sodium (FENa) helps differentiate between pre-renal AKI andintra-renal AKI, i.e. acute tubular necrosis (ATN). FENa <1% indicates pre-renal AKI, whereas FENa >2%indicates ATN.¨In patients taking diuretics, fractional excretion of urea (FEUrea)<35% is used to diagnose pre-renal injury.¨Order renal ultrasound to rule out post-renal AKI, i.e. obstructive uropathy.ConditionUrine Sodium (mEq/L)FENaUrinalysis with MicroscopyPre-Renal AKI< 20< 1%Specific Gravity >1.020,Normal +/- Hyaline CastsIntra-Renal AKIAcute Tubular Necrosis (ATN)> 40>2%Muddy Brown CastsAcute Interstitial Nephritis (AIN)VariableVariableMild Proteinuria,Leukocyte Casts,EosinophiluriaAcute GlomerulonephritisVariableVariableProteinuria,Dysmorphic Erythrocytes,Erythrocyte CastsPost-Renal AKIVariableVariableVariable, Bland
Case 1¨35F presents with abdominal pain x 3 months. She has been taking ibuprofen6x/day to manage the pain. The patient now reports worsening abdominal pain,fatigue, and melena x 3 days. She is otherwise healthy without significant PMH.On exam, she is afebrile with HR 115 and BP 98/72. Investigations reveal HB8.5, Cr 220, and BUN 25. You appropriately diagnose UGIB secondary to PUDand start omeprazole and ranitidine IV. The patient continues to report severepain. What is your next step in diagnosis/management?

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Term
Spring
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AKI

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