Brought to you by the intern asking for the consult and the first year fellow responding!
It’s intern year and you are working up another patient for an AKI. You have examined the patient and sent off some labs but do not yet have a satisfying explanation for your patient’s worsening kidney function. You and your team decide it’s time to consult nephrology and as the intern it is your job to make the phone call. However, you may find yourself in the uncomfortable position of not knowing what work up you should have already started prior to the consult. Every case is certainly different but there are some basic patterns to the algorithm that are helpful to know!
I had the opportunity to interview Sayna Norouzi, Kidney Zone fellow lead and Baylor College of Medicine first year nephrology fellow. I was able to get a sense of what was expected. My questions to her were:
1) What are the first questions the fellow asks the intern once they are on the case?
2) What work-up typically do you expect to be already done when called?
3) Are there any basic tips/information that you often get asked that you would want all interns to know?
THE FELLOW’S RESPONSE:
Not surprisingly, she told me that AKI is one of the most common consults that they get. While patients will have different reasons for developing AKI, the approach always starts with the same questions…
What are the first questions you ask the intern when you are consulted re an AKI?
1- Tell me about patient’s clinical status AKA vital signs: Is the patient stable? Crashing with a low blood pressure? Or maybe coming in with uncontrolled hypertension?
2- History of present illness; while all parts of the history are important, I would pay extra attention to the recent events i.e. anything in the history that suggests hypo or hypervolemia will catch my attention. Also, any changes in urinary habits, recent hospitalizations, major trauma, surgeries, procedures, or any indications of sepsis?
3- Tell me about the urine output! Is the patient making urine and if so, how much?
4- Pertinent past medical history: hx of CKD? If so what is their baseline creatinine? Uncontrolled DM? CHF? Chronic GI issues? etc.
5- Drug hx: Any use of nephrotoxic medications recently? How about contrast? Newly added or recently changed antihypertensive or antidiabetic medications? Any NSAIDS (after asking by common brand names)?
6- Physical exam: I would ask for extra details on the volume status. Is the patient clinically volume depleted or volume overloaded?
What work-up typically do you expect to be already be done when you are called?
Assuming the primary team is medicine:
1- From the hx, try to find out the baseline creatinine level; not all creatinine elevations are AKI.
2- Make sure that you have ruled out obstruction. You can do this by checking a post-void residual, bladder scan, ordering a kidney ultrasound, asking about any history of prostate pathology, or palpating the bladder on physical exam.
3- Order UA, and urine lytes (I know this is debatable but we still check).
4- Quantify protein if present on dip.
5- I/Os + daily standing weights – Measure intake (remembering that this includes antibiotic volume and parenteral feeds) and output (cumulative daily output).
Basic tips (from fellow to intern):
1- No, you do not need to insert a foley for output measurements.
2- Stop nephrotoxic medications. Go through the medication record systematically including PRN meds. Check with the pharmacist if you’re not sure if it’s nephrotoxic.
3- Dose adjust medications such as anticoagulants and antibiotics even while you are waiting for the consult.If your patient is on antibiotics, attention to dosing is critical and often people will use the eGFR which is unreliable in AKI.
4- Hold off on giving fluids or lasix if you are not sure about the volume status and cause of AKI.
In summary, dealing with AKI involves thinking of it, recognising when it occurs, early treatment, and prevention of further episodes. Educating the patient that an episode of AKI has occurred is very important particularly if it is medication or volume depletion related; this will empower them to recognise and advocate for themselves by seeking early treatment.
Sayna Norouzi, MD
Matt Sparks, MD