A podcast about acute kidney injury covering topics like distinguishing pre-renal from intrarenal disease, nephritic syndrome, urine electrolytes, imaging choices, POCUS usage, CK levels in rhabdomyolysis, and indications for dialysis.
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Quick takeaways
The initial approach to acute kidney injury involves ruling out immediate life threats, assessing perfusion and fluid status, and avoiding nephrotoxins while determining the underlying cause.
Nephritic syndrome, characterized by hypertension, hematuria, and proteinuria, requires urgent evaluation and management, with timely intervention by nephrologists and blood pressure control being crucial.
In managing rhabdomyolysis patients with acute kidney injury, fluid resuscitation with balanced crystalloids like Ringer's lactate is essential, and the need for dialysis is determined based on general AKI indications like acidemia and electrolyte imbalances.
Deep dives
Approach to AKI: Pre-renal causes and initial management
The approach to acute kidney injury (AKI) begins with ruling out immediate life threats and assessing the patient's perfusion and fluid status. Essential initial steps include measuring post-void residual (PVR), performing a urine dip to check for blood and protein, monitoring urine output, and avoiding nephrotoxins. For patients with adequate perfusion, potential pre-renal causes should be considered, such as hypovolemia or impaired forward flow. Treatment involves fluid resuscitation, usually with balanced crystalloids like Ringer's lactate, and determining the need for diuretics or pressor support based on signs of pulmonary or peripheral edema. The goal is to ensure optimal perfusion while identifying the underlying cause of AKI. Urgent imaging for post-renal causes is generally unnecessary, except for specific indications such as suspected urinary obstruction or sepsis.
Intrinsic Causes of AKI: Nephritic Syndrome and Rhabdomyolysis
Two important intrinsic causes of acute kidney injury (AKI) are nephritic syndrome and rhabdomyolysis. Nephritic syndrome, characterized by hypertension, hematuria, and proteinuria, requires urgent evaluation and management due to its potential severity. Patients presenting with these symptoms, often accompanied by shortness of breath and peripheral edema, may indicate glomerulonephritis or systemic diseases like vasculitis or lupus. Timely intervention by nephrologists and blood pressure control are crucial for these patients. Rhabdomyolysis, typically seen in marathon runners or those with severe exertion or trauma, presents with muscle pain, weakness, and dark urine. A serum creatine kinase (CK) level above 5,000 may suggest AKI, and prompt fluid resuscitation with balanced crystalloids like Ringer's lactate is essential. Monitoring urine output, avoiding nephrotoxins, and assessing the need for dialysis are important considerations in managing rhabdomyolysis.
Treatment and Disposition of Rhabdomyolysis Patients
In the treatment of rhabdomyolysis patients with acute kidney injury (AKI), fluid resuscitation is the cornerstone. Ringer's lactate is the preferred fluid due to its balanced composition and pH compatibility. Higher urine outputs (around 2 cc/kg/hr) are targeted to facilitate renal flushing. The need for dialysis is determined using general AKI indications like acidemia, electrolyte imbalances, intoxication, fluid overload, and severe uremia. When considering discharge for rhabdomyolysis patients, factors such as the peak CK level, downward trend in CK values, toleration of oral fluids, and availability for follow-up care should be evaluated. Patients who have received appropriate IV fluids and show improvement, or those who never required IV fluids, may be considered for discharge with clear instructions and close monitoring.
POCUS for Acute Kidney Injury
Point of care ultrasound (POCUS) can be utilized to assess acute kidney injury (AKI). POCUS can help evaluate for post-renal causes of AKI by examining the bladder and looking for distention, hydrouretor, and hydronephrosis. In pre-renal AKI, POCUS can be used to identify an empty bladder, absence of hydronephrosis, and a flat inferior vena cava (IVC) and jugular venous pressure (JVP). Additionally, POCUS can assist in assessing volume status by visualizing the IVC and evaluating for distension in patients with fluid overload. Overall, POCUS is a valuable tool in diagnosing and managing AKI, especially in cases where the etiology is unclear.
Rhabdomyolysis and Contrast-Induced Nephropathy
In patients with rhabdomyolysis, POCUS can play a role in assessing the severity and aiding in management decisions. POCUS findings in rhabdomyolysis include hydronephrosis and hydrouretor in post-renal cases, while pre-renal causes show an absence of hydronephrosis. Monitoring creatine kinase (CK) levels and trending them over time is essential to guide treatment and determine the need for dialysis. Contrast-induced nephropathy (CIN) remains a topic of debate, but it is crucial to avoid unnecessary contrast administration in patients with severe AKI unless there is a compelling diagnostic need. Individual patient factors and the urgency of diagnosis should guide the decision to use IV contrast in AKI cases.
In this first part of our 2 part podcast series on AKI we answer questions such as: Is there any value in the BUN:Cr ratio in distinguishing prerenal from intrarenal disease? Why is nephritic syndrome one of the most important intrarenal causes to pick up in the ED? Is there any value in urine electrolytes for the ED workup of AKI? Is there a role for bicarb in patients with severe AKI? How can we choose wisely when it comes to imaging for patients with AKI? How can we utilize POCUS best in working up the patient with AKI? What are the indications for ordering a CK to look for rhabdomyolysis? At what CK level do patients typically develop AKI? How can the McMahon score help us manage rhabdomyolysis? What is the value of urine myoglobin in the workup of rhabdomyolysis? What are indications for dialysis in patients with rhabdomyolysis? What are safe discharge criteria for patients with rhabdomyolysis? and many more...
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