Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Medical Series: Nephrology 1 Dr. Inuri Patabendi Post-Foundation Doctor F3 SSocial Medias S Contents S Urinary tract infections S Acute kidney injury S Dialysishttps://www.cdc.gov/kidneydisease/images/take-care-problems.png 66 year old lady attends her GP complaining of burning while passing urine. While waiting for you, she has already passed urine 3 times in the last hour. You suspect that she has a UTI What would be the most appropriate course of action? A. Urine dip- if positive for nitrites then start antibiotics. B. MSU and wait for result prior to starting antibiotics. C. Prescribe a 3 day course of antibiotics and send MSU. D. Admit to hospital for IV antibiotics. E. Don’t Know 66 year old lady attends her GP complaining of burning while passing urine. While waiting for you, she has already passed urine 3 times in the last hour. You suspect that she has a UTI What would be the most appropriate course of action? A. Urine dip- if positive for nitrites then start antibiotics. B. MSU and wait for result prior to starting antibiotics. C. Prescribe a 3 day course of antibiotics and send MSU. D. Admit to hospital for IV antibiotics. E. Don’t Know Urinary tract infections S Lower S bladder/cystitis • E coli • Klebsiella Pneumonia • Proteus mirabilis (renal S Upper stones) • Staph Saprophyticus S kidneys/pyelonephritis More common in women Due to shorter urethras. Symptoms and signs S Dysuria S Frequency/urgency Upper UTI S Nocturia • Fever and rigors S Supra-pubic pain/tenderness • Nausea and vomiting • Flank pain S Haematuria • Costovertebral angle tenderness Cystitis management S Urine dipstick not reliable in >65years S And catheterised patients S MSU S Men, women >65 years, pregnant, catheterised, recurrent UTI, haematuria S Nitrofurantoin, trimethoprim S Women 3/7 S pregnant, catheterised, male 7/7 S Treat asymptomatic acteruria in pregnancy Pyelonephritis management S Always send MSU S Oral or IV antibiotics: cefalexin S 7-10 days S Refer if S pregnant, immunosuppressed, structural abnormality AKI https://thumbs.dreamstime.com/b/sad-suffering-sick-cute-kidneys-character-sad-suffering-sick-cute-kidneys-character-vector-flat-cartoon-illustration-icon-design-150460058.jpghttps://www.cdc.gov/kidneydisease/images/take-care-problems.png Acute kidney injury is defined as… A. Creatinine rise 26 µmol/L or greater within 48 hours B. 20% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days C. Fall in urine output to less than 0.5 ml/kg/hour for more than 24 hours KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2012; 2:8. Acute kidney injury A. Creatinine rise 26 µmol/L or greater within 48 hours B. 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days C. Fall in urine output to less than 0.5 ml/kg/hour for more than 6 hours or more KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2012; 2:8. Classification of AKI SPre-renal SRenal SPost–renal https://cdn1.vectorstock.com/i/1000x1000/37/30/geek-kidney-character-cartoon-style-vector-19913730.jpgWhat are the causes of AKI? S Pre-renal Renal/intrinsic • Acute tubular necrosis S Hypovolaemia • Glomerulonephritis S Renal artery stenosis • Interstitial nephritis • Rhabdomyolysis S Post renal S Renal stones S Benign prostatic hyperplasia How to find the cause? S HISTORY, HISTORY, HISTORY S Medication! S Fluid status S Mucous membranes S Peripheral perfusion S JVP S Lung bases S Peripheral oedema S Blood pressure and heart rate S Investigations… https://hips.hearstapps.com/ame-prod-goodhousekeeping-assets.s3.amazonaws.com/main/embedded/25836/glass_water.jpghttps://www.cdc.gov/kidneydisease/images/take-care-problems.png All patients should have _______________ as soon as an AKI is diagnosed or suspected. (NICE guidance 2019) A. IV fluids B. Urine dip C. Renal USS D. Catheterisation E. Renal referral https://t4.ftcdn.net/jpg/02/72/25/87/360_F_272258728_LWOA70FSLXFzhOLFedNexVvyxNAe3dNF.jpg All patients should have _______________ as soon as an AKI is diagnosed or suspected. (NICE guidance 2019) A. IV fluids B. Urine dip C. Renal USS D. Catheterisation E. Renal referral https://t3.ftcdn.net/jpg/03/07/56/74/360_F_307567493_dvQdFL5HqYzDYZ94JFZ4lK5AMoCO3ErW.jpg Urinalysis S Pre-renal/ post-renal : no blood or protein S Renal: protein +/blood S Not very useful S Catheterisation S CKD S Renal stones: blood https://www.jucm.com/wp-content/uploads/2020/06/Clinical-Article-Urinalysis-1140x760-2.jpg Investigations S Bladder scan S Renal USS S <24 hours if obstruction/not improving S Nephritic screen: ANCA, ANA, myeloma (serum free light chains, electrophoresis, bence jones protein), ANCA, ANA, immuglobulins, complement,https://www.cdc.gov/kidneydisease/images/take-care-problems.pngAdmitting F1, reviewing a drug chart for patient with AKI ?cause. Which drug can be continued safely in AKI? A. Naproxen B. Metformin C. Lisinopril D. Candersartan E. WarfarinAdmitting F1, reviewing a drug chart for patient with AKI ?cause. Which drug can be continued safely in AKI? A. Naproxen B. Metformin C. Lisinopril D. Candersartan E. WarfarinAdmitting F1, reviewing a drug chart for patient with AKI ?cause. Which drug can be continued safely in AKI? Hold: A. Naproxen • Non-steroidal anti-inflammatory drugs B. Metformin • Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor C. Lisinopril blockers (ARBs) • Metformin- lactic acidosis D. Candersartan • Nephrotoxins (aminoglycoside) E. Warfarin When looking at the drug chart… S Suspend S NSAIDs, ACE inhibitors and nephrotoxics S Drugs that may accumulate e.g. metformin, morphine S Review dosage S Antibiotics S Insulin renally excreted (reduced dose) S Renal drug database/pharmacy Normally… Afferent EfferentEfferent arteriole vasoconstricts Afferent Efferent ACE inhibits/ARBs Afferent Efferent S Prevents efferent arteriole vasoconstriction Normally Afferent Efferent Afferent arterioles vasodilate Afferent Efferent NSAIDs Afferent Efferent S Prevents afferent arteriole vasodilation Monitoring S U and E Renal referral S Creatinine • Renal transplant • AKI 3 S Potassium • Failure to respond S Urea • No clear cause S Bicarbonate • Suspect renal AKI • Vasculitis S Fluid balance • Glomerulonephritis • Interstitial nephritis S Input/output • Myeloma S Daily weights S Urology S Post-renal AKI Stages of AKI Stage Creatinine Urine output 1 Increase in creatinine to 1.5-1.9 times Reduction in urine output baseline, or to <0.5 mL/kg/hour for ≥ Increase in creatinine by ≥26.5 µmol/L, 6 hours 2 Increase in creatinine to 2.0 to 2.9 times Reduction in urine output baseline, to <0.5 mL/kg/hour for ≥12 hours 3 Increase in creatinine to ≥ 3.0 times baselReduction in urine output or to <0.3 mL/kg/hour Increase in creatinine to ≥353.6 µmol/L for ≥24 hourshttps://www.cdc.gov/kidneydisease/images/take-care-problems.png 89 year old man found on floor by son who thinks he has been on the floor for 2 days. He is now complaining of muscle pain, tiredness and coca cola -like urine. Which of these features is least associated with the likely diagnosis? A. Hypophosphataemia B. Raised creatinine kinase C. AKI D. Hyperkalaemia https://www.eatthis.com/wp-content/uploads/sites/4/2020/12/coca-cola- cinnamon.jpg 89 year old man found on floor by son who thinks he has been on the floor for 2 days. He is now complaining of muscle pain, tiredness and coca cola -like urine. Which of these features is least associated with the likely diagnosis ? A. Hypophosphataemia B. Raised creatinine kinase C. AKI D. Hyperkalaemia https://www.eatthis.com/wp-content/uploads/sites/4/2020/12/coca-cola- cinnamon.jpg Rhabdomyolysis Muscle necrosis S After fall and long lie or prolonged seizure S Ecstasy, crush injury, statins and clarithromycin S Damage to muscle cells –release contents S Potassium and phosphorus Management S Creatine Kinase : 1500 to 100 000s • IV fluids • Correct S Myoglobulin electrolyte S Excreted in urine imbalance S Haem pigment -toxic to tubuleshttps://www.cdc.gov/kidneydisease/images/take-care-problems.pngWhich of these drugs helps remove potassium from the body? A. Calcium gluconate B. Insulin/dextrose C. Salbutamol D. Calcium resonium E. Sodium zirconium cyclosilicateWhich of these drugs helps remove potassium from the body? A. Calcium gluconate B. Insulin/dextrose C. Salbutamol D. Calcium resonium E. Sodium zirconium cyclosilicate Hyperkalaemia S ECG: tall tented T waves, loss of P waves, broad QRS and sinusoidal wave pattern S IV Calcium gluconate: stabilises cardiac membrane S Insulin/dextrose infusion shifts potassium from extracellular to intracellular S Salbutamol nebulisers S Calcium resonium enema/sodium zirconium cyclosilicate : removal from body RCHT guidelinehttps://www.cdc.gov/kidneydisease/images/take-care-problems.pngYour patient being treated for rhabdomyolysis but on reviewing todays bloods, you think he is deteriorating. Which of these findings would indicate the need to start acute dialysis? A. Urea 48 B. Egfr 4 C. K 5.8 D. pH 7.20Your patient being treated for rhabdomyolysis but on reviewing todays bloods, you think he is deteriorating. Which of these findings would indicate the need to start acute dialysis? A. Urea 48 B. Egfr 4 C. K 5.8 D. pH 7.20 Indications for dialysis S Acidosis S Electrolyte imbalance –hyperkalaemia(refractory) S Intoxication –lithium S Oedema-pulmonary oedema (refractory) S Uraemic pericardits/encephalitis Summary S UTI classification and management S AKI S Classification of causes S Investigations and management S Rhabdomyolysis and hyperkalaemia S Indications for dialysis Take home messages S Urine dip S For AKI S Fluid balance S Keep monitoring S Refer to renal S Do basics first Until next time… S Renal causes of AKI S Glomerulonephritis S Vasculitis S CKD S Complications S Management Thank you References 1. https://cks.nice.org.uk/topics/urinary-tract-infection-lower-men/ 2. https://www.nice.org.uk/guidance/ng109/chapter/Recommendations#treatment- for-women-with-lower-uti-who-are-not-pregnant (NICE guidance) 3. https://cks.nice.org.uk/topics/pyelonephritis-acute/labour 4. Kidney Disease: Improving Global Outcomes (KDIGO). Acute Kidney Injury Work Group. KDIGO clinical practice guidelines for acute kidney injury. Kidney Int Suppl 2012; 2:1. 5. https://www.nice.org.uk/guidance/ng148/chapter/Recommendations#identifying- the-causes-of-acute-kidney-injury 6. https://doclibrary- rcht.cornwall.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/Clinical/Renal/A dultHyperkalaemiaManagementClinicalGuideline.pdf 7. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of- rhabdomyolysis?search=rhabdomyolysis&source=search_result&selectedTitle=1~15 0&usage_type=default&display_rank=1 O 3C O F Feedback & In +agram O N Please complete feedback to receive slides and cheat sheet!llow our Instagram page for MCQs! N H O C l CH CH O CH 3 3 H 3 CH O 3 H 3H CH O C 3 3 C