AKI Management

How should you treat leptospirosis if it is the underlying cause of AKI?

Doxycycline or Penicillin

How should you treat pyelonephritis if it is the underlying cause of AKI?

Broad spectrum antibiotics while awaiting culture results

Name the FOUR major small animal fluid types in order from lowest to highest pH.

0.9% NaCl (5.6) -> LRS (6.2) -> Plyte 148 (6.6) -> Plasma (7.4)

What is the formula for total volume of fluid therapy?

Rehydration + maintenance + ongoing losses = total volume

How dehydrated is a patent with minimal loss of skin turgor, semidry mucus membrane, and normal eye?

Mild (5%)

How dehydrated is a patient with moderate loss of skin turgor, dry mucus membranes, weak rapid pulses, and enophthalmos?

Moderate (8%)

How dehydrates is a patient with considerable loss of skin turgor, severe enopthalmos, tachycardia, extremely dry mucus membranes, weak/thready pulses, hypotension, and altered level of consciousness?

Severe (>10%)

The presence of dry mucus membranes may NOT always reflect hydration status. What is ONE example of this?

Decreased salivary secretions with uremia (xerostomia)

Skin turgor may be reduced in what TWO situations outside of the normal?

1. Older animals that are well hydrated

2. Dramatic weight loss

What is the calculation for total fluid deficit?

BW (kg) x % dehdyration = TOTAL fluid deficit (L)

T/F: You may rehydrate a patient over as little as 6 hours unless there is an underlying conditions that would result in fluid overload , like cardiac disease.

True!

What is the maintenance fluid rates for dogs and cats?

Dogs: 60 ml/kg/day

Cats: 40 ml/kg/day

Vomiting, diarrhea, PU, excessive panting all contribute to —————- in a fluid therapy plan and you should roughly estimate it.

Ongoing losses

T/F: When calculating a fluid plan, total ongoing losses and maintenance rate should be added together over the initial dehydration period is complete.

True!

___: increasing urine output by delivering higher fluid rates

Diuresis

Diuresis is falling out of fashion. What TWO methods are the current recommendation?

1. Resuscitate and rehydrate patient

2. Adjust fluid dose to match urine output

What THREE things should be performed to monitor fluid balance?

1. Repeat exam

2. Body weight

3. Blood pressure (would be high if overload)

Check at least 2x/day

What method of monitoring fluid balance quantifies urine output, measures ins and outs, and assesses oliguria and anuria?

Closed urine collection

What would you be concerned about with a patient who becomes bradycardic and experiences atrial standstill, idioventricular rhythms, or ventricular tachycardia?

Hyperkalemia

What are the FOUR features of a hyperkalemic EKG and which is considered the hallmark?

1. Tall, tented T waves (hallmark)

2. Prolonged PR interval

3. Wide QRS

4. Absent P waves

What treatment of hyperkalemia is cardioprotective and counteracts effects on the heart?

10% calcium gluconate

T/F: You must be careful with using 10% calcium gluconate, as it can shift serum potasssium concentration in the opposite direction.

False! 10% calcium gluconate does NOT affect serum potassium concentration.

What treatment of hyperkalemia increases urine output?

Fluid therapy

T/F: Fluid therapy is adequate for mild hyperkalemia that is NOT associated with cardiovascular disturbances.

True!

What type of fluids are best for treating hyperkalemia?

Something with less K+ than patient (NaCl)

Why is dextrose (2.5% dextrose CRI) a treatment for hyperkalemia?

Insulin release from pancreas -> drives K+ into intracellular space and lowers serum K+ concentration

Hyperkalemic patients with —— should not receive dextrose as a potential treatment.

Diabetes

What treatment of hyperkalemia has the same mechanism as dextrose alone, but is more aggressive?

What MUST be done if this treatment is performed?

Insulin with dextrose

Check BG first and during

What bronchodilator can be given for hyperkalemia? Why?

Terbutaline- stimulate cellular potassium uptake and causes hypokalemia

What treatment of hyperkalemia drives K+ into the intracellular space and lowers serum concentration, but is NOT frequently used as it can worsen hypocalcemia and cause rapid pH shifts?

Sodium bicarbonate

T/F: Fluids alone typically correct metabolic acidosis in renal failure patients.

True!

In what situations do you just give fluids vs fluids with bicarb in a patient with metabolic acidosis in renal failure?

Fluids: pH >7.2, HCO3 >16

Fluids + Bicarb: pH

What other electrolyte imbalance is common in AKI due to decreased GFR and can also be managed with IVF?

Hyperphosphatemia

Phosphate binders can be used in hyperphosphatemic patients in renal failure once they start ---.

Eating

What THREE drugs are often used in combination to manage uremic gastropathy and why?

1. Maropitant- vomiting

2. Ondansetron- nausea

3. Metoclopramide- dysmotility

Why is antacid therapy (proton pump inhibitors + H2 blockers) controversial for treatment?

Prophylaxis use could make more prone to issues

What GI drug is sometimes given to promote healing of ulcerations/erosions and acts as a band aid?

Sucralfate

T/F: You should introduce renal diet to a patient sick and in the hospital.

False! DO NOT introduce renal diet to a sick and hospitalized patient, especially a CAT- can cause food aversion

Capromorelin and mirtazapine in (dogs/cats) and capromorelin, mirtazapine, and cyproheptadine in (dogs/cats) can be used for what?

Dogs

Cats

Appetite stimulant

If anorexia goes more than --- hours without adequate oral nutritional intake, what are TWO alternatives for nutrition to take?

48

1. Enteral nutrition (feeding tubes)

2. Parenteral nutrition (PPN/TPN)

Hypertension affects ---% of dogs and ---% cats with AKI.

80%

60%

What should ideal BP be?

What drug is the first-line therapy for hypertension in renal failure patients?

Amlodipine

T/F: ACE inhibitors and Angiotensin receptor blockers are often used in AKI.

False! ACE inhibitors and angiotensin receptor blockers are typically AVOIDED in AKI.

The goal of treating oliguric renal failure is to ------------- and make sure the patient is ---.

Increase urine output

Hydrated

What is the best way to monitor an oliguric patient?

How do you do this?

Matching ins and outs

Outs- urine output q4

Ins- measured collected urine + calculated insensible loss + estimated ongoing loss over same 4 hour period

Delivers "ins" volume next 4 hours

What is the average insensible loss rate?

22 ml/kg/day

T/F: Minimum fluid rate with NO urine output is calculated by 22 ml/kg/day + estimated ongoing losses.

True!

What drug improves urine output by paralyzing the sodium channel in the Loop of Henle and does not absorb electrolytes?

Furosemide

What are the TWO contraindications/warnings with furosemide use in AKI patients?

1. Avoid if dehydrated

2. Concentrates aminoglycoside abx

What treatment to promote urine output causes a safer but less effective osmotic diuresis?

When should it be discontinued?

10-20% dextrose

No glucosuria

What are the TWO possible options for an anuric patient?

1. Dialysis

2. Euthanasia

___: removal of uremic waste products by means other than renal function

Dialysis

What kind of patient is best chosen for dialysis?

Acute renal failure with a chance of recovery

Name at least FOUR of the seven indications for renal replacement therapy.

1. Anuria or severe oliguria

2. Failure of therapy to control azotemia

3. Life-threatening fluid overload

4. Life-threatening electrolyte and acid-base disturbance

5. Severe azotemia

6. Refractory to medical therapy for 12-24 hours

7. Acute toxicities

What are the FOUR methods of renal replacement therapy?

1. Peritoneal dialysis

2. Intermittent hemodialysis

3. Continuous renal replacement

4. Renal transplantation

What renal replacement therapy uses peritoneal lining as dialysis exchange surface and diffusive forces transfer toxic wastes, excessive fluid from blood to dialysate solution in the abdominal cavity?

Peritoneal dialysis

Why is the omentum removed in peritoneal dialysis?

Prevent clogging of catheter

What determines which substances are removed using peritoneal dialysis?

Concentration gradient between blood and dialysate

T/F: Dialysate should contain similar concentrations of blood substances you want to keep, like electrolytes in patients with normal Na, K, and Cl.

True!

What are the TWO indications for intermittent hemodialysis?

1. CKD

2. Hemodynamically stable AKI

What is the major indication for continuous renal replacement therapy?

AKI

What are the FIVE complications of peritoneal dialysis?

peritonitis, hypoproteinemia, anemia, omental occlusion, catheter leakage

What are the SIX complications of hemodialysis?

hypotension, dialysis disequilibrium, hypoproteinemia, anemia, thromboembolism, clotting

What THREE acquired conditions are indicated for renal transplant?

1. Chronic interstitial nephritis

2. Toxic nephropathy

3. Membranous glomerulopathy

What TWO congenital disorders are indicated for renal transplantation?

1. Renal dysplasia

2. Polycystic kidney disease

Name at least FOUR situations in which renal transplant is contraindicated.

1. Amyloidosis

2. Pyelonephritis

3. Obstructive nephropathy from oxalate nephrolithiasis

4. Animals with IBD

5. FeLV/FIV infected cats

6. Animals with heart disease

T/F: 60% of canines recovered when managed with hemodialysis and renal transplantation, while 60% of felines died and 60% of the survivors develop CRF.

False! 60% of FELINES recovered when managed with hemodialysis and renal transplantation, while 60% of CANINES died and 60% of the survivors develop CRF.

T/F: Severity of azotemia, hypocalcemia, anemia, proteinuria, specific cause, and systemic disease are all associated with death in AKI animals.

True!