{"id":37016,"date":"2026-06-11T12:06:03","date_gmt":"2026-06-11T06:36:03","guid":{"rendered":"https:\/\/atsixty.com\/?p=37016"},"modified":"2026-06-11T12:10:43","modified_gmt":"2026-06-11T06:40:43","slug":"acute-kidney-injury","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/neet-pg\/acute-kidney-injury\/","title":{"rendered":"Acute Kidney Injury"},"content":{"rendered":"\n<meta charset=\"UTF-8\">\n<meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0\">\n<title>Morning Rounds \u00b7 Acute Kidney Injury<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&#038;family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&#038;display=swap\" rel=\"stylesheet\">\n<style>\n#nep01 *,#nep01 *::before,#nep01 *::after{box-sizing:border-box;margin:0;padding:0}\n#nep01{\n  --nep:#2A5470;\n  --nep-light:#3A7499;\n  --nep-pale:#EBF3F8;\n  --nep-dark:#1C3D52;\n  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.mr-band-s{background:var(--nep-pale);color:var(--nep)}\n#nep01 .mr-retry{display:block;margin:18px auto 4px;background:transparent;border:2px solid var(--nep);color:var(--nep);border-radius:8px;padding:9px 28px;font-family:'Playfair Display',serif;font-size:0.92rem;font-weight:700;cursor:pointer}\n#nep01 .mr-retry:hover{background:var(--nep);color:#F0F7FC}\n@media(max-width:480px){#nep01 .mr-title{font-size:1.4rem}#nep01 .mr-num{font-size:1.7rem}#nep01 .mr-stem{font-size:0.9rem}#nep01 .mr-opt-text{font-size:0.86rem}}\n<\/style>\n\n<!-- RIFLE\/KDIGO classification diagram for Q1 debrief -->\n<div id=\"nep01-img1\" style=\"display:none\">\n  <figure class=\"mr-img-wrap\">\n    <svg viewBox=\"0 0 560 210\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" style=\"width:100%;max-width:560px;display:block;margin:0 auto\">\n      <!-- Background -->\n      <rect x=\"0\" y=\"0\" width=\"560\" height=\"210\" rx=\"8\" fill=\"#f0f6fa\"\/>\n      <!-- Title row -->\n      <text x=\"14\" y=\"20\" fill=\"#1A2C38\" font-size=\"9.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">AKI Classification Systems<\/text>\n      <!-- Header row -->\n      <rect x=\"10\" y=\"26\" width=\"150\" height=\"22\" rx=\"3\" fill=\"#2A5470\"\/>\n      <rect x=\"165\" y=\"26\" width=\"185\" height=\"22\" rx=\"3\" fill=\"#2A5470\"\/>\n      <rect x=\"355\" y=\"26\" width=\"195\" height=\"22\" rx=\"3\" fill=\"#2A5470\"\/>\n      <text x=\"85\" y=\"41\" text-anchor=\"middle\" fill=\"#F0F7FC\" font-size=\"8.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Stage<\/text>\n      <text x=\"257\" y=\"41\" text-anchor=\"middle\" fill=\"#F0F7FC\" font-size=\"8.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Serum Creatinine<\/text>\n      <text x=\"452\" y=\"41\" text-anchor=\"middle\" fill=\"#F0F7FC\" font-size=\"8.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Urine Output<\/text>\n      <!-- Row 1 \u2014 Risk \/ Stage 1 -->\n      <rect x=\"10\" y=\"50\" width=\"150\" height=\"36\" rx=\"3\" fill=\"#d4e8f4\"\/>\n      <rect x=\"165\" y=\"50\" width=\"185\" height=\"36\" rx=\"3\" fill=\"#e8f3f9\"\/>\n      <rect x=\"355\" y=\"50\" width=\"195\" height=\"36\" rx=\"3\" fill=\"#e8f3f9\"\/>\n      <text x=\"85\" y=\"63\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">RIFLE: Risk<\/text>\n      <text x=\"85\" y=\"76\" text-anchor=\"middle\" fill=\"#2A5470\" font-size=\"8\" font-family=\"Georgia,serif\">KDIGO: Stage 1<\/text>\n      <text x=\"257\" y=\"62\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7.5\" font-family=\"Georgia,serif\">&#x2191; &#x2265;1.5&#x00D7; baseline OR &#x2265;0.3 mg\/dL<\/text>\n      <text x=\"257\" y=\"76\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7.5\" font-family=\"Georgia,serif\">(within 48 h)<\/text>\n      <text x=\"452\" y=\"69\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7.5\" font-family=\"Georgia,serif\">&lt;0.5 mL\/kg\/h for &gt;6 h<\/text>\n      <!-- Row 2 \u2014 Injury \/ Stage 2 -->\n      <rect x=\"10\" y=\"88\" width=\"150\" height=\"36\" rx=\"3\" fill=\"#b8d8ed\"\/>\n      <rect x=\"165\" y=\"88\" width=\"185\" height=\"36\" rx=\"3\" fill=\"#e0eef5\"\/>\n      <rect x=\"355\" y=\"88\" width=\"195\" height=\"36\" rx=\"3\" fill=\"#e0eef5\"\/>\n      <text x=\"85\" y=\"101\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">RIFLE: Injury<\/text>\n      <text x=\"85\" y=\"114\" text-anchor=\"middle\" fill=\"#2A5470\" font-size=\"8\" font-family=\"Georgia,serif\">KDIGO: Stage 2<\/text>\n      <text x=\"257\" y=\"107\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7.5\" font-family=\"Georgia,serif\">&#x2191; &#x2265;2.0&#x00D7; baseline<\/text>\n      <text x=\"452\" y=\"107\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7.5\" font-family=\"Georgia,serif\">&lt;0.5 mL\/kg\/h for &gt;12 h<\/text>\n      <!-- Row 3 \u2014 Failure \/ Stage 3 -->\n      <rect x=\"10\" y=\"126\" width=\"150\" height=\"36\" rx=\"3\" fill=\"#7db8d9\"\/>\n      <rect x=\"165\" y=\"126\" width=\"185\" height=\"36\" rx=\"3\" fill=\"#d4e8f4\"\/>\n      <rect x=\"355\" y=\"126\" width=\"195\" height=\"36\" rx=\"3\" fill=\"#d4e8f4\"\/>\n      <text x=\"85\" y=\"139\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">RIFLE: Failure<\/text>\n      <text x=\"85\" y=\"152\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"8\" font-family=\"Georgia,serif\">KDIGO: Stage 3<\/text>\n      <text x=\"257\" y=\"138\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7.5\" font-family=\"Georgia,serif\">&#x2191; &#x2265;3.0&#x00D7; baseline OR &#x2265;4.0 mg\/dL<\/text>\n      <text x=\"257\" y=\"152\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7.5\" font-family=\"Georgia,serif\">OR initiation of RRT<\/text>\n      <text x=\"452\" y=\"145\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7.5\" font-family=\"Georgia,serif\">&lt;0.3 mL\/kg\/h for &#x2265;24 h OR anuria &#x2265;12 h<\/text>\n      <!-- Row 4 \u2014 RIFLE outcomes -->\n      <rect x=\"10\" y=\"164\" width=\"150\" height=\"36\" rx=\"3\" fill=\"#2A5470\" opacity=\"0.15\"\/>\n      <rect x=\"165\" y=\"164\" width=\"370\" height=\"36\" rx=\"3\" fill=\"#f4f9fc\"\/>\n      <text x=\"85\" y=\"177\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">RIFLE only:<\/text>\n      <text x=\"85\" y=\"190\" text-anchor=\"middle\" fill=\"#2A5470\" font-size=\"7.5\" font-family=\"Georgia,serif\">Loss \/ ESRD<\/text>\n      <text x=\"350\" y=\"177\" text-anchor=\"middle\" fill=\"#3d5a6a\" font-size=\"7.5\" font-family=\"Georgia,serif\">Loss: persistent AKI &gt;4 weeks &nbsp;|&nbsp; ESRD: &gt;3 months<\/text>\n      <text x=\"350\" y=\"190\" text-anchor=\"middle\" fill=\"#7a9bad\" font-size=\"7\" font-family=\"Georgia,serif\" font-style=\"italic\">KDIGO does not include outcome stages<\/text>\n    <\/svg>\n    <figcaption>\n      RIFLE vs KDIGO staging. Both systems stage by creatinine rise or urine output fall. KDIGO added the 0.3 mg\/dL within-48h criterion (Stage 1) and dropped RIFLE's outcome stages (Loss, ESRD). In clinical practice and PG exams, knowing both is expected \u2014 particularly the Stage 3 \/ Failure thresholds and the RRT trigger.\n    <\/figcaption>\n  <\/figure>\n<\/div>\n\n<!-- FENa interpretation diagram for Q3 debrief -->\n<div id=\"nep01-img3\" style=\"display:none\">\n  <figure class=\"mr-img-wrap\">\n    <svg viewBox=\"0 0 520 160\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" style=\"width:100%;max-width:520px;display:block;margin:0 auto\">\n      <rect x=\"0\" y=\"0\" width=\"520\" height=\"160\" rx=\"8\" fill=\"#f0f6fa\"\/>\n      <text x=\"260\" y=\"18\" text-anchor=\"middle\" fill=\"#1A2C38\" font-size=\"9.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">FENa \u2014 Fractional Excretion of Sodium<\/text>\n      <!-- Formula box -->\n      <rect x=\"10\" y=\"24\" width=\"500\" height=\"30\" rx=\"4\" fill=\"#d4e8f4\"\/>\n      <text x=\"260\" y=\"35\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">FENa (%) = (U<\/text>\n      <text x=\"260\" y=\"35\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">FENa (%)  =  (U&#x2099;&#x2090; &#x00D7; P&#x2063;&#x2090;) \u00f7 (P&#x2099;&#x2090; &#x00D7; U&#x2063;&#x2090;)  &#x00D7;  100<\/text>\n      <text x=\"260\" y=\"48\" text-anchor=\"middle\" fill=\"#2A5470\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-style=\"italic\">U = urine  |  P = plasma  |  Na = sodium  |  Cr = creatinine<\/text>\n      <!-- Three columns -->\n      <rect x=\"10\" y=\"60\" width=\"155\" height=\"90\" rx=\"4\" fill=\"#e8f3f9\"\/>\n      <rect x=\"182\" y=\"60\" width=\"155\" height=\"90\" rx=\"4\" fill=\"#eaf6ef\"\/>\n      <rect x=\"354\" y=\"60\" width=\"156\" height=\"90\" rx=\"4\" fill=\"#fdf0eb\"\/>\n      <!-- Pre-renal -->\n      <text x=\"87\" y=\"76\" text-anchor=\"middle\" fill=\"#2A5470\" font-size=\"8.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Pre-renal AKI<\/text>\n      <text x=\"87\" y=\"90\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"11\" font-family=\"Georgia,serif\" font-weight=\"bold\">FENa &lt; 1%<\/text>\n      <text x=\"87\" y=\"105\" text-anchor=\"middle\" fill=\"#3d5a6a\" font-size=\"7.5\" font-family=\"Georgia,serif\">Tubules intact \u2014<\/text>\n      <text x=\"87\" y=\"116\" text-anchor=\"middle\" fill=\"#3d5a6a\" font-size=\"7.5\" font-family=\"Georgia,serif\">avidly reabsorbing Na<\/text>\n      <text x=\"87\" y=\"130\" text-anchor=\"middle\" fill=\"#7a9bad\" font-size=\"7\" font-family=\"Georgia,serif\" font-style=\"italic\">U&#x2099;&#x2090; &gt;20 mEq\/L, SG &gt;1.020<\/text>\n      <text x=\"87\" y=\"142\" text-anchor=\"middle\" fill=\"#7a9bad\" font-size=\"7\" font-family=\"Georgia,serif\" font-style=\"italic\">BUN:Cr &gt;20<\/text>\n      <!-- ATN -->\n      <text x=\"259\" y=\"76\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"8.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Intrinsic (ATN)<\/text>\n      <text x=\"259\" y=\"90\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"11\" font-family=\"Georgia,serif\" font-weight=\"bold\">FENa &gt; 2%<\/text>\n      <text x=\"259\" y=\"105\" text-anchor=\"middle\" fill=\"#3d5a6a\" font-size=\"7.5\" font-family=\"Georgia,serif\">Tubular damage \u2014<\/text>\n      <text x=\"259\" y=\"116\" text-anchor=\"middle\" fill=\"#3d5a6a\" font-size=\"7.5\" font-family=\"Georgia,serif\">cannot conserve Na<\/text>\n      <text x=\"259\" y=\"130\" text-anchor=\"middle\" fill=\"#7a9bad\" font-size=\"7\" font-family=\"Georgia,serif\" font-style=\"italic\">U&#x2099;&#x2090; &gt;40 mEq\/L, SG ~1.010<\/text>\n      <text x=\"259\" y=\"142\" text-anchor=\"middle\" fill=\"#7a9bad\" font-size=\"7\" font-family=\"Georgia,serif\" font-style=\"italic\">Muddy brown casts on UA<\/text>\n      <!-- Caveat -->\n      <text x=\"432\" y=\"76\" text-anchor=\"middle\" fill=\"#8B3D20\" font-size=\"8.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Important caveat<\/text>\n      <text x=\"432\" y=\"93\" text-anchor=\"middle\" fill=\"#3d2010\" font-size=\"7.5\" font-family=\"Georgia,serif\">FENa &lt;1% despite ATN:<\/text>\n      <text x=\"432\" y=\"106\" text-anchor=\"middle\" fill=\"#5a3020\" font-size=\"7.5\" font-family=\"Georgia,serif\">contrast nephropathy,<\/text>\n      <text x=\"432\" y=\"118\" text-anchor=\"middle\" fill=\"#5a3020\" font-size=\"7.5\" font-family=\"Georgia,serif\">myoglobinuria,<\/text>\n      <text x=\"432\" y=\"130\" text-anchor=\"middle\" fill=\"#5a3020\" font-size=\"7.5\" font-family=\"Georgia,serif\">early obstruction<\/text>\n      <text x=\"432\" y=\"145\" text-anchor=\"middle\" fill=\"#8B3D20\" font-size=\"7\" font-family=\"Georgia,serif\" font-style=\"italic\">Use FEUrea if on diuretics<\/text>\n    <\/svg>\n    <figcaption>\n      FENa interpretation in AKI. The formula uses spot urine and plasma values for both sodium and creatinine. Key caveat: diuretics falsely raise FENa even in pre-renal states \u2014 use <strong>FE-Urea (&lt;35% = pre-renal)<\/strong> instead in patients on diuretics.\n    <\/figcaption>\n  <\/figure>\n<\/div>\n\n<div id=\"nep01\">\n\n  <div class=\"mr-header\">\n    <div class=\"mr-eyebrow\">Morning Rounds \u00b7 Nephrology Series \u00b7 Round 01<\/div>\n    <div class=\"mr-title\">\n      Acute Kidney Injury<br><em>Diagnosis &amp; Clinical Reasoning<\/em>\n    <\/div>\n    <div class=\"mr-subtitle\">Five cases &middot; Read carefully &middot; Trust your instinct<\/div>\n    <div class=\"mr-chips\">\n      <span class=\"mr-chip\">5 Cases<\/span>\n      <span class=\"mr-chip\">+4 \/ &minus;1 scoring<\/span>\n      <span class=\"mr-chip\">Options reshuffled<\/span>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-sentinel\" id=\"nep01-sentinel\"><\/div>\n\n  <div class=\"mr-progress\" id=\"nep01-progress\">\n    <div class=\"mr-prog-inner\">\n      <div class=\"mr-pips\" id=\"nep01-pips\"><\/div>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-body\">\n    <div id=\"nep01-cases\"><\/div>\n    <div class=\"mr-submit-wrap\">\n      <button class=\"mr-btn\" id=\"nep01-submit\">Submit for Debrief<\/button>\n    <\/div>\n    <div class=\"mr-score\" id=\"nep01-score\">\n      <div class=\"mr-score-in\">\n        <div class=\"mr-score-ey\">Round Complete<\/div>\n        <div class=\"mr-ring\" id=\"nep01-ring\">\n          <div class=\"mr-ring-in\">\n            <span class=\"mr-ring-pct\" id=\"nep01-pct\">0%<\/span>\n            <span class=\"mr-ring-sub\">net<\/span>\n          <\/div>\n        <\/div>\n        <div class=\"mr-score-title\">Your Debrief<\/div>\n        <div class=\"mr-score-net\" id=\"nep01-net\"><\/div>\n        <div class=\"mr-verdict\" id=\"nep01-verdict\"><\/div>\n        <div class=\"mr-bands\">\n          <span class=\"mr-band mr-band-c\" id=\"nep01-ct-c\"><\/span>\n          <span class=\"mr-band mr-band-w\" id=\"nep01-ct-w\"><\/span>\n          <span class=\"mr-band mr-band-s\" id=\"nep01-ct-s\"><\/span>\n        <\/div>\n        <button class=\"mr-retry\" id=\"nep01-retry\">&#8635; New Round<\/button>\n      <\/div>\n    <\/div>\n  <\/div>\n\n<\/div><!-- end #nep01 -->\n\n<script>\n(function () {\n  'use strict';\n\n  var NS    = 'nep01';\n  var TOTAL = 5;\n  var MAX   = 20;\n  var LTRS  = ['A','B','C','D'];\n\n  var QS = [\n\n    {\n      id:      1,\n      tag:     'AKI &mdash; RIFLE &amp; KDIGO Staging',\n      stem:    'A <strong>55-year-old man<\/strong> is admitted with severe community-acquired pneumonia. His baseline serum creatinine (from 3 months ago) was <strong>0.9 mg\/dL<\/strong>. Today it is <strong>1.8 mg\/dL<\/strong> (a 2.0&times; rise). His urine output over the last 8 hours has been <strong>0.4 mL\/kg\/h<\/strong>. He is not on dialysis. How would you stage this AKI under <em>both<\/em> the RIFLE and KDIGO systems?',\n      correct: 'RIFLE: Injury &nbsp;|&nbsp; KDIGO: Stage 2',\n      opts: [\n        'RIFLE: Injury &nbsp;|&nbsp; KDIGO: Stage 2',\n        'RIFLE: Risk &nbsp;|&nbsp; KDIGO: Stage 1',\n        'RIFLE: Failure &nbsp;|&nbsp; KDIGO: Stage 3',\n        'RIFLE: Risk &nbsp;|&nbsp; KDIGO: Stage 2'\n      ],\n      exp:     'A <strong>2.0&times; rise<\/strong> in creatinine from baseline maps to <strong>RIFLE: Injury<\/strong> and <strong>KDIGO: Stage 2<\/strong>. Under KDIGO, Stage 1 requires a &#x2265;1.5&times; rise (or &#x2265;0.3 mg\/dL rise within 48 h); Stage 2 requires &#x2265;2.0&times;; Stage 3 requires &#x2265;3.0&times; or absolute creatinine &#x2265;4.0 mg\/dL or need for RRT. The urine output of 0.4 mL\/kg\/h for 8 h is consistent with Stage 1 by UO criteria, but creatinine-based staging takes priority here and gives the higher stage. The RIFLE &#x201C;Injury&#x201D; tier corresponds exactly to the 2&times; creatinine threshold.',\n      imgId:   'nep01-img1'\n    },\n\n    {\n      id:      2,\n      tag:     'AKI &mdash; Pre-renal vs ATN',\n      stem:    'A <strong>70-year-old woman<\/strong> with heart failure is brought in with three days of vomiting and reduced oral intake. Examination shows dry mucous membranes, JVP not visible, and postural hypotension. Investigations: serum creatinine 2.8 mg\/dL (baseline 0.8 mg\/dL), BUN 84 mg\/dL, urine sodium 10 mEq\/L, urine specific gravity 1.026, no casts on urine microscopy. What is the most likely diagnosis and the single best initial intervention?',\n      correct: 'Pre-renal AKI; IV isotonic saline fluid resuscitation',\n      opts: [\n        'Pre-renal AKI; IV isotonic saline fluid resuscitation',\n        'Acute tubular necrosis; fluid restriction and furosemide',\n        'Cardiorenal syndrome type 1; IV furosemide for decongestion',\n        'Obstructive uropathy; urgent renal ultrasound and bladder catheterisation'\n      ],\n      exp:     'The clinical picture is classic <strong>pre-renal AKI<\/strong>: volume depletion (vomiting, reduced intake), evidence of hypovolaemia on examination, <strong>low urine sodium (&lt;20 mEq\/L)<\/strong>, <strong>high specific gravity (&gt;1.020)<\/strong>, <strong>BUN:creatinine ratio &gt;20:1<\/strong> (here ~30:1), and absence of casts. The tubules are structurally intact and avidly conserving sodium and water. The immediate intervention is <strong>IV isotonic saline<\/strong> to restore intravascular volume. Furosemide would worsen hypovolaemia. Cardiorenal syndrome type 1 refers to AKI complicating acute cardiac decompensation with congestion &mdash; not the picture here. Obstruction is possible in the elderly but this clinical scenario points clearly to volume depletion.',\n      imgId:   null\n    },\n\n    {\n      id:      3,\n      tag:     'AKI &mdash; FENa Interpretation',\n      stem:    'A <strong>62-year-old man<\/strong> undergoes emergency repair of a ruptured abdominal aortic aneurysm. Post-operatively, his creatinine rises from 1.0 to 3.2 mg\/dL over 48 hours. Urine sodium is <strong>52 mEq\/L<\/strong>, urine creatinine 45 mg\/dL, plasma sodium 138 mEq\/L, plasma creatinine 3.2 mg\/dL. Urine microscopy shows <strong>muddy brown granular casts<\/strong>. What is the FENa, and what does it indicate?',\n      correct: 'FENa ~2.6%; intrinsic AKI (acute tubular necrosis)',\n      opts: [\n        'FENa ~2.6%; intrinsic AKI (acute tubular necrosis)',\n        'FENa ~0.5%; pre-renal AKI from intra-operative hypotension',\n        'FENa ~2.6%; obstructive nephropathy from retroperitoneal haematoma',\n        'FENa is unreliable post-surgery; urine sodium alone should guide management'\n      ],\n      exp:     '<strong>FENa = (U&#x2099;&#x2090; &times; P&#x2063;&#x2090;) &divide; (P&#x2099;&#x2090; &times; U&#x2063;&#x2090;) &times; 100<\/strong> = (52 &times; 3.2) &divide; (138 &times; 45) &times; 100 = 166.4 &divide; 6210 &times; 100 &asymp; <strong>2.68%<\/strong>. An FENa &gt;2% indicates tubular dysfunction &mdash; the kidney cannot conserve sodium because tubular epithelium is damaged. Combined with the <strong>muddy brown granular casts<\/strong> (shed tubular epithelial cells), this confirms <strong>acute tubular necrosis (ATN)<\/strong>. The context &mdash; ischaemia during aortic repair &mdash; is the classic ischaemic ATN scenario. Management is supportive: correct volume, avoid nephrotoxins, dose-adjust medications, and monitor for RRT indications.',\n      imgId:   'nep01-img3'\n    },\n\n    {\n      id:      4,\n      tag:     'AKI &mdash; Indications for Urgent Dialysis',\n      stem:    'A <strong>48-year-old man<\/strong> with known CKD Stage 3 (baseline creatinine 2.0 mg\/dL) develops AKI following an NSAID overdose. Current values: creatinine 8.4 mg\/dL, potassium 6.8 mEq\/L with <strong>peaked T-waves on ECG<\/strong>, bicarbonate 10 mEq\/L, pH 7.18. He has pulmonary oedema that is not responding to furosemide, and urine output is 30 mL over the past 6 hours. Which statement best describes the indications for renal replacement therapy (RRT) in this patient?',\n      correct: 'Multiple absolute indications are present: hyperkalaemia with ECG changes, severe metabolic acidosis, and pulmonary oedema refractory to diuretics',\n      opts: [\n        'Multiple absolute indications are present: hyperkalaemia with ECG changes, severe metabolic acidosis, and pulmonary oedema refractory to diuretics',\n        'Initiate RRT only when creatinine exceeds 10 mg\/dL or GFR falls below 10 mL\/min',\n        'IV sodium bicarbonate and calcium gluconate are sufficient; RRT is not yet indicated',\n        'Oliguria alone (urine output &lt;400 mL\/24h) is the sole absolute indication for RRT'\n      ],\n      exp:     'RRT indications in AKI are remembered by the mnemonic <strong>AEIOU<\/strong>: <strong>A<\/strong>cidosis (pH &lt;7.2 unresponsive to treatment), <strong>E<\/strong>lectrolyte disturbance (K&#x207A; &gt;6.5 with ECG changes), <strong>I<\/strong>ntoxication (dialysable toxins), <strong>O<\/strong>verload (pulmonary oedema not responding to diuretics), <strong>U<\/strong>raemia (encephalopathy, pericarditis, bleeding). This patient meets three: severe metabolic acidosis (pH 7.18, HCO&#x2083;&#x207B; 10), hyperkalaemia with ECG changes, and refractory pulmonary oedema. Creatinine alone is never an absolute threshold. Calcium gluconate stabilises the myocardium temporarily but is not definitive. Urgent haemodialysis or CRRT is indicated.',\n      imgId:   null\n    },\n\n    {\n      id:      5,\n      tag:     'AKI &mdash; Contrast Nephropathy',\n      stem:    'A <strong>65-year-old diabetic woman<\/strong> with CKD Stage 3b (eGFR 32 mL\/min\/1.73 m&sup2;) is scheduled for CT pulmonary angiography to rule out PE. Her attending is concerned about contrast-induced AKI (CI-AKI). Which single intervention has the strongest evidence for reducing the risk of CI-AKI in high-risk patients?',\n      correct: 'IV isotonic saline hydration before and after contrast administration',\n      opts: [\n        'IV isotonic saline hydration before and after contrast administration',\n        'Pre-treatment with oral N-acetylcysteine (NAC) 600 mg twice daily for 2 days',\n        'Prophylactic haemodialysis within 2 hours of contrast exposure',\n        'Switching to iso-osmolar iodixanol contrast is sufficient alone; hydration is not required'\n      ],\n      exp:     '<strong>IV isotonic saline hydration<\/strong> (typically 1 mL\/kg\/h starting 3&ndash;12 h before and continued 6&ndash;12 h after contrast) is the single most evidence-supported intervention for CI-AKI prevention. It dilutes the contrast in the tubular lumen, maintains renal perfusion, and prevents tubular concentration. <strong>N-acetylcysteine (NAC)<\/strong> has a long history of use but multiple large trials (PRESERVE, ACT) have shown it offers no significant benefit over hydration alone &mdash; it is no longer routinely recommended. <strong>Prophylactic dialysis<\/strong> is not indicated and does not reliably prevent CI-AKI. Iso-osmolar contrast reduces osmotic injury but does not replace hydration as the primary protective measure. Risk stratification (diabetes + CKD eGFR &lt;45 = high risk) should guide hydration intensity.',\n      imgId:   null\n    }\n\n  ];\n\n  var answers  = {};\n  var answered = 0;\n  var shuffled = {};\n  var done     = false;\n\n  function byId(id) { return document.getElementById(id); }\n  function gid(suffix) { return byId(NS + '-' + suffix); }\n\n  function shuffleArr(arr) {\n    var a = arr.slice(), i, j, tmp;\n    for (i = a.length - 1; i > 0; i--) {\n      j = Math.floor(Math.random() * (i + 1));\n      tmp = a[i]; a[i] = a[j]; a[j] = tmp;\n    }\n    return a;\n  }\n\n  function countVal(val) {\n    var k, n = 0;\n    for (k in answers) {\n      if (answers.hasOwnProperty(k) && answers[k] === val) n++;\n    }\n    return n;\n  }\n\n  function buildPips() {\n    var cont = gid('pips'), i, q, wLine, wPip, line, pip;\n    cont.innerHTML = '';\n    for (i = 0; i < QS.length; i++) {\n      q = QS[i];\n      if (i > 0) {\n        wLine = document.createElement('div');\n        wLine.className = 'mr-pip-wrap';\n        line = document.createElement('div');\n        line.className = 'mr-pip-line';\n        line.id = NS + '-pl' + q.id;\n        wLine.appendChild(line);\n        cont.appendChild(wLine);\n      }\n      wPip = document.createElement('div');\n      wPip.className = 'mr-pip-wrap';\n      pip = document.createElement('div');\n      pip.className = 'mr-pip';\n      pip.id = NS + '-pip' + q.id;\n      pip.textContent = String(q.id);\n      wPip.appendChild(pip);\n      cont.appendChild(wPip);\n    }\n  }\n\n  function build() {\n    var cont, i, q, opts, card, top, numDiv, meta, tag, stem,\n        rule, optsDiv, expDiv, lbl, txt, imgDiv, imgSrc, j,\n        optEl, ltrSpan, txtSpan;\n\n    cont = gid('cases');\n    cont.innerHTML = '';\n    answers = {}; answered = 0; shuffled = {}; done = false;\n    gid('score').style.display = 'none';\n    buildPips();\n\n    for (i = 0; i < QS.length; i++) {\n      q = QS[i];\n      opts = shuffleArr(q.opts);\n      shuffled[q.id] = opts;\n\n      card = document.createElement('div');\n      card.className = 'mr-case';\n\n      top = document.createElement('div');\n      top.className = 'mr-case-top';\n\n      numDiv = document.createElement('div');\n      numDiv.className = 'mr-num';\n      numDiv.textContent = q.id < 10 ? 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