Nephro

Kidney function:

#CKD:

Patient's baseline creatinine is ____ mg/dL, per EMR records.  Renal function currently appears at baseline (Cre ____ mg/dL).  No acute issues noted at this time. 

Secondary to ____

-Adjust medication dosing to account for impaired renal clearance. 

-Continue with judicious use of IVFs if needed. 

-Continue to monitor renal function on daily labs, and adjust medication doses as needed. 

  

#AKI on CKD: 

Patient's baseline creatinine is ____ mg/dL, per EMR records.  Recent labs obtained in the ED demonstrate acute renal insufficiency with evidence of elevated creatinine, and reduced GFR.

Etiology most likely prerenal intrinsic renal postrenal based on ____

-Adjust medication dosing to account for impaired renal clearance (CrCl ____ mL/min, per Cockcroft-Gault equation). 

-Avoid nephrotoxic medication, and continue with judicious use of IV fluids if needed. 

-Continue to monitor renal function on daily labs, and adjust medication doses as renal function improves.  

 

#AKI - Patient presents with a Creatinine of ------- which is increased from baseline of -------.  GFR xxxxx; Creatinine Clearance xxxxx. 

Etiology most likely prerenal intrinsic renal postrenal based on ____

-Continue PO intake as tolerated and IV fluids  

-Urine lytes (and FE urea if on loop diuretics) 

-UA with microscopy 

-Renal US to evaluate for obstruction 

-Hold ACE-I or ARB if taking

-Renally dose medications, avoid nephrotoxins 

 

#nephrogenic diabetes insipidus 

Causes: furosemide, hypercalcemia, hypokalemia, congenital, ATN, CKD, sickle cell disease, osmotic diuresis 

 

#contrast induced nephropathy

Aycock RD, Westafer LM, Boxen JL et al.  Acute Kidney Injury after CT:  A meta-analysis.  Annals of Emergency Medicine 2018.(28811122)  Exhaustive, modern literature review in the Annals showing no difference in acute kidney injury, mortality, or dialysis.

Hinson JS, Jalbout NA, Ehmann MR et al.  Acute kidney injury following contrast media administration in the septic patient:  A retrospective propensity-matched analysis.  Journal of Critical Care 2019.(28131489)  Large study evaluating patients presenting to John Hopkins with suspected sepsis.  No effect was detected from contrast dye, even among patients with GFR<30 ml/min. 

Ehrmann S, Aronson D, Hinson JS.  Contrast-associated acute kidney injury is a myth: Yes.  Intensive Care Medicine 2017 (29242967)

 

 

 

Electrolytes:

Calcium:

#Hypercalcemia:

Level on admission: ____; level today ____; baseline _____

DDx: 1˚ hyperPTH, FHH, 3˚ hyperPTH, malignancy (PTHrP, increased calcitriol, osteolytic), vitD intoxication, granulomatous disease, medications, hyperthyroid, acromegaly, pheochromocytoma, adrenal insufficiency, immbolization, parenteral nutrition, milk-alkali syndrome 

Presenting with polyuria/polydipsia, AKI, nephrolithiasis, anorexia, nausea, abd pain, constipation, pancreatitis, osteoporosis, fragility fractures, bone pain, drowsiness, lethargy, confusion, band keratitis 

EKG with shortened QT? 

Check phos, TSH, PTH, PTHrP, 25 and 1,25 vit D, 24hr calcium, SPEP/UPEP/light chains, skeletal survey, DEXA 

Hold thiazides, lithium, teriparitide, vitA, theophylline 

 

 

#Hypocalcemia:

Corrected for albumin (); level on admission: ____; level today ____; baseline _____; 

Sx: numb/tingling, paresthesia, spasm 

CV: qt prolongation, myocardial dysfunction, sudden cardiac death 

Neuro: seizure, basal ganglia calcification 

Eye: cataract formation, papilledema 

DDx: Low PTH (genetic disorders, postsurgical, autoimmune, infiltrative, radiation induced destruction, hungry bone, HIV), high PTH (vit D def or resistance, PTH resistance, renal disease, loss from circulation (high phos, tumor lysis, acute pancreatitis, osteoblastic mets, acute resp alkalosis, sepsis/severe illness); drugs (bisphosphonate, cinacalcet, calcium chelators, foscarnet, gadolinium based agents, phenytoin, fluoride poisoning, hypomagnesemia 

Monitoring: get 24hr urine calcium 

 

Magnesium:

#Hypermagnesemia 

Sx: at 6: nausea, flushing, headache, lethagy, decreased DTRs 

At 10: somnolecnce, hypocalcemia, loss of DTRs, hypotension, bradycardia, ECG changes 

 

 

Sodium:

#Hypernatremia 

Why is patient not drinking?  

Why are they predisposed to losing water? (diarrhea, diuretics, insensible losses) 

Sodium overload? (post code (sodium bicarb), soy sauce/salt intake) 

Free water deficit:  

H20 lost while repleting: based on UOP; ignore 1L, 2-3L, x0.5, beyond 3L, 1x UOP 

 

#Hyponatremia:

Decreased sodium to ***, last known baseliine ***. Fluid status assessment: ***. History consistent with ***, though will initiate work-up as below. 

-Send out for urine and serum Osm.  

   - serum osm >295: false hyponatremia (rule out glucose, mannitol) 

   - 285-295: pseudohyponatremia (rule out MM, IVIG, hyperlipidemia) 

   - <285: true hyponatremia:  

Uosm: <100-200 = ADH independent – tea and toast/beer potomania/primary polydipsia/renal failure 

Uosm: >200-300 = ADH dependent – volume status:  

-Consider IV NS vs fluid restriction  

-RFP  

-Urine sodium <30, representing either true hypovolemia or low effective arterial volume

 

 

Phosphate:

#Hypophosphatemia

Kidney function? Calcium? Magnesium?

Symptoms? Such as seizure, paresthesia, tremor, confusion, dysarthria, stupor, coma, heart failure, arrhythmia, rhabdomyolysis, muscle weakness, hemolysis

Ddx: hyperparathyroidism, hungry bone syndrome (immediately post parathyroidectomy), vitamin D deficiency, oncogenic osteomalacia, pseudohypophosphatemia (hyperbilirubinemia, mannitol, paraproteins, acute leukemia), refeeding syndrome, chronic diarrhea, chronic antacid use, diuresis, dialysis, alcoholism, critical illness (sepsis, trauma, surgery, burns)

-workup: Fe-Phos(<5% = GI loss, shifting into cells, >5% = renal phosphate wasting)

-treatment: replete with na-phos 15-30mmol PRN, infused at 7.5mmol/hr; replete PO if able (8-16mmol K-Phos)

-if concern for refeeding syndrome, consider thiamine repletion

 

 

U/A abnormalities:

#proteinuria 

History of Dm, malignancy, systemic autoimmune disease, prior history of kidney disease? 

Glomerular disease? Ie hematuria, rbc casts, wbcs or wbc casts in absence of infection 

 

#hematuria

Gross, history of trauma?

First step is centrifugation of urine sample

 

Urology:

#urolithiasis 

Risk factors: previous stones, metabolic syndrome, gout, genetic (RTA, cystinuria, hypercalciuria), occupational (truck driver, limited bathroom access) 

Differential: peritonitis, appendicitis, ovarian cysts, ectopic pregnancy, UTI, diverticular disease   

-low dose non contrast CT renal stone protocol 

   -stone size: 5mm 50% chance of passing 

     8mm 20% chance 

-urology referral placed for procedural intervention 

-patient counseled on relaxation techniques 

-NSAIDs superior to opiates for pain control 

-fluids not indicated for passage of acute stone 

-RFP, u/a, urine cx 

-stone sample, 24hour urine 

-patient counseled on prevention of future stones:  

Without prevention, 50% of patients will have another stone at 10 years and 80%  will have recurrence at 20 years 

  ->96 fl oz daily 

 -diet/exercise: Borghi diet 

-initiate HCTZ 25