RE: PICC Placement
- Cutoff for PICC is GFR 30 for cosult to Nephrology
- Use 2 lumens to go home
- Triple lumens are more likely to occlude in the arm and should only be used in critical illness.

-- Great Nephrology Note

Patient 0001 *
- Final Note from Nephrology:
AKI: KDIGO stage 3 of 3: an increase in serum creatinine that is 3 times baseline or greater. This can also be defined as an absolute creatinine of >/= 4.0 mg/dL or the initiation of renal replacement therapy. This also can be defined as urine output of less than 0.5 ml/kg/hr for 6-12 hours. Urine output of < 3 ml/kg/hr for >/= 24 hours or anuria >/= 12 hours. Will continue to monitor closely.  
-urine electrolytes, suggests an intact tubule vs HRS.  
*FENa 0.31% and FEUrea 20.6% both indicate pre-renal indices or HRS
*Likely a type 2 HRS
-Serum creatinine worse today at 1.8.
-Continue midodrine
-Would be poor candidate for dialysis, would not offer dialysis
-Would consider repeat LV paracentesis before discharge
Hyponatremia: Multifactorial and due to liver disease, AKI, fluids, etc. Now back to normal
Hypokalemia: Improved today, supplemented
Anemia: hgb 12.2
Cirrhosis: Hospice seems appropriate. 
No objection to discharge, would encourage palliative care. I would not consider him to be a dialysis candidate should his renal function turn for the worse again.
UTI: neg cx. Finish 3 days course of abx. 

MC cause of interstitial nephritis is ABX

Kidney injury: Great talk with Dr. Suresh - would like to finish / go back over it. 
- NS -> 1/2 NS to decrease Cl
- in AKI last to occur is the ability to acidify urine
- Cl accumulates & it can't excrete H+
- tubules regenerate but as above ability to acidify urine occurs last
- Electrolyte transport, etc occurs earlier than acidification.
- In ATN the last to regenerate are the distal Na2+/2H+ + carbonic anhydrase pump.
- Distal RTA is caused by ATN.

TypeType 1Type 2Type 4
LocationDistal tubulesProximal tubulesAdrenal
Acidosis?Yes (severe)YesMild when present
PathophysiologyFailure of H+ secretion by the α intercalated cellsFailed HCO3reabsorption from the urine by the proximal tubular cellsDeficiency of aldosterone, or a resistance to its effects, (hypoaldosteronism orpseudohypoaldosteronism)


AGN - RBC casts.
acute pyelonephritis - WBC casts
lupus nephritis - positive serum antinuclear antibodies
drug-induced nephritis - urine eosinophils
- complement levels are decreased in various forms of glomerulonephritis.