AKI
According to the RIFLE criteria, this increase in serum creatinine from baseline should cause the clinician to consider a diagnosis of AKI.
What is an increase in serum creatinine >1.5x baseline?
This is the rough estimate of iron present in a unit of blood
What is 200-300 mg?
This is the location you should look to find renal adjustments of antibiotics at Nebraska Medicine for dialysis and non-dialysis patients with renal dysfunction
What is the antimicrobial stewardship page?
These medications are used for patients with hyperkalemia to urgently prevent arrhythmia
What is calcium gluconate, albuterol, bicarbonate, IV insulin regular with dextrose, and potassium binders.
This medication commonly used for UTI and SSTI can cause creatinine reabsorption which mimics AKI in patients without kidney injury
What is Bactrim?
This type of AKI is associated with a FeNa score >1%
What is intrinsic AKI? (Also acceptable is post-obstructive AKI)
This is the medication and dosing strategy used at Nebraska Medicine most commonly for replacing iron intravenously
What is ferric gluconate 250 mg administered daily for four days? (also acceptable: 125 mg x10 days, and dosing based on the Ganzoni equation for iron deficiency). Note - iron sucrose is currently being used in pregnant/lactating mothers and children </= 5 years of age as it has benzyl alcohol in it.
These are the indications for dialysis
What is Acidosis, Electrolyte disturbance, Ingestions, Overload, and Uremia? (AEIOU)
These medications can be used to reduce phosphate but are only effective in patients receiving enteral (PO or per tube) nutrition
What are phosphate binders?
Urea, considered a medical food, can be used for this indication in patients with hyponatremia
What is SIADH? Urea works by inducing osmotic diuresis of free water. Note that 15 grams BID of urea costs ~$300/month and insurance companies will not pay for it under prescription drug coverage plans.
This scoring tool can be used in place of the FeNa score in patient receiving diuretics
What is the fractional excretion of urea (FeUrea) score?
According to the KDIGO guidelines, continuing erythropoiesis stimulating agents (ESAs) is considered contraindicated in patients with a hemoglobin above this level
What is a Hgb >13 g/dL? (Also acceptable: >11.5 g/dL in patients without informed decision making)
A patient with type I diabetes is receiving CCPD nightly. You noticed today that the patient consistently has a blood sugar of 250-350 every night from 2300 to 0500, while the rest of the day his sugar averages 115 to 175. What may explain this phenomenon?
Dextrose is the osmotically active component of peritoneal dialysate and can leech out of PD bags into the systemic circulation.
This liquid medication which is given for low bicarbonate levels requires a functioning liver for conversion to bicarbonate
What is Bicitra? (sodium citrate/citric acid)
A patient receiving vancomycin on your service was expected to have dialysis MWF, but nephrology added a dialysis session on Tuesday due to hyperkalemia on the Tuesday morning BMP. They were due for a drug level Wednesday morning and are currently in dialysis for the next three hours. How might you remedy this situation?
Order an add-on drug level to the patient's AM BMP, as this was drawn prior to the patient's dialysis session. Depending on the clinical situation, a drug level could also be added post-HD, but it is recommended to wait roughly 4-6 hours for the drug to redistribute from the tissues back into the circulation
This is a clinical syndrome associated with >3.5 grams of protein loss in the urine per day
What is nephrotic syndrome?
This peptide hormone elevates in periods of inflammation in an attempt to reduce the amount of free iron available to invading pathogens
What is hepcidin?
This is a method to administer antibiotics to patients with peritonitis caused by peritoneal dialysis
What is intraperitoneal administration?
This medication is a non-absorbable polymer which binds and removes potassium and does not increase a patient's sodium level
What is patiromer (Veltassa)?
This biomarker of kidney function is metabolized in the tubules, secreted by every cell, and not influenced by a patient's muscle mass
What is cystatin C?
A 68 YO M patient admitted to your service for profuse nausea/vomiting and diarrhea has had his SCr increase from his baseline of 0.7 mg/dL to 1.6 mg/dL in the last 24 hours. Current inpatient medications include amoxicillin-clavulanate 875 mg BID (day 2 of therapy for possible intra-abdominal infection), aspirin 81 mg daily, losartan 100 mg daily and vancomycin 1250 mg IV Q12H. What is the most likely cause of AKI for this patient, and what would you do to manage it?
Most likely cause is pre-renal AKI from dehydration due to N/V and diarrhea. Management would include stopping losartan, holding vancomycin and collecting a drug level tomorrow with AM labs, and administering an LR fluid bolus.
Your team is considering starting Epoetin alfa for your adult patient with ESRD on HD. MCV is 88, RDW is 18.5 (H), Hgb is 7.5 (L), Ferritin is 38, iron is 80, Tsat is 16%, and TIBC is 500 (H). How would you approach their anemia treatment?
This patient should have iron replacement before starting an ESA. If not already drawn, collecting a folate and B12 would also be reasonable to rule-out multiple nutritional deficiencies given elevated RDW.
A nephrologist calls you asking you how to order IP antibiotics. He wants to start intraperitoneal cefepime in the last dwell of his patient's peritoneal dialysis. The PD bag he has ordered is the standard 2L icodextrin bag. You notice in order review that the last bag fill volume is 1L. Using your Nebraska Med resources, how much cefepime should you tell him to add to this bag?
2000 mg of cefepime should be added to this bag. Since the nephrologist will be infusing half of the 2L as the patient's last dwell, the total amount of drug administered will be 1000 mg.
A patient admitted to your hospital with a new diagnosis of ESRD requiring dialysis is found to have a corrected calcium of 6.5 (L), a phosphate of 18 (H), an intact PTH of 5124 (H, normal range 10-65), 25-hydroxy vitamin D <7 (L), and an alkaline phosphatase of 300 (H). What is the most likely explanation for these findings?
The patient in question is experiencing high bone turnover due to secondary hyperparathyroidism from ESRD.
What is warfarin and calcium products (including calcium-based phosphate binders)