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Therapeutics 4 - Acute and Chronic Kidney Disease

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khfsu1's version from 2015-04-27 00:10

Acute Kidney Injury

Question Answer
Clinical definition of AKIGFR decrease > 25% or 1.5-fold increase in SCr
or
Urine output < 0.5 mL/kg/hr
Anuria definitionUrine output < 50 mL/day
Oliguria definitionUrine output < 500 mL/day
Non-oliguric definitionUrine output > 500 mL/day
Prerenal AKIAssociated with decreased renal perfusion in presence of normal kidney
Usually due to volume depletion/dehydration
Intrinsic AKIAssociated with kidney damage
Postrenal AKIKidney is initially undamaged
Usually caused by bladder outlet/ureteral/renal pelvis or tubular obstructions
Risk factors of AKIUnderlying CKD
Age > 65 years
Multisystem organ failure
Sepsis
Infection
Chronic diseases
Drugs
Surgery
Malignancy
Bone marrow or organ transplantation
NSAID contribution to AKINSAIDs inhibit prostaglandins which normally cause vasodilation of the afferent arterioles
Vasoconstriction occurs, causing a decrease in GFR
ACE-I/ARB contribution to AKIACE-I/ARB block activity of AngII which normally causes vasoconstriction of the efferent arterioles
Vasodilation occurs, causing a decrease in GFR
Prevention of AKI1) Hydration
2) Antioxidants (N-acetylcysteine reserved for contrast-induced nephrotoxicity)
3) Glycemic control
4) Withdrawal of causative agents
Treatment of AKI1) Remove offending agents or adjust doses for renal function
2) If dehydrated, infuse IV NS boluses
3) Blood products if a result of anemia (Hgb <7 or <9 and symptomatic)
4) Supportive care (electrolyte and nutritional abnormalities (hyperkalemia!!!)
5) Use of loops may be beneficial in non-oliguric
6) RRT (dialysis) may be necessary
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Question Answer
Normal BUN:Creatinine10-20:1
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Chronic Kidney Disease

Question Answer
Risk factors of CKDSystemic inflammation
Dyslipidemia
Diabetes
Hypertension
Glomerulonephritis
Proteinuria
Obesity
Complications of CKDFluid and electrolyte abnormalities (hyperkalemia and hyperphosphatemia)
Anemia
CKD-related mineral and bone disorder and renal osteodystrophy
Hypertension
Hyperlipidemia
Metabolic acidosis (generally in Stage 5 disease)
Hypertension goals in CKDPre-dialysis BP of <140/90
Post-dialysis BP of <130/80
Hypertension treatments and rationaleACE-Is or ARBs
>Renal protective: prevent arterial remodeling and stiffening and possess sympathetic activity in Stages 4 and 5 disease

Diuretics
>Only use if benefit (non-oliguria) exists
Hyperphosphatemia treatmentsPhosphate binders (calcium acetate/carbonate, lanthanum, sevelamer)
Avoid calcium products if hypercalcemia exists)
Hypocalcemia treatmentsCalcium supplementation with or without calcitriol
Anemia treatmentsIron supplementation (PO only for Stages 1-3; IV for Stages 4-5)
ESA if Hgb <10 (target goal is 11-12)
Vitamin D deficiency treatmentsStages 1-3: any OTC vitamin D
Stages 4-5: calcitriol
Elevated PTH treatmentsCinacalcet (Sensipar) and vitamin D supplementation
>Except when serum calcium < 8.4mg/dL
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CKD

Question Answer
ESA Hgb Indication<10
Hyperphosphatemiacalcium carbonate, calcium acetate, sevelamir, lanthanum carbonate
HypocalcemiaCalcium w/ or w/o calcitriol
HyperparathyroidismCalcitriol or doxercalciferol
Volume overloadLoops or dialysis
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