Question

1) Review the body systems assessments noted for AKI. Prioritize the assessments and explain which symptoms most are concerning and why.

2) Your patient is on antihypertensives and a diuretic. What actions will you take to prevent these medications from contributing to prerenal failure?

Answer 1

Review the body systems assessments noted for AKI. Prioritize the assessments and explain which symptoms most are concerning and why.

SERUM CREATININE LEVEL

To evaluate the duration and acuity of the disease, it's important to compare the current serum creatinine level of the patient with previous levels. The concept of acute kidney injury suggests an increase in creatinine occurred within 48 hours, although it may be difficult to determine when the increase actually occurred in the ambulatory environment. A high level of serum creatinine in a patient with a reported level that was previously normal indicates an acute process while an increase over weeks to months reflects a subacute or chronic process.

URINALYSIS

Urinalysis is the most effective noninvasive examination of acute kidney injury in the initial workup. Urinalysis results guide the diagnosis of differentials and direct further study.

COMPLETE BLOOD COUNT

The occurrence of acute hemolytic anaemia in the setting of acute kidney injury with the peripheral smear indicating schistocytes should increase the risk of hemolytic uremic syndrome or thrombotic purpura thrombocytopenic.

URINE ELECTROLYTES

Measurement of FENa in patients with oliguria is helpful in separating prerenal from the intrinsic causes of acute kidney injury

IMAGING STUDIES

Renal ultrasonography should be done to rule out obstruction (i.e., a postrenal cause) in most patients with acute kidney injury, especially in older men. The presence of postvoid residual urine greater than 100 mL (determined by bladder scanning or urethral catheterization if bladder scanning is not available) indicates posttrenal acute kidney injury and involves ultrasonography of the renal system to detect blockage by hydronephrosis or outlet. Other imaging modalities, such as computed tomography or magnetic resonance imaging, might be needed to diagnose extrarenal causes of obstruction (e.g., pelvic tumours).

RENAL BIOPSY

Renal biopsy is reserved for patients in whom acute kidney injury has been removed from prereal and postrenal causes and the cause of intrinsic kidney injury is unknown. Renal biopsy is especially important when clinical assessments and laboratory findings indicate a diagnosis that needs clarification before the establishment of disease-specific therapy ( e.g., immunosuppressive drugs). Renal biopsy may need to be done urgently in oliguria patients who have rapidly worsening acute kidney injury, hematuria and casts of red blood cells. In this setting, the biopsy can support the initiation of special therapies, such as plasmapheresis, if there is Goodpasture syndrome, in addition to suggesting a diagnosis that needs immunosuppressive therapy.

2) Your patient is on antihypertensives and a diuretic. What actions will you take to prevent these medications from contributing to prerenal failure?

Several medicines can cause acute kidney injury to the prerenal system. These and other medications restrict normal homeostatic responses to loss of volume and may be associated with a decrease in renal function. In patients with prereal acute kidney injury, kidney function usually returns to baseline once adequate volume status is identified, the underlying cause is treated or the offending drug is discontinued.

· The dosages of essential medications should be adjusted for the lower level of kidney function.

· Supportive treatments (e.g., antibiotics, adequate nutrition care, mechanical ventilation, glycemic control , management of anaemia) should be sought based on standard management practises.

· If necessary, avoid medication with nephrotoxic effects

· Measure and monitor drug levels where available

· Using acceptable dosages, cycles, and therapy period