Tag Archives: nephrology

CSW vs SIADH

Table compares clinical and laboratory findings in CSW vs SIADH.  Both conditions will present with low serum (osm and Na) and high urine (osm and Na).  The key to distinguishing between the two is extracellular fluid status (increased or normal in SIADH and decreased in CSW).

 

SIADH criteria proposed by Janicic and colleagues:

  1. Posm <275
  2. inappropriate urinary concentration (Uosm >100)
  3. clinical euvolemia (no orthostasis, tachycardia, dec skin turgor, dry mucous membranes or edema and ascites)
  4. elevated urinary Na excretion with normal salt and water intake
  5. absence of other causes of euvolemic hypoosmolality (hypothyroidism, hypocortisolism)

Reference:

Layon, A. Joseph, Andrea Gabrielli, and William A Friedman. Textbook Of Neurointensive Care. Print.

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Prophylaxis for Acute Kidney Injury

Prevention of Acute Kidney Injury

  1. acetylcysteine 1,2000m g PO on day before and on the day of administration of the contrast agent, x 2 days PLUS
  2. saline 0.45% IV at 1ml/KgBW/h x12h before and 12h after administration of contrast agent
  3. for EMERGENCY procedures:  154 mEq/L NaHCO3 bolus of 3 ml/Kg/h x 1h before iopamidol contrast ffd by infusion of 1 ml/Kg/h x6h after procedure
  4. reduce contrast load

 

General Measures:

  1. maintain adequate BP
  2. optimize fluid balance
  3. adjust med dosage to renal function
  4. avoid NSAIDs

 

Reference:

Layon, A. Joseph, Andrea Gabrielli, and William A Friedman. Textbook Of Neurointensive Care. Print.

Lab Findings in Acute Kidney Injury

Neat table to differentiate the different types of AKI:

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REFERENCE:

Parrillo, J., et al.  Critical Care Medicine: Principles of Diagnosis and Management in the Adult
Fourth Edition, 2014 Elsevier Inc.,

RIFLE Criteria for Acute Kidney Injury

The table below shows the RIFLE (Risk Injury Failure Loss End stage) classification scheme for acute kidney injury.

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This system has a separate criteria for creatinine and urine output.  If the patient’s condition falls under two different levels, then the worse classification should be used.

RIFLE-FC = denotes ‘acute-on-chronic’ disease.

RIFLE-FO = when RIFLE-F classification is reached by urine output criteria only

 

Checklist:  AKI work-up

  • Urinary sediment
  • Urinalysis
  • exclude obstruction
  • review of meds
  • rhabdomyolysis: creatine kinas, free myoglobin
  • vasculitis: CXR, blood smear, measurement of nonspecific inflammatory markers, specific antibodies (anti-GBM, ANCA, anti-DNA, anti-smooth muscle)
  • TTP: LDH, haptoglobin, unconjugated bilirubin, free hemoglobin
  • Cryoglobulins
  • Bence-Jones proteins
  • Renal biopsy

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References

Bersten, Andrew D, and Neil Soni. Oh’s Intensive Care Manual. London: Elsevier Health Sciences UK, 2013. Print.

Drug Dosage During Dialysis

Drug Dosage During Dialysis

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*These values represent approximations and should be used as a general guide only. Critically ill patients have markedly abnormal volumes of distribution for these agents, which affects dosage. CRRT is conducted at variable levels of intensity in different units, also requiring adjustment. The values reported here relate to continuous venovenous hemofiltration at 2 L/h of ultrafiltration. Vancomycin is variably removed during continuous venovenous therapies, and constant evaluation of serum levels is recommended. IHD also may differ from unit to unit. The values reported here relate to standard IHD with low-flux membranes for 3 to 4 hours every second day.

 

 

Reference:

Vincent, J. L. Textbook Of Critical Care. Philadelphia, PA: Elsevier/Saunders, 2011. Print.

 

 

How much hypertonic solution?

To determine how much hypertonic solution to give a patient with hyponatremia:

  1.  calculate sodium deficit (mEq) = weight (kg) x 0.6 x (desired Na – actual Na)
    1. use 0.5 for females
    2. desired sodium in mEq/L
  2. calculate the safe rate of sodium correction for the patient in mEq/hr (0.5-1 mEq/L/hr) = weight (Kg) x 0.6 x 1.0 (rate of correction desired)
  3. 3% hypertonic saline contains 513 mEq/L; 2% contains 342 mEq/L; 1.5% contains 256 mEq/L and 0.9% contains 154 mEq/L
  4. desired rate = (safe rate of correction / 513) x 1000
  5. infusion time (hrs) = sodium deficit (mEq) / safe rate of correction (mEq/hr)

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Marino: estimate initial infusion rate of 3% NaCl by multiplying patient’s KgBW by the desired rate of increase in plasma Na. Example: 70Kg male, desired rise in plasma is 0.5 mEq/L per hour, then infusion rate = 70×0.5 = 35 ml/Hr

References

Globalrph.com,. “Sodium Chloride 3% –  Intravenous (IV) Dilution”. N.p., 2016. Web. 30 Jan. 2016.

Marino, 2014. The ICU Book.

Non Anion Gap Metabolic Acidosis

new doc 1_1

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Reference:

Table modified from Quick Medical Diagnosis and Treatment 2016.  www.accessmedicine.com, website accessed Jan 3, 2016