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🌱 來自: Huppert’s Notes
General Approach to the Diagnosis and Management of AKI🚧 施工中
General Approach to the Diagnosis and Management of AKI
• Step 1: Address any urgent management needs (e.g., treat severe hyperkalemia, hypoxemia due to pulmonary edema)
• Step 2: Confirm baseline Cr and diagnose the etiology. See differential diagnosis above and in Figure 6.3. Volume exam suggesting hypovolemia may suggest a pre-renal cause. Obtain a bladder scan to rule out postrenal causes. Get a UA with microscopy. Consider checking the fractional excretion of sodium (FENa), which can help differentiate pre-renal AKI from ATN.
- Pearl: Most AKI in the hospital will be pre-renal due to hypovolemia, intra-renal due to ATN, or postrenal due to obstruction. Thus, a majority of inpatient AKI can be resolved with fluids and/or a Foley catheter.
FIGURE 6.3: Etiologies of acute kidney injury (AKI). This diagram depicts the etiologies of AKI, divided into pre-renal (green), intrarenal (blue), and postrenal (pink) etiologies. *Nephrotoxins include both exogenous substances (e.g., aminoglycosides, iodinated contrast, cisplatin, PPIs, NSAIDs) and endogenous substances (e.g., damage due to rhabdomyolysis, hemolysis, multiple myeloma). Abbreviations: ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; NSAID, nonsteroidal antiinflammatory drug; TTP/HUS, thrombotic thrombocytopenic purpura/hemolytic uremic syndrome.
• Step 3: Treat the underlying cause (e.g., give fluids if pre-renal, place Foley if post-renal)
• Step 4: Monitor for complications. Check electrolytes, evaluate volume status, reassess for uremia regularly. AKI can cause CKD progression in patients with baseline kidney dysfunction.
• Step 5: Avoid factors that may worsen AKI or complications. Avoid nephrotoxic medications and adjust dosing of renally excreted medications.
• References:
- KDIGO Work Group. KDIGO clinical practice guideline for acute kidney injury (Kidney Int Suppl 2012;2(1):1–138)
- Mercado et al. Acute kidney injury: Diagnosis and management (Am Fam Physician 2019;100(11): 687–694)