SIM session 4

Question 1

Risk factors for development of AKI

Answer 1

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
• neurological or cognitive impairment or disability, which may mean limited access to fluids because of reliance on a carer

Question 2

What urine output is considered as AKI?

Answer 2

oliguria (urine output less than 0.5 ml/kg/hour)

Question 3

What happens in AKI / when kidneys stop working?

Answer 3

• oliguria = urine output of less than 0.5 ml/kg/hour
• fluid overload
• a rise in molecules that the kidney normal excretes/maintains a careful balance of. Examples include potassium, urea and creatinine

Question 4

Signs and symptoms of AKI

Answer 4

Many patients with early AKI may experience no symptoms

However, 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)

Question 5

Criteria for AKI detection

Answer 5

Any of the following criteria:

• a rise in serum creatinine of 26 micromol/litre or greater within 48 hours
• a 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days
• a fall in urine output to less than 0.5 ml/kg/hour for more than 6 hours in adults

Question 6

Management of AKI

Answer 6

• largely supportive
• careful fluid balance (properly perfused but avoid fluid overload)
• review a patient’s medication list
• Hyperkalaemia -> prompt treatment to avoid arrhythmias
• nephrologist input -> if the cause is not known or where the AKI is severe
• urologist input -> if AKI suspected secondary to urinary obstruction require
• renal replacement therapy -> when a patient is not responding to medical treatment of complications, for example hyperkalaemia, acidosis or uraemia.

Question 7

Medications that are usually safe to continue in AKI

Answer 7

• Paracetamol
• Warfarin
• Statins
• Aspirin (at a cardioprotective dose of 75mg od)
• Clopidogrel
• Beta-blockers

Question 8

Medications that should be stopped in AKI - they do worsen kidney function

Answer 8

• NSAIDs
• Aminoglycosides
• ACE inhibitors
• Angiotensin II receptor antagonists
• Diuretics

Question 9

Medications that need to be stopped in AKI because renal increases risk of drug toxicity

Answer 9

• Metformin
• Lithium
• Digoxin

Question 10

Treatment of hyperkalaemia (3)

Answer 10

• Intravenous calcium gluconate -> to stabilise cardiac membrane
• Combined insulin/dextrose infusion & Nebulised salbutamol -> to induce short-term shift of potassium from extracellular to intracellular fluid
• Calcium resonium (oral or enema), loop diuretics, dialysis -> to remove potassium from the body

Question 11

1st line treatment for hypertension according to NICE guidelines

Answer 11

Depends on age: either ACE-inhibitor or CCB

Question 12

What’s AKI stage 1? (3)

Answer 12

AKI stage 1

• rise of >/= 1.5 x baseline creatinine level -> which is known or presumed to have occurred within prior 7 days
• OR >26 micromol/L within 48 hours
• OR urine output <0.5 ml/kg/h for 6-12 h

Question 13

What’s AKI stage 2?

Answer 13

AKI stage 2

• rise of >/= 2 x baseline creatinine levels
• OR urine output < 0.5 mL/kg/hr for >/= 12 hours

Question 14

Questions to be asked in pt presenting with diarrhoea

Answer 14

• how long for
• how often during the day
• colour/blood
• change to diet
• travel
• weight loss

Question 15

What are common causes of diarrhoea in an adult?

Answer 15

• norovirus/rotavirus
• campylobacter

Question 16

What’s AKI stage 3?

Answer 16

Stage 3 AKI

• rise of >/= 3 x baseline creatinine
• OR raise >/=1.5 baseline to >354 micromol/L
• OR urine output <0.5 ml/kg/hr for >/= 24 hour
• OR anuria for >/= 12 hours

Question 17

Red flag symptoms for diarrhoea

Answer 17

• blood in the stool
• recent hospital Rx or antibiotics
• persistent vomiting
• weight loss
• painless, watery. high-volume diarrhoea -> risk of dehydration
• nocturnal symptoms/ sleep disturbing -> organic cause is likely

Question 18

Red flag symptoms for back pain

Answer 18

• thoracic pain
• fever
• unexplained weight loss
• bladder or bowel dysfunction
• history of carcinoma
• ill health/ presence of other medical illness
• progressive neurological deficit
• disturbed gait
• saddle anaesthesia
• age onset <20 years or >55 years

Question 19

What’s the first step in Rx of hyperkalaemia?

Answer 19

• Salbutamol -> first as it is neb and it’s easy and quick to set up (in clinical practice/ guidelines usually say calcium gluconate 1st)
• Insulin/dexterose-> when there is no indication for calcium gluconate
• Calcium gluconate -> to protect the heart

* if there are ECG changes

Question 20

How to monitor a patient’s potassium in hyperkalaemia Rx?

Answer 20

• do VBG
• monitor: 1, 2, 4, 6 and 24 hours after diagnosis
• monitor BM half hourly