Timing is Everything… or is it? – Nephro Critical Care Society

🚨 Timing is Everything… or is it? 🚨

Clinical Vignette

A 65‐year‐old male with acute decompensated heart failure secondary to a urinary tract infection is admitted to the ICU. Over 24 hours, he develops AKI with rising creatinine and oliguria alongside signs of fluid overload (acute pulmonary edema). The team must decide whether to initiate or delay renal replacement therapy (RRT) to balance renal recovery with patient stability.

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Q1. In an AKI patient with fluid overload, which integrated approach is most crucial for guiding the decision to initiate RRT?

A. Monitor only weight changes

B. Rely solely on urine output trends

C. Correct acidosis before volume status

D. Integrate fluid overload, diuretic responsiveness, urine output, and acid–base status

E. Use diuretic responsiveness alone

Q2. Which set of urinary findings most reliably indicates intrinsic renal parenchymal injury rather than a reversible prerenal state?

A. Normal urinalysis with low FeNa

B. Proteinuria (>0.5 mg/mg), hematuria, and muddy brown casts

C. Low fractional excretion irrespective of context

D. Isolated creatinine rise with normal sediment

E. Slight protein increase in urinary sediment

Q3. Which “red flag” in AKI evolution would most strongly support early RRT initiation?

A. Fluid overload >5% unresponsive to diuretics

B. Brisk urine output >200 ml after frusemide

C. Oliguria despite improved acidosis

D. Stable hemodynamics with a modest creatinine rise

E. Mild fluid overload responsive to diuretics

Q4. In a patient with cardiorenal syndrome, which combination is best for optimizing cardiac and renal function while guiding RRT timing?

A. Early RRT with VExUS only

B. Delay RRT with isotonic bicarbonate and FSTB. Delay RRT with isotonic bicarbonate and FST

C. Early RRT with hypertonic (4.2%) bicarbonate, FST, and VExUS monitoring

D. FST only with isotonic bicarbonate

Q5. For a hemodynamically unstable AKI patient, which bedside maneuver is supported to correct severe metabolic acidosis and stabilize the patient?

A. Immediate high-intensity ultrafiltration

B. Hypertonic (4.2%) bicarbonate infusion

C. Aggressive fluid resuscitation

D. Withhold diuretics until stability

E. Rapid escalation to continuous RRT

Q6. How does the VExUS score best contribute to managing fluid overload in AKI patients compared to the frusemide stress test (FST)?

A. VExUS predicts decongestion need and replaces FST

B. VExUS assesses LV systolic function for RRT timing

C. VExUS monitors venous congestion, while FST predicts diuretic response

D. VExUS estimates right atrial pressure in ventilated patients

E. VExUS and FST are identical in function

Q7. When aiming for optimal renal recovery, what strategy regarding RRT intensity is associated with improved outcomes?

A. High-intensity RRT throughout

B. Gentle RRT with planned “off” periods

C. Continuous high-intensity RRT

D. Ignoring RRT intensity

E. Maximizing ultrafiltration rates

Q8. Which clinical indicator best predicts renal recovery and guides safe RRT discontinuation?

A. Spontaneous urine output of 400–500 ml/24 hours or diuretic-assisted output >2000 ml/24 hours

B. Isolated serum creatinine improvement

C. Consistent decrease in body weight

D. Normal acid–base balance only

E. Timed urine GFR >20 ml/min

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🚨 Timing is Everything… or is it? 🚨

Clinical Vignette

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