Nephrology. 3 rd Year Revision Session 06/05/17 Cathal Hannan

Transcription

1 Nephrology 3 rd Year Revision Session 06/05/17 Cathal Hannan

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4 Aims Acute Kidney Injury-recognition and management Sample OSCE Station Clinically relevant renal physiology Aetiology of Chronic Kidney Disease What we didn t have time for

5 AKI RISK ASSESSMENT Background Factors CKD (egfr <60mL/min) Age >65 yr Co morbidity (IHD, CCF, DM) Acute Context Sepsis Peri operative period Illness Severity Hypovolaemia Systolic BP<110mmHg Deteriorating NEWS Medication Use NSAID, COX II, ACEi, ARB Aminoglycoside Iodinated Radiocontrast AKI AT RISK Daily U&E Accurate Urine Output record Close attention to fluid balance ESTABLISHED AKI DEFN: screatinine rise >26umol/L in 48hrs, >50% from baseline value within 7 days, UO < 30mL/hr for 6hrs INVESTIGATE URGENTLY LABS U&E, FBP, CRP, LFT, Glucose, Bone profile, Coagulation Screen Urine dipstix analysis, Urine Na RENAL ULTRASOUND Within 6hrs if upper tract obstruction considered Within 24hrs if AKI not responding to treatment SELECTED CASES Nephritis ANCA, Anti GBM HCO 3 <19mmol/L ABG Rhabdomyolyisis CK SBP <110mmHg Lactate RESTORE KIDNEY PERFUSION OPTIMISE VOLUME Bolus mL crystalloid targeting SBP >110mmHg/ clinical evidence of euvolaemia 2L max IV fluids within 2hr After each bolus check for signs of fluid overload Seek senior help before repeating 2L fluid challenge OPTIMISE BLOOD PRESSURE If despite adequate volume challenge hypotension persists (SBP<110 +/or MAP <65mmHg) obtain a urgent senior review Consideration should be given to HDU/ICU referral PRESCRIBE SAFELY STOP NSAIDs, COX II, ACEi, ARBs Metformin AVOID WHEN SBP <120mmHg Antihypertensives, Diuretics CORRECT dosing to GFR level (e.g. aminoglycosides, metformin and sulphonylureas, LMWH and many antibiotics) IV FLUID PRESCRIBING MAINTENANCE FLUIDS RATE = Urine Output + 30mL/hr BOLUS FLUIDS AVOID >5.5mmol/L INDICATIONS FOR REFERAL TO NEPHROLOGY Suspected intrinsic renal disease Blood and Protein on urinalysis with suspicion of glomerulonephritis Unclear aetiology of AKI (no prerenal or obstructive cause identified) Potential need for renal replacement therapy (dialysis) Refractory hyperkalaemia (>6.5mmol/L) or pulmonary oedema Severe metabolic acidosis (HCO3 < 15mmol/L) Progressive AKI (creatinine >300umol/L or rise >100umol/L in 24hr) AKI occurring in Renal transplant patients Patients with baseline GFR <30mL/min

6 AKI Made Extremely Simple RECOGNITION Rise in serum creatinine >26 mmol/l Urine output <500ml over 24 hours SBP <90 mmhg MANAGEMENT A-Address Medications B-Boost blood pressure C-Calculate fluid balance D-Dip Urine E-Exclude Obstruction

7 Sample OSCE Station (1) You are the FY1 on the acute medical team, clerking in an 85 year old lady, Mrs O Neill, sent to hospital by her nursing home, who are concerned she is not herself following a recent diarrhoeal illness. Her past medical history includes hypertension, ischaemic heart disease and osteoarthritis. A list of her current medication is provided below: Bisoprolol 10mg od Ramipril 10mg od Furesomide 40mg od Naproxen 50mg bd Atorvastatin 40mg od

8 Sample OSCE Station (2) Unfortunately, Mrs O Neill is unable to provide much of a history. As you examine her, you note that her eyes appear sunken, she has a very dry mouth, and her skin turgor is decreased. The nursing staff have helpfully performed a set of observations for you: HR 78 Temp: 36.7 BP 95/63 RR: 25 There is a marked postural drop in her blood pressure, with her systolic blood pressure dropping to 70mmHg on standing. As you are assessing her, the a nurse approaches you with the result of her U&E: Na Urea 12 C02 17 K Creatinine 150

9 Sample OSCE Station (3) Outline how you would manage this patient

10 Clinically Relevant Physiology

11 Chronic Kidney Disease Abnormality of kidney structure and/or function, persisting for 3 months or more. All people with an egfr <60ml/min on at least 2 occasions separated by 90 days Common causes: Diabetes Hypertension Renovascular Disease Polycystic Kidney Disease Chronic Glomerular Disease

12 What we didn t have time for Hyperkalaemia Polycystic Kidney Disease Renal transplant and risks of Immunosuppression Complications of CKD-Anaemia, Vit D Metabolism/Renal Bone Disease, Neuropathy Acid/Base Disturbance

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