AKI Patho Fall 2012 Updated version

Orthostatic hypotension skin tenting signssymptoms of

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Orthostatic hypotension Skin tenting Signs/symptoms of volume overload Edema Pulmonary rales S3 heart sound Ascites
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TP, a 72kg male urinated 16ml/hr over the past 24 hrs. How would you best quantify his urine production? 1. Anuric 2. Oliguric 3. Nonoliguric 4. Normal
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Does TP have AKI? 1. Yes 2. No 3. Need more information
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Laboratory Abnormalities ↑ SCr Is not sensitive to rapid changes in GFR Look at trends Cannot be used quantitatively GFR and creatinine clearance Not accurate for patients with changing SCr values
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Laboratory Abnormalities Urine output More reliable than GFR/creatinine clearance Anuria – complete renal failure Oliguria –kidney damage Depends on hydration status & medications
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Laboratory Abnormalities BUN:SCr ratio > 20:1 Dehydration Seen with functional or prerenal failure Normal (15:1) in ATN or post renal obstruction Electrolyte abnormalities Metabolic acidosis Accumulation of hydrogen ions
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Urinalysis (UA) Sediment Presence indicates kidney damage (ATN) or inflammation Absent in prerenal AKI Protein Moderate amount in ATN Low or absent in prerenal AKI
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Urine Chemistry Specific gravity Low in ATN High in prerenal failure Urine osmolality: Serum osmolality > 1.5 associated with prerenal failure < 1.5 associated with ATN or post renal obstruction
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Urinalysis (UA) Urine Sodium Lower (<20 mEq/L) in prerenal failure Elevated (>40 mEq/L) in ATN or post renal obstruction
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Urinalysis (UA) Fractional excretion of sodium (FENa) Good diagnostic parameter to differentiate AKI etiology Not accurate with recent diuretic use % of filtered Na that is excreted into urine <1% = prerenal failure >2% = intrinsic failure FENa(%) = (UNa)(SCr) (UCr)(SNa) *100
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Summary of Urine Laboratories Prerenal/ functional ATN Obstruction Sediment None Yes Yes Protein None Moderate None Specific Gravity >1.018 <1.012 Variable Urine:serum osmolality >1.5 <1.5 <1.5 Urine Sodium (mEq/L) <20 >40 >40 FENa (%) <1 >2 variable
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What type of AKI does my patient have? Use RIFLE Criteria to tell whether or not a patient has AKI To identify the type of AKI, look at urine laboratories & patient presentation
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Case LR, a patient with massive surgical blood loss After surgery, she remained hypotensive for one week (max BP 100/60 mmHg) despite appropriate treatment BUN and SCr increased progressively: (BUN: 46 to 75 to 80mg/dl; SCr: 2.3 to 3.6 to 5.1mg/dl)
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Do you have enough information to determine the type of AKI? 1. Yes 2. No
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LR’s Day 7 Laboratory Values Serum Na = 145 K = 4.7 BUN = 77 Creatinine = 5.1 Osmolality = 279 Urine Sediment = epithelial cells Protein = moderate Specific Gravity = 1.008 Na = 86 Cr = 91
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Calculate LR’s FENa: 1. 0.3% 2. 3.3% 3. 1058% 4. 3008%
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Urinalysis (UA) Fractional excretion of sodium (FENa) FENa(%) = (UNa)(SCr) = (86)(5.1) (91)(145) (UCr)(SNa) x 100 x 100 = 3.3%
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What is your assessment of LR’s labs? 1. They indicate prerenal failure 2. They indicate ATN 3. They indicate glomerulonephritis 4. They indicate postrenal obstruction
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QUESTIONS??
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Orthostatic hypotension Skin tenting Signssymptoms of...

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