Moffitt Renal Report Pearls 6.16.17

Thank you to Kenny for his sense of humor AND for presenting an elderly patient with h/o BPH, recent acute prostatitis, now presenting with altered mental status and acute renal failure w/ hyponatremia 2/2 multiple mechanisms including obstruction with concurrent use of NSAIDs and an ACEi. We discussed the management of post-obstructive diuresis, hyponatremia, and volume overload.

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Key Pearls:

  1. The old rule of thumb that you get an elevation in creatinine of 1 for each day of renal injury turns out NOT to be totally accurate. [20mg/kg/day with volume distribution of 0.6 allows for increases in Cr by as much as 3mg/dL per day!!]
  2. Approach to AKI anatomically: Pre, Intrinsic and Post-renal (more below)
  3. Postobstructive diuresis is primarily a problem with CHRONIC, not ACUTE, urinary retention with management details outlined below.

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More Review on AKI

– Definition: < 48 hours (abrupt) time course with 1 or more of the following:

  1. Increase in serum Cr > 0.3 mg/dL
  2. Greater than 50% increase in serum creatinine from baseline
  3. Reduction in urine output of < 0.5 mL/kg/hr for > 6 hours

– Oliguria is defined as UOP < 400 mL/day, while anuria is < 100 mL/day

Approach to AKI based on anatomy

  • Pre-renal – 70% of community acquired and 40% of hospital acquired AKI
    • Hypovolemia: vomiting, diarrhea, diuretics, hemorrhage, burns
    • Decreased effective circulation volume: Cardiorenal, hepatorenal
    • Change in renal vascular tone: ACEi, NSAIDs
  • Intrinsic Renal – urinalysis is the key here!
    1. Glomerular – RBCs; Anti0GBM, Pauci-immune, Immune complex
    2. ATN – muddy brown casts; prolonged pre-renal -> ischemic, toxic, septic shock (most common)
    3. AIN – WBCs; drug-induced, Infectious (fevers, rash and eosinophilia ~ 15% of pt)
    4. Vascular – micro: HUS/TTP or macro: renal artery stenosis, thrombosis
  • Post-renal – important to exclude early
    1. Obstruction from BPH, acute prostatitis, constipation, pelvic masses, neuogenic bladder

 

 Post-obstructive diuresis

  • A postobstructive diuresis is primarily a problem with CHRONIC, not ACUTE, urinary retention and usually represents an appropriate attempt to excrete excess fluid retained during the period of obstruction

 

  • Management of post-renal obstruction:
    1. Relieve the obstruction
    2. Anticipate a post-obstructive diuresis if chronic (more below)
    3. Frequent monitoring of I/Os and electrolytes (q6-q8)
    4. If going to give fluid, caution with chloride-containing fluids: Loss of hypotonic urine, may need replacement fluid, usually in a 2:1 ratio (replace approximately half the volume the patient is putting out).
    5. Fluid replacement is usually with one-half isotonic solution
    6. Remember that “The kidney is a better judge of the volume status than the doctor!” per Dr. Chi Hsu – In most patients, things will correct themselves.

Altered Mental Status (AMS)

Remember the MISTO mnemonic for AMS:

    1. Metabolic (electrolytes, esp Na and Ca; endo, esp thyroid and glucose; liver; kidney)
    2. Infectious
    3. Structural (stroke, mass, bleed)
    4. Toxin
    5. Oxygen/Other
    6. As Jen O mentioned in report “AMS” can be a very nonspecific description – it’s helpful to break this down into more specific characteristics, such as decreased level of consciousness, agitation, confusion, disorientation, etc. This helps one to narrow your differential – also remember MISTO!!

Evernote Blog: https://www.evernote.com/shard/s307/sh/e439308e-78dd-4bd4-b961-c58b1e56c367/24a999bd59e136463395763977087573

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