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Chapter 9: Acute Kidney Injury

A 58-year-old Caucasian female patient develops oliguric AKI after a motor vehicle accident. She is mechanically ventilated and requires pressor therapy with 0.2 mcg/kg/min of norepinephrine to maintain a mean arterial BP of 75 mm Hg.

Which ONE of the following statements regarding renal replacement therapy in this setting is evidence based?

A. Intermittent hemodialysis is associated with decreased mortality as compared to continuous renal replacement therapy.

B. Intermittent hemodialysis should be prescribed to deliver a single-pool Kt/V of 1.3 on a three-times-per-week schedule.

C. Continuous renal replacement therapy will provide greater volume control with less hemodynamic instability than intermittent hemodialysis.

D. Continuous renal replacement therapy should be prescribed to deliver an effluent flow rate of 16 mL/kg/h.

E. Continuous renal replacement therapy leads to better survival.

The answer is C. Continuous renal replacement therapy is able to provide greater net volume removal than intermittent hemodialysis with less hemodynamic instability. Despite this benefit, continuous therapy has not been demonstrated to provide a survival benefit as compared to intermittent hemodialysis.

Large studies did not show any survival benefits between with CRRT and conventional intermittent hemodialysis.

A 77-year-old African–American man undergoes coronary artery bypass and aortic valve replacement. His past medical history includes type 2 diabetes mellitus, hypertension, congestive heart failure, and chronic kidney disease stage 4 (baseline serum creatinine 2.7 mg/dL). He receives perioperative therapy with dopamine (3 mcg/kg/min) to prevent acute-on-chronic kidney disease.

Which ONE of the following statement regarding the use of low-dose dopamine (<3 mcg/kg/min) to prevent or treat AKI in is CORRECT?

A. It reduces AKI.

B. It decreases the duration of dialysis dependence.

C. It increases the risk of atrial fibrillation.

D. It decreases mortality.

E. It improves urine output.

The answer is C. Several studies in cardiac surgery patients have associated low-dose dopamine therapy with increased incidence of atrial arrhythmias, presumably mediated by β-adrenergic stimulation. Low-dose dopamine has not been found to have any of the above benefits (decreased duration of dialysis-dependence, increased diuretic-responsiveness, lower mortality) in prospective studies.

A 31-year-old Hispanic man with HIV admitted with high-grade fever, cough, and an infiltrate on chest X-ray. He was diagnosed with Pneumocystis jirovecii pneumonia and started on high dose sulfamethoxazole-trimethoprim for pneumocystis. BUN/creatinine on admission 13/1.0, potassium 4, and after 4 days BUN/creatinine 17/1.8 and serum potassium increased to 6.3.

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