Intern Survival Series Lecture #9 Renal Insufficiency Shaping the Future of Healthcare | www.thewrightcenter.org
Goals and Objectives • Be able to recognize the various types of renal disease, and initiate an appropriate workup • Be able to recognize signs and symptoms of Hyperkalemia and address it with appropriate treatment modalities Shaping the Future of Healthcare | www.thewrightcenter.org
A Brief Note • This lecture series is not meant to be all inclusive or totally comprehensive to all of internal medicine • It is not meant to supersede clinical judgment • It is not meant to replace daily reading or bedside teaching • It is meant to act as a starting point for which to grow from as new primary care physicians • It is a tool to help you survive the your new job Shaping the Future of Healthcare | www.thewrightcenter.org
Most Frequent Primary Care, Inpatient Diagnosis • 1)Pneumonia • 2)Congestive Heart Failure • 3)Osteoarthritis • 4)Coronary Artery Disease • 5)Septicemia • 6)Cardiac Dysrhythmias • 7)Chronic Obstructive Pulmonary Disease Shaping the Future of Healthcare | www.thewrightcenter.org
Fastest Growing Inpatient Diagnosis in Medicine • 1)Acute Renal Failure • 2)Anemia • 3)Diabetes Mellitus • 4)Malaise and Fatigue • 5)Pulmonary Heart Disease Shaping the Future of Healthcare | www.thewrightcenter.org
Most Common Secondary Diagnosis • 1)Hypertension • 2)Hyperlipidemia • 3)Fluid and electrolyte disorders • 4)Coronary Atherosclerosis • 5)Diabetes Mellitus • 6)Anemia • 7)Cardiac Dysrhythmias • 8)Esophageal Disorders Shaping the Future of Healthcare | www.thewrightcenter.org
Kidney Disease • About 20 million Americans have kidney disease. • The number of people diagnosed with kidney disease has doubled each decade for the last two decades • Diabetes and hypertension (high blood pressure) are the number one and number two causes of kidney disease, respectively. • Diabetes accounts for 35% of all new ESRD cases Shaping the Future of Healthcare | www.thewrightcenter.org
Renal Failure • Chronic Renal Failure • Acute Renal Failure – Now referred to as chronic – Now referred to as acute kidney disease kidney injury – A glomerular filtration rate – abrupt and usually less than 60 mL/min for reversible decline in the three months or more GFR. – and/or evidence of kidney – Develops in hours to days damage – Can develop into rapidly • albuminuria progressing renal failure • urine sediment abnormalities • Kidney disease that • findings on renal imaging or progresses for weeks renal biopsy Shaping the Future of Healthcare | www.thewrightcenter.org
AKI Incidence • The number of hospitalizations that included an AKI diagnosis rose from 3,942 in 1996 to 23,052 in 2008. Shaping the Future of Healthcare | www.thewrightcenter.org
Common Causes of AKI • Acute tubular necrosis (ATN ) – Most common cause in hospitalized patients • Ischemia • nephrotoxin exposure • sepsis • Volume Depletion • Urinary Obstruction • Rapidly Progressive Glomerulonephritis • Acute Interstitial Nephritis Shaping the Future of Healthcare | www.thewrightcenter.org
Defining AKI KDIGO criteria (Kidney Disease Improving Global Outcomes) • An increase in serum creatinine of ≥0.3 mg/ dL (≥26.5 micromol/L) within 48 hours • An increase in serum creatinine of ≥1.5 times baseline, which is known or presumed to have occurred within the prior 7 days; or • Urine volume <0.5 mL/kg per hour for more than 6 hours Shaping the Future of Healthcare | www.thewrightcenter.org
Staging AKI • Stage 1 AKI – increase in the serum creatinine of 1.5 to 1.9 times baseline OR – serum creatinine increase of ≥0.3 mg/ dL OR – urine output <0.5 mL/kg per hour for 6 to 12 hours. Shaping the Future of Healthcare | www.thewrightcenter.org
Staging AKI • Stage 2 AKI – increase in the serum creatinine of 2.0 to 2.9 times baseline OR – urine output <0.5 mL /kg per hour for ≥12 hours. Shaping the Future of Healthcare | www.thewrightcenter.org
Staging AKI • Stage 3 AKI – increase in the serum creatinine of 3x baseline OR – increase in serum creatinine to ≥4.0 OR – urine output of <0.3 mL /kg per hour for ≥24 hours, OR – anuria for ≥12 hours OR – the initiation of renal replacement therapy OR, – in patients <18 years, decrease in estimated GFR to <35 mL/min Shaping the Future of Healthcare | www.thewrightcenter.org
AKI Workup • UA • Strict I/Os, daily weights • Urine Electrolytes – Urine Na, K, Cr • Renal Imaging to assess for – urinary tract obstruction – kidney stones – renal cyst or mass – renal vascular diseases Shaping the Future of Healthcare | www.thewrightcenter.org
Fractional Excretion of Na • The FENa is the most accurate screening test to differentiate between prerenal disease and ATN. • A value below 1 percent suggests prerenal disease • A value above 2 percent usually indicates ATN • A value between 1 and 2 percent can be seen with either disorde Shaping the Future of Healthcare | www.thewrightcenter.org
FENa Shaping the Future of Healthcare | www.thewrightcenter.org
FENa • Be aware that there are limitations to FENa • Some examples (but not all) – The FENa may remain below 1 percent when ATN is superimposed upon a chronic prerenal disease – Diuretics can raise the FENa, even in patients with prerenal disease giving misleading numbers – A low FENa is not unique to prerenal disease, and can be seen in: • Acute glomerulonephritis • Vasculitis • Contrast-induced nephropathy. Shaping the Future of Healthcare | www.thewrightcenter.org
Shaping the Future of Healthcare | www.thewrightcenter.org
Complications of AKI • Fluid overload • Hyperkalemia or a rapidly increasing serum potassium • Signs of uremia, such as pericarditis, or an otherwise unexplained decline in mental status • Severe metabolic acidosis (pH less than 7.1) Shaping the Future of Healthcare | www.thewrightcenter.org
Hyperkalemia • The urgency of treatment of hyperkalemia varies with the cause and the presence or absence of the symptoms and signs associated with hyperkalemia. – muscle weakness or paralysis – cardiac conduction abnormalities – cardiac arrhythmias Shaping the Future of Healthcare | www.thewrightcenter.org
Call from Tele • Patient’s Rhythm strip is showing some abnormalities….. Shaping the Future of Healthcare | www.thewrightcenter.org
Shaping the Future of Healthcare | www.thewrightcenter.org
Shaping the Future of Healthcare | www.thewrightcenter.org
Hyperkalemia Shaping the Future of Healthcare | www.thewrightcenter.org
#1 Peak T waves #2 Increased PR intervals #3 Increased QRS #4 Loss of P waves #5 SINE Waves Shaping the Future of Healthcare | www.thewrightcenter.org
Hyperkalemia Treatment Rapid Acting Treatment Indications • Patients with hyperkalemia and electrocardiographic changes • Patients with a serum potassium greater than 6.5 to 7 meq/L Ok to wait if potassium is ≥7.0 meq/L in patients who have no clinical or – electrocardiographic signs of hyperkalemia, use clinical judgment • Ok to give rapid acting analogs in patients with a serum potassium that is rapidly increasing, but again, use clinical judgment Shaping the Future of Healthcare | www.thewrightcenter.org
Hyperkalemia • Rapid Treatment – Calcium Gluconate • 1 ampoule, infused over two to three minutes, with constant cardiac monitoring • Stabilized the myocardium • can be repeated after five minutes if the ECG changes persist or recur Shaping the Future of Healthcare | www.thewrightcenter.org
Hyperkalemia • Rapid Treatment – Insulin with dextrose • 10units of regular insulin in 500ml D10W over 1hr – Begins to work in 10-20mins, lasts 4-6 hours • If Serum Glucose >250 ~ 10 Units only • If Serum Glucose <250, but still on high side can give 10 unit insulin bolus w 50ml of 50% dextrose • asdf Shaping the Future of Healthcare | www.thewrightcenter.org
Hyperkalemia Rapid Treatment – Albuterol Nebulizers – Bicarb • Mostly ineffective, but in hypovolemic patients it is ok to give One liter of ½ NS with 75 Units of Bicarb – Hemodialysis Shaping the Future of Healthcare | www.thewrightcenter.org
Hemodialysis Indications • A cid base disorders – i.e. Severe Metabolic Acidosis • E lectrolytes – i.e. Hyperkalemia • I ntoxication – i.e Lithium, Ethylene Glycol • O verload – Fluid Overload, not responding to diuretics • U remia – Usually seen in patients with BUN>100 Shaping the Future of Healthcare | www.thewrightcenter.org
Chronic Kidney Disease • Defined as the presence of kidney damage or decreased kidney function for three or more months • irrespective of the cause • Decreased kidney function is identified in most cases by an eGFR less than 60 mL/min Shaping the Future of Healthcare | www.thewrightcenter.org
CKD • Kidney damage is identified in most cases by the presence of: – albuminuria – urinary sediment abnormalities – anatomic abnormalities discovered with imaging studies – pathologic abnormalities discovered with kidney biopsy – a history of kidney transplantation Shaping the Future of Healthcare | www.thewrightcenter.org
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