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Yeah. Uh huh. Okay. Hi, everyone. Welcome to the webinar on acute kidney injury. Um, if you just give us a few more minutes, we'll just wait for a few more people to join and we'll get started. Great. Thank you. So Hi, everyone. My name's Lizzie. I'm currently, um Anesthetics ST one doing my, uh, replacement. Um, I'm currently doing this from my phone due to some technical issues. So do bear with me samples gonna kindly do the power point for me. So today we're doing acute kidney injury, which is something you're definitely gonna be coming across throughout your foundation years and throughout your career, something I can go to the next slide, please. So today we're going to cover what AKI is an acute kidney injury. What the risk factors are for developing acute kidney injury and what to look out for. Then we'll go through. The cause is of a K I. And then how to approach a patient. So how to take a history? The examination finding is you might get and then lastly, how to manage patients with acute kidney injury. Next side. So just a pointer. So AKI has now replaced the acute renal failure terminology. And it's essentially a reduction in renal function, which can happen over days, two weeks, uh, sometimes even hours. Essentially, the discretion of the kidney is malfunctioning, which means that your fluid balance your acid base balance. The homeostasis going on the body is all impaired. I think it's about 15% of all hospital admissions or secondary or linked to acute kidney injury. So it's certainly popular among patients. And in terms of the incidents, it's increasing due to increased comorbidities amongst an aging population. Um, and also we're looking out for a lot more. There's lots more drive to pick them up early, so you certainly come across that quite frequently in terms of the actual definition. So it's three separate criteria, so either it's a rising serum creatinine of 26 microscope a liter or more within a 48 hour period. Or it's that the baseline serum creatinine has increased by 50% within the last seven days, or it's a fall in urine output over a six hour period of less than 0.5 mL per kilogram per hour. Just a note to say that we are looking at serum creatinine in, um, a k I e Jafar is to the estimated filtration rate is useful in your CKD s. But within your acute kidney injuries, because the Christians so up and down and it's a dynamic process, sometimes the far can overestimate or underestimate the kidney function. So within the remits of a K, I were referring to Claritin. Um, so if you just go into next slide, so this is busy. So some of these slides are quite busy slides. I apologize, but there's quite a lot of information to get across now. By no means panic. Looking at this slide, I appreciate there's a lot of information. It's just a point to say that that is the baseline criteria for an acute kidney injury, but it can be classified into three. Further stage is to Stage one is what we mentioned. The increase of 26 microscope a liter or more within 48 hours. The baseline is increasing by 50% so we say kind of 1.5 to 2 times the baseline within seven days or the there's college area over six hours. Stage two is more that the baseline over seven days has gone up by 2 to 3 times the baseline, Um, and again the olajire can be present for 12 hours, and Stage three is that the baseline creatinine has gone up by three times, plus within seven days. The urine output is essentially mostly a generic, so the urine output is less than 0.3 mil per kilogram per hour over 24 hours. Or complete a neuro for 12 hours and by nearly when you know urine output. Or there's a caveat that is the same as stage one that it goes up by more than 26 or goes up by 1 to 2 times within 48 hours. But that the creatinine is more than 354 is a specific number, but it's still relative to their baseline. So if the baseline is 370 the creatinine has only gone up to 372 it's not an acute kidney injury. If it's gone from 3 72 4 10, so it's gone up by more 2026 micromole Pelita in 24 hours. Sorry, Microarray help a little within 48 hours, then it would be an a k I. And it would be stage three because of the level of the Claritin. Um, so again, don't panic too much about it. You don't certainly don't need to memorize this off my heart. The point is to have an appreciation for what? My baseline diagnosis for an acute kidney injury and have an appreciation for what the different stages are because the higher the stage, the higher the morbidity and mortality with online system and everything these things do get flagged. So again don't need to remember it kind of the criteria to memory. But it's good to have an appreciation. So with that in mind and again, don't panic. But I don't expect you to memorize this. I just want you to have a go to go to the next slide. So you've got a 65 year old lady who's been admitted with diarrhea and vomiting. Her blood tests are low. Bear in mind what you said already. If you can remember, how would you classify her? AKI. So you've got the bloodstream five days ago on the left hand side and you got the blood from today. Have a quick look through we'll give you a couple of minutes and see if you can have you go with that question. You can write it in the comments down below. I hope you can see everything. So if you just in case you can't see on the left hand side, The craftsman is 85 that was five days ago. And the blood's from admission. Today is a cross section of 210. I'll just give you a couple more minutes to have a Think again. Don't worry. If you haven't memorized that busy slide, I haven't memorized the busy slides, so don't worry. Okay? So if you go onto the next slide so this is a Stage two, a k I. So the creatinine has gone up by about 2.5 from the baseline within a seven day period. Obviously, we don't have the urine output documented, and you may not remember it's not. It can be one or the other. It doesn't have to be both parts of the criteria. Um, reached So this idea as a stage two, a k I. Because a baseline question has increased between by 2.5 ish within a seven day period. Okay, so on to the next slide. So, in terms of risk factors, as with anything in medicine, prevention is better than cure, right? So when you're seeing patients before you even get the blood back or if they have a normal renal function, you still need to think about is this patient at risk of developing an A k I? And the reason for that is again because of the mortality and morbidity associated with so in terms of the presenting complaint patients are presenting with diarrhea, vomiting change in their GCS mean the oral intake is compared or reduce urine output. That's something you might be at risk of developing. Uh, okay, I equally the acute illnesses patients are over 65. They have a background of CKD or may have had previous ache. I improved submissions if they have presented the sepsis, if they're on a multitude of nephrotoxic meds or have had recent contrast or again cognitive impairment there, maybe a high risk. So this is nice guidelines advice in terms of what the risk factors would be So again, it doesn't mean that people are going to develop a I something to appreciate that if you're blocking them in and we're reviewing them, is this person in front of the high risk for developing a renal impairment next side? So if you go on to the causes of AKI next side, so the way to resonate to clarify it or classify it if you're presenting if you're approaching the patient is to think about if it's pre renal, cause a renal cause or post renal cause. So if you go through those individually so your pre renal cause is the most common cause of AKI that you come across, Um, and it's usually something we can reverse quite quickly if recognized, so different causes of that may be fluid losses. So if you have someone who's dehydrated, reduced or an intake, have lots of diarrhea, vomiting. It might have rathers tubes or N G tubes UM, that have got high output losses or stones or bags, et cetera. Patients who are third spacing. So perhaps, if they have cardiac failure, heart failure, a background of CKD, they maybe intravascularly dry. But the food is going into the wrong space. Another thing of major hemorrhage bleeding Upper GI bleeds, maybe another occult cause underlying everything that may put you at high risk of hypovolemia and therefore prerenal course, um, some medication. So if you think about your, um, your diuretics, particularly if they they've had starting dose of four is, um, I had given you, um, if they're on big BP tablets in multiple doses, high doses alongside any of these things sepsis, major hemorrhage, etcetera, they're gonna be a high risk of intravascular depletion. I remember that your kidneys again in about 25% of your cardiac output. So if you're getting a reduction in blood flow to the kidneys are going to start trying to hold on to fluid. Concentrate the urine, um, reabsorb sodium and try and, uh, repeat the intravascular space. So any of these losses a drop in the BP is going to mean that there's less Cardiff help going to the kidney overall, and that's going to be in the back of your mind. Is renal artery stenosis Not really something you going to pick up immediately? But it's a pre renal cause for patients. So in primary care, a patient who's got background hypertension has been started on an ACE inhibitor and has a disproportionate rise in their creatinine. It may be worth thinking about that as a cause next side, so let me get into the renal side so the renal causes. So this is if there's a structural damage to the kidney itself, Um, so you can break this down by the structures within the kidney. So and toxins and drugs are a big thing, so Nephrotoxic six can cause lots of different things. So if you go via sometimes it's easier to go via the structures. So vascular causes were thinking about your vasculitic screens or again, gross vascular changes. So diabetes, hypertension causing gross vascular changes, arthrosclerotic disease can have effects on the kidney as well as calcium in the body. Your vasculitis say things like Lupus vacationers. Your small vessel vasculitis can all contribute and affect the kidney as well. In terms of your memory loss, which is a word I can't say, I apologize if you have. But again, I can't say this glomerulonephritis, uh, inflammation of your, uh, memory lie. So things like I think you nephrotic and the Nephrotic syndrome. If you go down that pathway, they can lead to a renal intrinsic renal failure, causing an a k I. The most important one of those. Your rapidly progressive glomerulonephritis, which are important ones to pick up um, and then from a tubular and interstitial point of view again that can be from hypertension or hyperperfusion to the kidney causing. Um, most commonly it's 18, so you're due to benign process. Um, and that's normally from prolonged renal hyperperfusion. Also, some medications that going back to toxins the drugs So, um NSAID, um, omeprazole or lansoprazole penicillins can cause interstitial inflammation, and longer term, it means that you can get scar and fibrosis to the function of the kidney is impaired. So again as an F one or a pa, or someone in junior high is reviewing a patient, you don't necessarily need to think. Gosh, I need to start doing biopsies, etcetera and renal screens, but it's important to have that in the back of your mind. Could this be a, uh, an intrinsic cord that's driving my AKI and the next side, please? And then the last one is your post renal, which apparently is the least common, I think, and I said it's about 10% of a K I as a secondary post renal, but I've certainly come across it quite quite a lot, at least as a contributing factor. So this is there is down basically downstream obstruction from the kidneys. So within your your Etta's the bladder prostate urethra, which is causing backflow and increasing your pressures within the kidney. Um so common cause is again the renal stones, which can cause blockage and get hydro process. Um, benign prostatic hyperplasia if they have long term catheters that are blocked, um, malignancies downstream in your ureters your prostate, your bladder or if they've got a neurogenic bladder from, uh, like multiple sclerosis or they've got atonic bladder's, which might mean that the bladder isn't function as it should be. So these are all post renal causes to consider when reviewing your patient next side. So see if I can read this. This is the scenario to get you thinking about what the cause is in this patient could be for their AKI. So you are the one uncle, and you've been called to see a 79 year old gentleman who's had been in for a couple of days, and they had a bit of confusion, reduced oil intake. Overnight, there was a one of temperature 37.8, but otherwise his labs are fine. Um, the catheter that he's got in situ was from admission, and the nurses say, Oh, it's been draining, but we haven't had time to document the output We didn't realize we had. We were that was required in in terms of personal medical history. So this long term catheter has been in situ for a long time. Now he's got a benign prostatic hyperplasia and a background of CKD. That's all the information you have. So again, we've got his blood through remission on the left hand side, which is, um, two days ago. And then he's got his blood today. So having a look can you cast your mind back to the first few slides, the busy one, and have to think about what his status, a K I might be and then having a look at his what he's presented with what the kind of what's been going on this admission what his past medical history is, just have a little thing trying to drop down as many causes, whether it's pre renal, renal, post renal that you can think of that might be contributing to this gentleman's AKI. So again, a couple of minutes. Just get some water. I apologize if it's noisy, by the way, I'm sitting in one of the offices that works. So people are coming in now. Um so apologies. I can't stop them. Unfortunately, so again, a 79 year old, two days admission confusion, reduced oral intake, a one off low grade temperature and a background of the long term catheter BPH and CKD. So what stage AKI do you think this gentleman has? And what do you think the possible causes with a K I could be before you even gone to see him. So just in case you can't see on admission um so his hemoglobin was 115, white cells 10 and crp six, potassium and sodium was with within normal limits. And he has the area of eight and a crack in the 125 today. His hemoglobin is stable, his white cells have gone from 10 to 16. His CRP has gone from 6 to 45 his urea 8 to 12 and is crashing 125 255. So how do you think what the cause is? Might be. So we've got a few people replying a people saying Stage one, uh, what people are saying Post renal from BPH and long term catheter. Yeah, people saying prerenal hypovolemia due to reduce the oral intake as well. It's great. Perfect should be going to next side and see what I thought. I think I generally agree from my own scenario. Yeah, I agree that this is a stage one, a k i. His classes increased by about 30 and a 40 hour period, so I agreed on that one. So I thought, prerenal I agree to produce oral intake may be a bit of infection is inflammatory markers have gone up. There's a long term catheter in situ, and there's a low grade temperature. Um, so again, maybe, you know, that's driving to reduce your intake. We assume he's not septic from his observations, but we need to do a bit more digging into that, I thought, arguably intrinsic. We don't know what this background of CKD is. What's driving the CKD? Could it be a progression of that that's driving the AKI again? Unlikely, given the 48 hour period. But we don't know without knowing etiology, difficult to know and then I agree. So post. Really. We've got the background of BPH. There is a catheter in situ, So could the catheter be blocked? We need to flush it. We don't We have been told it's draining, but we need to make sure we know that for ourselves and we see some output. So within one patient we've demonstrated there could be multiple causes for a K I. And as with anything, if you're going to see a patient, I always think it's good to think of what is the presenting plane or what's the main issue? And how can I what my red flags and what my main things I'm looking for when I see when I go to review them, because that's what I what I want to rule out as I'm going through my history and my examination. You remember your history. Examination is a way of testing your hypothesis as you're going in, So this one's got an A k I. As I ask my questions and do my examination, I'm testing the hypothesis. Could this be a catheter associated duty I could he be dehydrated? Has he got a blocked catheter? That's all. He's constipated, which is causing urinary obstruction? Or could this be a progression of CKD so trying to challenge your hypotheses as you're going through your history? Examination. Lovely. Well done, everyone. Next slide. Thank you for contributing if you're in the comments. So let's go on to how to approach a patient so briefly from history. I'm sure you all know how to take history, and it's the same structure. And, as you said, testing hypotheses. These are just some points to think of some additional stuff to think about when approaching a patient with a K I. So have you had any recent acute illness that you brought them in? Essentially, if you're in a GP and it's an incidental finding, have they got any symptoms of systemic illness? So think about vasculitis, any joint pain, fatigue, skin rashes, anything that might flag that this is a widespread systemic cause. Have they had any symptoms of outflow obstruction, so abdominal pain flank pain changes in their urinary stream so intermittent not emptying your bladder properly in terms of your past medical history? Is there any abdominal malignancy or past medical history or family history of bladder cancers, renal cancers, et cetera. That might be appropriate. Do they have risk factors such as their occupation? Etcetera? Remember, myeloma is a big reason. So particularly over 65 new renal dysfunction. They've got lower back pain. Myeloma is myeloma. Screen is always a reasonable differential to come up with. Um, have they had any medications? Have their fur? Is, um, I've been increased. Have they been started on a new BP tablet? Have they been taken something from Holland and Barrett, which is new and might be contributing? Is there anything in their history or family history contributing, you know, a renal disease, their history vascularitis et cetera, or CKD that needs to know about. And then just general past medical history. What the risk factors for CKD or AKI? Any diabetes, high BP that might be controlled so trying to think about more focused history for renal, but keeping it with open questions and doing what you normally do for your history. Next side in terms of examination, I think last week for those who attended the fluid IV fluid lecture, we went through the assessment of fluid status. So just for those who haven't, uh, didn't attend that lecture. So this is how I do my fluid balance examination. It's a systematic approach that I have now just kind of do without even thinking. Fluid balance is something you will without doubt, be asked to see on most all cool shifts. Um, out of hour shifts. You always have to do for the balance reviews as we should, because we're providing IV fluids. So the purpose of your fluid assessment just to remind you on is the question you're answering at the end is Is this patient hypovolemic euvolemic or hyperkalemic? I think last week were having conversations about what different signs mean. The most important thing is it's never one sign, you know, on its own that's going to push you one way or the other. You're looking at the global picture of the patient in front of you, so the cat refills okay, but the BP is low and the dry don't let the cat really confuse you and knock you off. Think about the overall picture. So just quickly for reminders. So I like to again look at the end of the bed. Is there anything obvious that they've got IV fluids running a big thing of leukocyte next to them? How they got an N G tube or rods, tubing or vomiting everywhere and then starting peripherally. So what's the peripheral cap refill? What's the central cap Refill? Um, feeling the pulse, the character, the rate and going up and then getting to stick the tongue out, tongue out. What's the as it dries it moist again? BP is helpful as well. And if the patient is stable, lying standing is helpful. Seeing as any fluid depletion, please don't do it if they're sick because it won't help and it will make them worse. Um, so once, because membranes going to the JVP so let's have a look is up by their ear. Do you have to push on the hepatic angle to try and improve it? Quick, listen to the heart sounds. Is there a Gallup rhythm or something that's that might suggest heart failure? Listen to the basis for crackles pitting edema, so feel for the sacrum and peripherally. See if any pitting edema and then is there any documentation of urine output? Have they got a catheter. And what do I think of the GCS? And that's like my go to structure. And normally, if you do a bit of all of that and you can answer those questions, you'll be able to conclude if your patient is hyperkalemic, euvolemic or hyperkalemic, and ultimately in identifying the cause of your a k I. Where this is pre renal, Um, and what would be appropriate treatment? That's a really important element of AKI next slide. So in terms of renal failure, just these are just some point is to think about if someone who may have an a k I on CKD. So does this person have a history of renal failure? Need to think about so just quickly. These are things you might pick up when Clark in patients or those Are you still doing exams? So top left. We've got the baby Fischler in the A, C. P uh, a CF. Sometimes it can be done by the radius as well. So if you see that pattern, it listening to brew is making sure it's patent looking at the next. The patients who have had acute decompensations in renal failure, who had to be rushed to intensive care for renal replacement therapy may have central line scars. So, again, having a look could this patient had a history of acute deterioration requiring dialysis Top, Right. We've got excoriations for, uh, uremia so pure. It is secondary to your anemia as a high area within the blood. So have you got any kind of rashes? Explorations on their chest on their arms. Awesome. Left. We got pitting edema. Sure. You've seen the middle one. We've got a renal transplant scar. So, having a look? Have they had any abdominal surgery? Have they been a donor? Have they received a transplant? And then the bottom right is a nephrostomy tube if they've got that in, uh, there are two urology, but again, you know, you don't know who you're seeing on on review. Sometimes if they're sick, you do review them. So that's what the frost YouTube will be in the flanks. Um, I think to consider alongside your examination. So have they had a few of balance chart documented? Can they tell you the oral intake? Have they had nuclear is prescribed recently? Um, what's the urine output have does The patient will be able to tell you. Is there a catheter? Have they been using bottles? And then any additional loss is the rose tube. Stoma is your ostomies all sorts. Imaging is helpful. So having a look through seeing particularly got a history of renal problems. So have they had any recent X rays on the X ray in front of you? Hopefully, you can see a left sided renal stone. I think it's probably hydronephrosis all right. It looks like it's related from her. Uh, have you had any previous ultrasounds or CT scans, which might be helpful as a baseline for diagnosis and then blood? So the most, as you can see from the criteria most of the diagnosis of AKI, is a comparison. So what were the Bloods before? When was the last taken? Do I need to repeat them now? Next side. So in terms of your management, once you've got a good history examination, as with any patient, regardless of uh, if they're stable or unstable, always do an 80 approach. The reason for that is if someone's stable in front of you, you can do an 80 approach pretty quickly, Um, but it's safest so And the more you see patients, the more you kind of do a two day anyway. And that's how you can get most of your information. So from a renal perspective you're thinking about when you're seeing your patient, Is this person in front of me decompensated or compensated decompensated? They're sick, compensated. You've got time. So for an airway perspective, there shouldn't really be obstruction from renal disease or AKI breathing. If they're decompensated, they may be short of breath tachypnea requiring oxygen, which maybe suggestive of palm or edema. Recirculation perspective. So what's the BP? Are they dry? What's my fluid balance examination? Heart rate? Um, and I was going to say, And if they're pretty shut down or not, Disability I normally do. Abdomen is soft. Nontender. Is there any tenderness when I'm palpating any scars? I need to see? Um, can I see any catheters or tubes? Can I feel their bladder when I'm palpating have a big, full bladder, suggest an obstruction, and then everything else always do a bm particularly that low GCS just in case, regardless of what you're looking at, um and, you know, carbs, peripheral edema, um, etcetera as part of view everything else. So just a quick 80 in terms of your management for your a k I. The main thing you're doing is what is the cause, And how can I fix that, Cause So, uh, the main thing with renal failure is that you want to increase the amount of blood going to the kidney and ultimately improve the urine output. Right. So you have a hypoglycemic patient, someone is clinically dry, you're gonna be going down the IV fluids Fruit generally both fluid bonuses. And so if you're hypertensive and dry, it's a resuscitation scenario. So go down the the IV bonuses. Um, there's a lecture online believe I did last week going into that more detail. Um, if you have any questions on that, if they are hyperkalemic, then your patient is decompensating, in which case you're in a difficult fluid balance because you need more blood flow to the kidney. And there probably intervascularly deplete. The fluid is going to the wrong place, in which case you're looking, you need senior support, and you're looking at probably critical care for management, particularly the hypertensive. I wouldn't start throwing diuretics, etcetera at them, particularly as you're starting off in your F one p a career, I wouldn't be going too heavy on that just because if they're already hypertensive, they run well. So you need to get a review from the senior urgently. So input output monitoring. So I think the catheter is always something that we're taught and if it's accepted patient, by all means. Catheterized. But remember, catheters have side effects of themselves. They can lead to field talks, people can be dependent on them, and it's an infection risk. So he's thinking about who is the patient in front of you? Is it a young person? I can tell you now If I was admitted with an A K I, I would not be accepted. A catheter. Um, so is this a stable patient who can manage their own urine output? And we can do it confidently, Obviously, a catheter. You can get out by our it's dripping into the bag so it's more accurate. But you can still calculate, you know, if you have everyone passes, someone passes urine every 4 to 6 hours. You can still calculate the average of how much you're in the past equally that you know if they're in mobile, if they're really dry and it's not reliable way of getting the urine out put a catheter is something to consider, but certainly not throwing a catheter with every patient again. I would also think about the stage of a K I, if they're cracking, has gone from 1 50 to 1 80 then mobile and moving around not necessarily need to catheterize. And there is, you know, the guidelines. Do you say that you need to balance the risk of catheterization? Um, so if any concerns, run it past the senior, but you need to have a good way of input. Output monitoring, bit bottles. Um, not really thinking of. So, um so what am I thinking of? What's the not catheter like the condom? Thanks. Confine. Confine. So it combines are like they're like condoms basically for men, and then they pee into it's it's not invasive, but they, uh can you can still pass urine, particularly there immobile or bedpans, etcetera. So, anyway, you can calculate the urine output. You want to stop any nephrotoxic drugs, which will go into in a little bit? Um, I think BBg is always helpful, particularly good a new AKI to get a baseline for the potassium and their pH using these. If they have not had a baseline for a while, to say 12 hours or so. I don't think it's unreasonable to take you sneeze if you're going to get a VBG anyway in terms of urine dip. Firstly, that rules out any signs of infection. Bear in mind If they have a catheter, it may still be positive for Leukocytes, So think about the clinical picture always equally. If you're gonna refer patient with a K I to an apologist, they generally want a urine dip. And that's to look if there's any protein or blood, which maybe suggestive of an intrinsic cause, it's a urine dip is important investigation. And then finally, if you're worried about obstruction, obviously they're obstructed. They're going to need a catheter, uh, bladder scan in to see what the residual is. If it's 506 107 100 they really can't be or it's post void, then the catheter is appropriate. Um, but in which case they may benefit from ultrasound, KBS or CT KBS to look at the renal tract next fight. So this was on a minor bleed website thinks from someone's entry prior. So there's an 80 of AKI, which you might find helpful to think about. So it's addressing the medications, which again will go into in a second, optimizing your BP either with fluids or maybe stopping antihypertensive drugs to maximize blood flow to the kidney again if they've got a systolic of over 200. I talked to someone before you, uh, stop antihypertensives, but again, clinical scenario. This is not, uh, black or white in terms of management calculating their fluids. So what's their, uh, requirement? Is this the resuscitation or maintenance scenario? And again, you can go back to the lectures last week for advice or not dips in the urine and exclude obstruction as we mentioned before. Next side. So a couple scenarios for you. So Oh, that's not good. Grammar isn't older. Sorry. So you're clerk in a 56 year old gentleman who has presented with fevers, some shortness of breath and a productive cough. He's had very little of intake over the last few days, and in the last 24 hours he's only past year in once, and he said it was really quite dark and smelly when he did so. So on the left, you've got some observations and the questions I have for you, based on this scenario, is what your main concerns with this patient. How did you manage this patient and what investigations would you like to order? So I'm going to be a bit of time for this, because a lot to think about Just to recap a 56 year old gentleman with fevers, shortness of breath and productive cough. There's very little oral intake over the last few days, and this past year and once in 24 hours, it was very dark and malodorous. This is a direct referral. Two medics from GP. So you haven't got any Bloods back yet? The first person to see him, Um, in terms of the observations, his SATs. 93% on two liters. He's got a respirator. 20 for his heart rate is 130 regular. His BP is 98 40 and his federal at 39.5. So what? Your concerns with this patient? How did you manage him? And what investigations would you like to order So if you write your ideas in the comments, um, no suggestion is silly. There's no judgment. This is a safe space. So all engagement is welcome. I can't see it directly, but I'm sure I will be told if there's any answers on that. I think people are going for the first one first. Of course. So a few people are worried about sepsis due to a UTI. Yeah, everyone's main concern right now, and I'll let you know people are coming in with their management plans now. Yeah, perfect. So main concern of sepsis. Absolutely. So this is a hypertensive, tachycardic federal patient. Interesting that we've gone for UTI. I would actually be more concerned if you think e So this is a 56 year old. We have no history on him with shortness of breath and productive cough is now on the two liters oxygen requirement that starts at 93%. So my concern is more from a chest perspective, actually, um, I agree he's certainly septic, and we need to do step to six or Chiti clue. Um, but in terms of, uh, he may well have a urinary tract infection as well. Um, and he has got malodorous urine. But my main concern, I think, firstly, is why is the 56 year old on two liters of oxygen and only 93%? So that's just something to think about. Any management plans coming in? Yeah, we've got a few. So a lot of people saying sepsis. Six. Like you said, people are saying, Give some fluid boluses potentially start antibiotics. We've got part of the steps is six. Uh, some people have said do an 80 response and then manage the hypochelemia as necessary, which is great loads of people coming in with different blood tests to do so. F B c crp. You sneeze BBg um, people saying chest X ray bladder scan is probably enough to go on now. It sounds like some great ideas. Lovely to go to the next side and see what my thoughts on my own scenario. So So my concerns as septic. So I've said my first concern, given the history and the saturation, is this could be chest, um, equally urine is perfectly another. Another good suggestion because I reduced your urine output malodorous. It could be a symptom, but if we're doing our 80 approach this airway, which is talking to us but always used to be before See, So you must correct be before you want to see. So this gentleman, I would whack up his oxygen. Um, I think if anyone is desaturating even if the COPD start on 15% and wean down, remember, hypocrisy kills more faster than hypercapnia. So you keep doing well. Patients start high titer it down. Aiming for scraps of 94 above. Depends on the patient in front of you know, part of that would be a K I, uh sorry. ABG, um, seeing that there are two or gases. So in which case you get part of the steps is six as well. With your VBG ABG, you just get your oxygen as well. Um, And then my main concern is also is that this man is not eating or drinking. He's had one urine output in 24 hours. He's septic. So in terms of his risk for a k I, he's a cute young. Well, he's probably dehydrated. Accept it in third space in and he has produced urine output. So I agree. So 80 approach Start with the chest. Another thing. Could he have a stock in a K I? And he's not going to be compensated? Uh, renal failure. 56. We hope not. It's properly or sepsis driven, but a chest X ray will be helpful in terms of the management for that, um, so your sector six to remember is your three and three out. So in is IV fluids IV antibiotics and oxygen and you're out. Is your blood cultures lactate and catheter? So in this scenario would be catheterizing because you accept six. Um, and remember all this should be done within the first hour of arrival within any input output monitoring. So he's going to have a catheter because of sepsis. But asking the nurses to kind of do your out the urine output, review him and then have a look. What this medication could there be any triggers or anything? We need to hold on submission, and I think we've gone through the investigation CABG, chest secretary, urine dip with the, um, CNS, if needed. And I think that the scan is reasonable. Is he having the urine output because he's obstructed? Or is it because he's oliguric lovely, Well done, have I got another one for you? Yes, I do. So next story you've got your A and d f. Uh, you've got a 35 year old lady who's had two days of left flank pain and abdominal pain. Uh, you review her and she's patient all around the cubicle crying out and pain won't sit still was in agony. Um, so you're going to get some analgesia and that settles. At which point, he tells you, The last couple of really hot and clammy really unwell. Bit nauseous, but not vomited. But actually, from a urinary perspective, it's past year and there's no blood in it or or urinary symptoms. So you have blood on the left hand side. From today, we have no baseline because she's a 35 year old woman. Doesn't come to any or GP, basically. So what, You're differentials with this patient? Given her history and her blood tests, how would you manage her? And what investigations would you request? So to remind you, a 35 year old, two days of left flank abdominal pain, uh, is in a lot of pain when you see her. She's hot and cold at home I felt nauseous, but no hematuria. Just in case you can't see her. Hemoglobin is 1 20. Her white cells at 12 with a CRP of 70 potassium sodium within normal range, which is the area of nine. And crossing 100 35. So what? You're differentials. How did you manage and what investigations would you request? Let me know if there's any suggestions coming through. I'm not in the interaction because I can't see anybody. Good. I think there's a few coming through. So we've got a pilot of ritis. Ritis is a few nephro like this is I can never say that we've got renal colic. Oh, this is interesting. Someone's written an ectopic cause the differential? Uh, yeah. Kidney stones again. Loads of people going for atopic, actually. So that's good thinking outside the box now, I guess. Yeah, that's what we've got for that one so far. And then I think we should have hopefully some management plans coming through there. Any priorities to management? So people have started with, so f b c urine pregnancy test. We've got ultrasound. K, you be good. Mhm. Manage with analgesia monitoring your kidneys and fluids. Perfect. Yeah, few more for ultrasound. Good. Someone's had a CT instead of an ultrasound. Okay. Yeah. I think that's a great lovely thank you guys for the interaction. Very good. So let's see if I agree with you with my makeup scenario next side. So my differential is primarily based on the right side, left side of flank and abdomen. Pain is renal stone versus UTI. A pilot. Arthritis completely agree. Thinking outside the scopes of, um, a k I Could this be ectopic torsion in women? All young women are pregnant. Proven otherwise. Um, torsion is another option. Constipation, Uh, effective colitis on that side? Um, diaphragmatic irritation. So left sided caps can sometimes called mimic pain around there. Muscle skeletal stuff. So lots of differentials and well done to thinking outside the box. Uh, those who said about the topics and that That's really good. Um, I think in the room it's an ache. I lecture and the left flank pain, given the fact he's pacing up and down, I'm thinking Renal stone versus pollen. Arthritis. Um, so again, we've been actually approach. Main thing is analgesia. So if we're thinking about renal stones, flank pain, pr diclofenac is really helpful and works a dream in renal stones. Uh, process. More codeine as well are helpful to titrate up. Um, I would give fluids. And if there's a positive urine dip, consider antibiotics, uh, particular, that she's been hot, cold, shiver and shaken. And there's a CRP of 17 and white cell count is 12. So I think infection or something is going on from an infection or inflammation setting, which is concerning given her renal function. Obviously, we don't have a baseline, which makes proven This is an A K. I buy the definition difficult. We don't know if she's had any CKD etcetera, but given she's a young female, across 135 is abnormal. So my concern is that she's got a renal dysfunction on top of this, so I just put pregnancy test. But absolutely all women who are of childbearing age who come through only get a pregnancy test, um, so pregnancy test, because if you don't want to miss anything like an ectopic urine dip, so again is that, you know is there is a microscopic blood, she said. There's no Frankie Material, but we need to make sure it's a microscopic leukocytes nitrates to prove that this is the real cause of her infection. So ultrasound versus CT. So CT is arguably better modality. Ultrasound is dependent on the user, but it's no. There's no radiation. It's normally quicker to get so in young again, fertile women or women of childbearing age. Ultrasound. KB is preferred over CT. If ultrasound can't necessarily prove that there's a stone and there's still a high suspicion they may go into CT later. But generally with young women, we go for the ultrasound first, um, so a little bit and then blood. So FBC using the CRP, which you've already BBg for baseline, uh, potassium. And for, uh, pH and pregnancy test Absolutely. Just thing to think about in this patient. We've got someone who has queria renal stones with college is sounding pain with it, raised inflammatory markers and, uh, abnormal grasping for what we would expect in her age group with no past medical history. So could this be an infected obstructive kidney so imaging would be urgent? I'd say this lady, which, and that isn't a urological emergency. So needs urgent review, so just something to bear in mind. But I agree This may not be really little, and it may be something completely different. Lovely next one. So just a quick note on prescribing in patients with renal failure. So whether it be a k i or CKD, there is a whole host of drugs which will need modification or stopping if you are have patients with reduced creatinine clearance. Now, remember, if it's a CKD, your EFR is more reliable. But with a K I. You should be looking at crafting clearance rather than your IgE. Far as it may not be accurate. So just some ones to bear in mind in terms of altering the doses. So your opiates, we tend to use oxycodone rather than, um, morphine. In renal patients, um, and Tramadol doses may need to be reduced. Antibiotics are some penicillin, such as, uh, Terazosin. There's renal dose before and, uh, UTI. There's a cut off for renal function with trimethoprim, um, nitrofurantoin as well. Some anti epileptics and immunosuppressant. So for Newtonian methotrexate, tacrolimus may we need to have a much higher, more frequent monitoring of their levels to make sure that they're not overdosing on them when they're renal function is impaired. Diabetic medications so we normally say Hold the metformin. If the creatinine is going up because of the risk of lactic acidosis and some modified release, hypoglycemic agents can have a prolonged effect in a k I. So there's a higher risk of hypoglycemia, and a common one that you come across is your low molecular weight Heparin. There are renal dose is for both V. T and treatment dose. So it's important to calculate your creatinine clearance as well. But again, I always speak to my pharmacist, uh, in my ward because I find it to be overwhelming. And it's better to check with someone who is much better medications than I am next side to some, some kind of found this acronym so damn to think about the main drugs to think about in a k I and renal patients. So D is diuretics A is your ace inhibitors and ARBs, so you should be really, ideally stopping. These are holding these while they've got an acute kidney injury, providing the BP that is okay. Um, in which case, if it's not, you may need to switch to a different agent metformin. Behold, um, NSAID again. It can be a cause of AKI but also won't help it. So you do Stop and hold those and think of alternative analgesia and lots of other drugs as well. Next one. So, uh, here we have a medication question. So, um, some sort of want to this one. This is your question. Do you want me to stop? Um, yeah, sure, I'll do it. So So this is a 56 year old past medical issue of diabetes and COPD. Um, they have an exacerbation of the COPD, and you've taken their blood's, um and actually, you guys can post in the comments What you think in terms of stage of a K. I, uh, is going on. So the baseline here is 96 let's say that was yesterday. So it's been about 24 hours, and now it's 200. Um, and they are on the following drugs. So, um, how do you think about which one you would think about stopping or holding? Uh, and then we'll run through them, and you can You can post them in the in the Facebook live chart if you like. Okay. So I'll carry on, actually, um, just any comments So shall we Shall I just go through? We put a few people saying Stage two a k I Mm. I think they're starting with that. And hopefully people will say some of the medications. Yeah. Some people are saying hold the metformin. I think it's a good idea. Yeah. Okay, um so So I'll let, uh, lazy run through the stages is probably better than the media. That but in terms of the meds, um, exactly so metformin it actually increases. The risk of lactic acidosis in kidney failure doesn't necessarily, um, contribute towards the kidney failure, but it can increase that risk of lactic acidosis, so you might want to consider holding it. And that's that's from what I know and then ibuprofen and and said can be toxic to the kidneys and the furosemide. So from that that pneumonic damn diabetics, 80 inhibitors ARBs metformin and said like ibuprofen. So those would be the ones to say at least consider holding. And if you're going to consider holding metformin, think about are they meeting their needs in terms of lowering their blood glucose for their diabetes? And, of course, you know, speak with your seniors about the drugs that you are going to hold because they may need something different. I'll hand it back to Lizzie. Yeah, great. Lovely. So, yeah, I would agree that the stage two a day and it's gone up. I had to get my calculator out home, viruses that it's not just over two times a baseline. So I would agree as a stage two a k I, um Yeah, I agree to metformin, I think is my lovely good. Thank you very much. So just a quick thing about dialysis. So this is in the terms of an acute kidney injury. So again, remember when I when I said If you're reviewing patients for the first time, the question the first thing you have to answer is this a decompensated or compensated patient? And that's regardless of what system you'll see him in renal failure. When we're talking about decompensation and particularly acute kidney injury, it does this patient meet the threshold requiring renal replacement therapy. So the main things to think about for renal replacement, um, and things that I would just have a look at and make sure that you're getting a baseline for is are they? You're anemic and how do they have complications of uremia? So, like an encephalopathy, they're very confused or pericarditis again. Not that you need to pick up as a I mean, I certainly won't pick up your Remicade pericarditis per se. But if there's, you know, that's a complication, or the ureter is incredibly high, and they're confused. That's something to consider, um, if they are overloaded. So remember I said a hyperkalemic patient who has a new good going AKI and you think he's in Palm Redeemer, you're going to need to get senior support, and that may be an indication for renal replacement therapy. Um, a word on that is that if your diaries in So if you have someone who's food overloaded, even if it's something with the heart failure or whatever, has a background of renal disease, if you're going to give diagnosis, the diagnosis may have some basic dilatory effects in the short term. But if you do, if you have a patient in front of you who does not produce you in a baseline and then maybe a dialysis patient anyway, um, dialysis is not going to do a whole lot, so asking patients basically more more or less a CKD who maybe dialysis patients do you normally past year, And that's on the side in the acute setting, if you have someone who has decompensated in fluid overload, um, that may be an indication for renal replacement therapy, and you need to speak to a senior soon. Metabolic disturbance is so they have a metabolic acidosis that is not improving with treatment. So sometimes, particularly hyperkalemic. You can give sodium bicarb again or advice of seniors and a renal you don't prescribe on your own. Um, if the the pH is low, you need to get a senior to review because they're becoming unstable. An orthotic. But they may want to give some treatments if it's resistant. Metabolic metabolic disturbances. Then again, it may be an indication for R T and again hypochelemia if you have treatment resistant hypochelemia. So you've given insulin, dextrose, renal or your seniors have suggested in sodium bicarb, and it's persistently elevated. That may also be an indication for acute renal replacement therapy, so that's where you can see that the getting the BCG is helpful, even if it's a baseline for the Ph and the potassium. Uh, pH. So baby's potassium can be a bit spurious. So if that's what you're looking for, I normally recently use the news anyway. To get a formal um, and fluid overload is where your fluid assessment comes in next side and in terms of referring to renal. So there's lots of criteria on nice guidelines about when you should refer to renal. This is for urgent referral. So in some trust, all AKI is regardless of the stage. Get referred to renal and they will give input depends on your trust. And certainly, as with all of this, you look at your trust guidelines and you speak your seniors because this is not necessary. A blanket will for all patients. But in terms of nice guidelines, urgent Referral to renal is if your patient has a baseline stage four stage five CKD. Um, if you think it might be an intrinsic or renal cause of AKI, then certainly refer to renal. If the pain has not responded to treatment again, refer if they have complications. So we're going down. You know, the indications for dialysis. They careers going up. Uh, they become a bit more acidotic. The potassium is kind of teaching and it's not really responding, referring to Renal. Um, and if they're renal transplant patients, um, coming in for anything, any transplant patient you should be at. Baseline was speaking to the transplant team and let them know of admission. There's been lots of, you know, their scares where patients have not had the tacrolimus help because there's concerns that they have infections and things. But that shouldn't really be done without discussion with senior staff um, renal team and ideally, should be letting the renal transplant team know sooner rather than later. So there are other things. But that's the main ones. Um, so I've been talking for a long time. Apologies. I'm sorry. This has been a bit heavy with lots of information, but hopefully it's helpful. So take home message is generally so as the only patient history examination is testing your hypothesis and will help you to come up with your main issues and start formulating management plan. Um, if you're seeing a patient with a K, I think about whether be BG and repeat, these needs may be helpful you had used in the last couple of hours. It's not necessarily going to be helpful but in an out of our setting, you might want to repeat them. And I think a baseline BBg is always helpful to get your baseline for your acid based balance and ph. Etcetera. Thinking about your index. Is there any intrinsic causes you can pick up and the importance of fluid balance and how you're going to measure the urine output? Medication reviews are really important whether you think it's the cause of the A k I or where do you think it may be contributing? Um, it's important. Generally, if you hold medication and then discuss them. It's safer than giving and then having to hold things later. So by no means don't don't kind of stop medications and go home, and that's it. Always escalate to a senior. If you have a concern of all, maybe I should hold the furosemide. Maybe I should do this, hold it or don't prescribe it and then directly speak to a senior immediately to have a conversation about whether it should be given and what alternatives can be given, um, and again, just to be thinking about Does this patient in front of me? Are they decompensating? Do I need to get senior review. Um, and is there something going on that I can't immediately fix? And we need to refer to Reno. And that's it, Um, in terms of I think that might be the last slide. You got any questions? Do you pop them in the place of chat in terms of the link, we tried the QR code earlier. We couldn't get it to work. So if it doesn't work, please do, uh, do the link because it's the only way you can get feedback to demonstrate have done some teaching. That means, you know, exams and I have been here and done the sides for you. And also, it means we can improve the sessions in future sound like you're going to go back to sides for me. So just quickly these are just some resources I found really helpful. So you got your nice guidelines in terms of your acute kidney injury, which is kind of put throughout the presentation today in terms of the TNF, there's always advice on prescribing in renal impairment if you're concerned. So you're friendly pharmacist and also be very helpful. And then we've got think kidney, which is a website that I came across. It's got. Firstly, this document is amazing for medications and advice on that. But it's got a whole source of information about tackling AKI patients. With CKD. It's got information. If it's for renal patients, Um, and it's got some advice of primary care as well. And then just in the bottom, there's an app that I used as an F one. I'm not sponsored, but pocket Doctor, I think you do have to pay for it, but has got a kind of a checklist on how to manage patients who may have hypochelemia or have renal dysfunction. And you can go through and think about your differentials and main investigations to do so. It may be something you find helpful, but that's it for me. I will stop talking because you listen to me for far too long. Um, and any questions just pop it in the chatter box and please, please, please fill out the feedback for Thank you very much. Great. Thank you so much, Lizzie. It was an excellent talk. I definitely learned a lot, and it was really good summary of everything. Um, we've got we've just got a question from Mohammed just saying what was the damn acronym again? He missed it earlier. I wouldn't mind going through that. Yeah, I remember it. So these diuretics is your ace inhibitors and ARBs m is your metformin, and then is your NSAID And then I think this is some other drug. Um, I can go back to the slides. I think they're the main four for the damn criteria. But remember, most drugs, whatever you prescribe me, just check to see if there's any real indications. Because there's so many of them. Yeah, Perfect. Thanks. I don't think there are any other questions, actually, but I think it was really great talk really summarized everything. Well, Lizzie said, please make sure you fill out the feedback. Sorry, I'm not sure if the QR code is working, but we've got a link in the comments on the Facebook page. And then also, you guys get a certificate and we'll get really helpful feedback on how to improve things. Um, so I think that's it for today. But make sure you join us next week at the same time we've got, I think Annabelle doing, reviewing and requesting blood, which would be really great topic. Something that's useful every day as a doctor. Um so I think that's it. If you do have any other questions, please put them in the comments and we'll be sure to look back at them and answer them if needed. Um, sorry. People are saying the QR codes are not working. I'm really sorry. It's on the website and I've also sent a link on the comment. But thank you very much, everyone. Thank you. Take care. Bye.