Algorithm of Acute Renal Injury

by Carlo Raj, MD

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    00:01 Now, with acute kidney injury, a very important, important algorithm or flow chart that becomes important is what you’re seeing here.

    00:08 Now, I’m gonna walk you through some of the important parts with specifically acute kidney injury but keep in mind though at some point in time, would you have azotemia part of your chronic renal failure as well? Absolutely.

    00:23 Alright, so with azotemia here, you’re gonna take a look at urinalysis, you’re going to do an ultrasound.

    00:29 When you do an ultrasound, you end up finding hydronephrosis.

    00:33 See, now you have a kidney issue.

    00:35 You find hydronephrosis then, now, you’re automatic, you’re looking for obstruction, you find your obstruction, you move to the right there.

    00:42 Diagnosis, post renal azotemia.

    00:45 Diagnosis, kidney stone, maybe it was PPH, older patient.

    00:51 Hydronephrosis, you don’t find obstruction, and then you start looking at, well, your renal size, and you start doing urinalysis.

    00:59 With urinalysis, what are you gonna do? Well, you might find the following.

    01:03 You might find well, let’s say, smaller kidney, negative for sediment, and you end up finding what’s known as isosthenuria, and your protein is less than 3.5 grams per day.

    01:15 Ladies and gentlemen, this would be chronic renal failure and we’ll walk into this a lot more in detail.

    01:21 Isosthenuria, what does that mean to you? You’ve lost ability to properly concentrate the urine and down in the loop.

    01:27 And so therefore, the type of urine that you end up producing will be Iso, there’s no variation aside, good.

    01:33 You should be able to concentrate the urine, you should be able to dilute the urine.

    01:37 But the fact that you’re producing isosthenuria along with these other issues, with negative sediments, and I’ll give you a bunch more symptoms in which we’ll walk through a chronic renal failure big time.

    01:48 You know in our society, one of the most common causes of chronic renal failure is your well, diabetes mellitus or diabetic neuropathy.

    01:58 Okay, now, let’s say that you have a normal size and this time though, there’s going to be cortical thickness.

    02:05 Upon further urinalysis you’d find, well, we’ll talk about the abnormalities that we have when we look at, well, what if it was bacteria? If it’s bacteria, you’re thinking about what kind of cast? WBC cast.

    02:19 Any findings to be neutrophils, then you know it’s pyelonephritis.

    02:23 Next, what if you find your WBC casts made up of eosinophils? Then, you’re thinking about interstitial nephritis.

    02:32 What if you find RBC’s, RBC casts? Well, now, you’re thinking about issues with maybe kidney and maybe nephritic syndrome.

    02:42 With RBC’s itself, maybe it’s some type of vascular occlusion and if you do find your RBC cast plus your protein, then, you should be thinking along the lines of nephritic glomerulonephritis or maybe perhaps even vasculitis.

    02:54 Now, that’s a brief little rundown of the different types of abnormalities and urine analysis that we’ve discussed earlier.

    03:01 Let’s take a look at what happened here.

    03:03 And you find a normal urinalysis, but now you start thinking about urine electrolytes.

    03:08 So what does this mean to you? Well, if you find your, pay attention, if you find your fractional excretion, of sodium to be decreased, you tell me, what kind of azotemia? You have oliguria less than 400 milliliters of urine being produced per day and you find your fractional excretion of sodium to be decreased, that’s prerenal azotemia, isn’t it? What does that mean? Remember our discussion, your renin will be stimulated, aldosterone works in a normal kidney or at this point normal, at the reabsorbing of sodium, fraction excretion of sodium will be decreased, less than 1%.

    03:45 That’s what your focus should be on.

    03:47 Now, we have prerenal azotemia.

    03:49 And hopefully, you’re able to get in there and address the issue ASAP but if you cannot and the prerenal azotemia continues, you then end up causing ischemic acute tubular necrosis or ischemic type of acute kidney injury.

    04:04 Here you find your fracture excretion to be increased and greater than 2% is what we said.

    04:10 So this put you in the realm of acute kidney injury, acute renal failure.

    04:15 Nice little overview of chronic renal failure, acute renal failure that we just talked about with the different phases and then, all of the different type of pathologies that we talked about in nephrology in brief.

    04:30 Obviously, details are required and we had those discussions in our respective topics.

    04:38 Let’s move on please.

    About the Lecture

    The lecture Algorithm of Acute Renal Injury by Carlo Raj, MD is from the course Tubulointerstitial Diseases.

    Included Quiz Questions

    1. Renal ultrasound
    2. Microalbuminuria dipstick
    3. Urine specific gravity
    4. Urine culture
    5. Glucose dipstick
    1. Post-renal obstruction
    2. Pre-renal ischemia
    3. Chronic renal failure
    4. Glomerulonephritis
    5. Renal artery stenosis
    1. Interstitial nephritis
    2. Acute tubular necrosis
    3. Minimal change disease
    4. Pre-renal ischemia
    5. Post-streptococcal glomerulonephritis
    1. Isosthenuria
    2. Protein > 3.5 g/d
    3. Urine osmolality > 500 mOsm/L
    4. Renomegaly
    5. RBC casts
    1. Chronic renal failure
    2. Acute tubular necrosis
    3. Acute interstitial nephritis
    4. Pyelonephritis
    5. Nephrotic syndrome
    1. Glomerulonephritis
    2. Pyelonephritis
    3. Interstitial nephritis
    4. Pre-renal azotemia
    5. Chronic renal failure

    Author of lecture Algorithm of Acute Renal Injury

     Carlo Raj, MD

    Carlo Raj, MD

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    Cocise, engaging, high learnability index
    By Nnamno E. on 03. November 2017 for Algorithm of Acute Renal Injury

    Lecturio is a solid and highly efficient learning Platform. Dr. Raj is a seasoned communicator, and has just the right balance of serious professional demeanor, clarity of speech and concepts, and good humor you want in a Teacher. This lecture, like the others I’ve watched so far, is excellent stuff!