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C E 2.

5

ANCC/AACN CONTACT HOURS

Kidneys, don’t
If toxic wastes build up too fast, I’m liable to shut down!

Unfortunately, acute renal failure is on the rise, attributed to our aging population, more people living longer with comorbidities, and an increasing use of nephrotoxic drugs. Diagnosing it early, while it’s still reversible, is key. Find out what your role is in preventing permanent damage to the kidneys.
KATHRYN WARD, APRN,BC, CDE, MSN Outcomes Manager • Suburban Hospital • Bethesda, Md.
The author has disclosed that she has no significant relationships with or financial interest in any commercial companies that pertain to this educational activity.

AS YOU KNOW, the rising population of older adults in this country is contributing to a greater prevalence of certain health problems, such as diabetes, hypertension, some cancers, and cardiac disease. There’s another one you may not have considered: acute renal failure (ARF). Of course, age isn’t the only factor: More people today are surviving longer with chronic illnesses, like congestive heart failure, human immunodeficiency virus infection, and other autoimmune diseases. These comorbidities can tax the kidneys and trigger ARF. Plus we’re using more and more nephrotoxic drugs, such as various aminoglycosides, nonsteroidal anti-inflammatory drugs (NSAIDs), and radiocontrast agents, that put the kidneys at risk (see Kidneys beware!). How prevalent is ARF? Between 5% and 7% of all hospitalized patients have it, with the percentage rising to around 20%
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in the critically ill. And these numbers are on the rise. Defined as a sudden loss of kidney function, ARF is characterized by a rapid accumulation of toxic waste products, such as urea and creatinine, in the blood. The sudden burden on the kidneys causes 50% or more of their nephrons to lose function so quickly that the body can’t compensate. The nephrons may eventually recover, if the cause of ARF is corrected. But if the damage is permanent, ARF becomes chronic renal failure. The most common sign of ARF is oliguria, a decrease in urine output (less than 400 ml in 24 hours). This volume is insufficient to excrete waste products. Some patients experience nonoliguric renal failure, in which the kidneys can’t filter out the waste products in the urine, but they’re still able to make urine. The waste products build up in the blood. Unfortunately, we haven’t found an effective pharmacologic therapy to prevent or treat ARF. So we generally fall back on

fail me now! Portrait of a nephron Glomerulus Bowman’s capsule Renal tubule Artery Vein Collecting tubule Loop of Henle Urine March/April 2005 Nursing made Incredibly Easy! 19 .

11 mg)—the weight of a stick of butter. Normal blood flow is es- 20 Nursing made Incredibly Easy! March/April 2005 . On average. In fact. In this article. Ecstasy) • aspirin • NSAIDs • COX-2 inhibitors • radiocontrast agents • venom The kidneys. The function of the nephron is to produce urine using three processes: glomerular filtration. Typically. An adult kidney weighs a quarter of a pound (0. bean-shaped organs. spherical structure. overwhelming infection or cardiopulmonary problems are the causes of death. a thin-walled. and every minute. At any given time. almost 30% of all the patients who experience ARF need renal replacement therapy. I’ll show you what steps to take to prevent acute kidney failure in patients at risk and how to assess it early.supportive care. they’re mighty in function and remarkably efficient. Despite improvements in this type of therapy. but your kidneys are working hard around the clock. the GFR drops. The GFR affects the amount of urine produced. two small. Because of this. When a serious illness or a surgical complication suddenly occurs. the blood urea nitrogen (BUN) and creatinine levels rise. conserve electrolytes. Besides excreting the waste products of cellular metabolism. anywhere from 20% to 70%. You may not realize it. Each kidney contains about 1 million nephrons. the kidneys filter about 50 gallons (more than 189 liters) of fluid every day. The glomerulus is a network of capillaries that receives blood from the renal artery. the mortality rate for ARF remains high. If the kidneys are damaged. and tubular secretion. and regulate blood pressure. Substances are exchanged through the walls of the tubules. the kidneys can stop working without warning. You play a pivotal role in assessing your patients and identifying changes associated with ARF. electrolyte concentration. tubular reabsorption. The kidneys also excrete wastes. prevention and early detection are vital. In review Kidneys beware! The following drugs and other substances have a potential for nephrotoxicity: Antibiotics • acyclovir (Zovirax) • aminoglycosides (various) • amphotericin B (Amphocin. The rate at which the kidneys filter blood through the glomerulus is called the glomerular filtration rate (GFR). and the pH of body fluids within a narrow margin. Each organ is about 4 inches long by 21⁄2 inches wide (about 10 cm x 6. Fungizone) • pentamidine (Pentam 300) • tetracycline Chemotherapies and immunosuppressants • cisplatin (Platinol) • cyclosporine (Sandimmune) • methotrexate (Trexall) • mitomycin (Mutamycin) Heavy metals • arsenic • bismuth • lead • mercury Miscellaneous • illicit drugs (cocaine. are located on either side of the spinal column below the rib cage. surrounds the glomerulus and then narrows. A nephron is composed of a glomerulus and a tubule. in your body. Bowman’s capsule. they receive about a quarter of the cardiac output. these processes maintain fluid volume. Although small in size. Kidney function The powerhouse of the kidney is the nephron. becoming the tubules. while it’s still reversible. Because the kidneys are no longer filtering wastes from the blood. Normally. with renal replacement therapy the primary treatment option (see The ins and outs of renal replacement therapy). the GFR is 120 to 125 ml/min. they’re filtering half of the blood When things go wrong Every minute of every hour.5 cm). concentrate urine. your kidneys are working without you being aware of it—or even needing to do anything to participate in the process. And they produce other substances that are important to the function of other organs.

ARF can do permanent damage. which is necessary to maintain renal perfusion. keep in mind that the potential for ARF is always there. sepsis. it accounts for 35% to 40% of all cases of ARF. When assessing any patient. System failure Acute renal failure is classified according to the area of the renal system that’s affected. these drugs can worsen the situation (see An ACE in the hole). This type of renal failure accounts for 55% to 60% of all cases of ARF. sepsis. a condition in which the tubules are destroyed. aminoglycosides) • excessive diuresis • Hantavirus infection • hemolytic blood transfusion reaction • HIV infection • hypovolemia • lithotripsy • medication allergies • myocardial infarction • renal artery thrombosis • rhabdomyolysis • septic shock • severe crush injury • trauma. and perineum • urinary tract obstructions (stricture. So quickly reaching a diagnosis and establishing an effective management plan should be the overriding concerns of the health care team. Acute tubular necrosis is frequently a hospital-acquired problem. pelvis. then. amphotericin. is caused by direct damage to both kidneys. doesn’t it? These conditions are seen in hospitals and other health care facilities on a daily basis. and heart failure. or use of contrast dye or some antibiotics. also called intrinsic ARF. stones. ethylene glycol) • congestive heart failure • dehydration • drugs (gentamicin. March/April 2005 Nursing made Incredibly Easy! 21 What’s behind ARF? Some of the diseases and conditions that can lead to kidney failure include: • acute glomerulonephritis • anaphylaxis • autoimmune disorders • burns • cardiogenic shock • chemical exposure (lead. hypertension. trauma. enlarged prostate) • vascular surgery . resulting from surgery. Let’s look at the three types of ARF and what triggers them. So any blood loss that compromises the kidneys’ blood supply can damage them and affect their function. Prerenal ARF is caused by decreased blood flow to the kidneys. Never underestimate the possibility of it occurring. Nearly 90% of cases of intrarenal ARF are caused by ischemia (reduced blood flow) or toxins. both of which can lead to acute tubular necrosis. NSAIDs.Looks like my MI patient’s heart isn’t the only organ at risk! sential to keeping the kidneys functioning smoothly. tumors. These drugs impair renal autoregulatory responses by blocking the production of prostaglandin. The key point to remember is that regard- less of the cause. Use of NSAIDs and cyclooxygenase-2 (COX-2) inhibitors can also cause prerenal ARF. The most common causes of prerenal ARF are severe blood loss and low blood pressure due to major abdominal or cardiac surgery. Take a look at the list of causes of ARF in What’s behind ARF? Looks familiar. arsenic. carbon tetrachloride. ACE inhibitors. Other causes include interruption of blood flow in the renal artery or renal vein and amyloidosis. especially to the back. as can a steep drop in the blood pressure or significant dehydration. rifampin. and dehydration. Intrarenal ARF. an abnormal depositing of protein in kidney tissues. But if the patient is already in ARF. Angiotensin-converting enzyme inhibitors (ACE-Is) are used to preserve and maintain renal function in patients with diabetes.

However. This condition is most commonly seen in older men with an enlarged prostate that interferes with urine flow. heart failure. the nephrons eventually shut down. but they’re especially helpful when a hypertensive patient has diabetes or a comorbidity caused by endothelial dysfunction. when used in a patient with renal failure. a neurogenic bladder. and traumatic injury to the kidneys are other potential causes. ACE-Is are appropriate treatment for any patient with hypertension. such as those with hypertension.Levels of renal dysfunction Description Normal function Mild renal failure Moderate renal failure Severe renal failure End-stage renal disease Approximate creatinine clearance (ml/min) >80 >50 to 80 30 to 50 <30 Requires dialysis Postrenal ARF is caused by a blockage that affects the outflow of urine from both kidneys. I said that quick identification of ARF is important to reversing it. such as heart failure. and renal insufficiency with a creatinine level <3 mg/dl. ARBs are used to treat hypertension and heart failure and maintain renal function in patients with diabetes. When urine flow is obstructed. quantified at <400 ml/day. cording to the degree of renal dysfunction (see Levels of renal dysfunction) and the etiology of the condition. How diagnostics help Lab tests and a thorough history and physical exam provide important information that can point to a diagnosis of kidney failure. These are red flags that the body’s not excreting fluid efficiently. the potential for permanent damage to renal system function increases. making them good choices for complex patients at risk for kidney disease. The quicker a diagnosis is made. So what are the clues to ARF? Symptoms vary ac- An ACE in the hole Angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin receptor blockers (ARBs) are renal protective. Because they affect the renin-angiotensin-aldosterone system at different places. See The farreaching effects of ARF for more information. these two classes of drugs are combined to treat patients with heart failure. early-stage ARF may not have symptoms. 22 Nursing made Incredibly Easy! March/April 2005 . the sooner appropriate intervention can begin. or diabetes. As the pressure builds. Recognizing renal failure Earlier. heart function improves and symptoms lessen. These drugs prevent endothelial dysfunction and maintain renal function. Left untreated. Remember that the effects of ARF aren’t confined to the renal system. Often. Only about 5% of cases of ARF are classified as postrenal ARF. Patients with mild. Always keep in mind that ARF is most reversible in its earliest stages. Bladder or kidney stones in both ureters. the urine backs up into the kidneys. ACE-Is can exacerbate renal problems. left ventricular hypertrophy. myocardial infarction. The classic sign of ARF is oliguria (reduced urine output relative to fluid intake). Be aware that pregnant women and women who are likely to become pregnant shouldn’t take ACE-Is or ARBs because of the potential for fetal injury or death. Also find out if the patient has a history of renal calculi or urinary outlet problems or if he has a family history of renal disease. You should also suspect renal failure when a patient presents with unexplained weight gain or edema.

eventually. the body can’t replace the lost RBCs. The most widely accepted indicators include a decline in renal function occurring over hours to days and involving an increase in serum creatinine by more than 0. detect tumors and blockages. Steps in managing ARF may include: ■ replacing fluids to restore fluid and electrolyte balance ■ discontinuing medications that may be the cause of the problem ■ instituting short-term renal replacement therapy to filter the blood and restore potassium and other electrolyte levels to normal ■ eliminating or bypassing urinary tract obstruction. and coma. or vascular. Further analysis may indicate if casts are glomerular. confusion. Electrolyte balance is vital to your patient’s well-being. and a decline in creatinine clearance of more than 25%. and reveal cystic disease. and fluid overload. Fluids and electrolytes • Alterations in the fluid and electrolyte balance can lead to hyponatremia. tented T waves on the electrocardiogram. hyperphosphatemia. which refers to a kidney with a dilated pelvis and collecting system caused by obstruction of the ureters or bladder outlet. vomiting. Because other processes. For example. Bradycardia. Neurologic • A build-up of metabolic wastes in the blood can cause sensory changes. Because there’s less erythropoietin in the bone marrow. and prevent permanent kidney damage. Several treatment modalities are available. can increase the BUN level. red cells and casts may indicate glomerular disease. Hyperkalemia. and asystole could develop if the serum potassium level rises above 6 mEq/L. an increase of 50% or more in serum creatinine over baseline levels. A renal biopsy may be needed if there’s no apparent cause of ARF or if glomerulonephritis is suspected. with the treatment selected according to the cause of ARF. which can arise from kidney failure. hyperkalemia. manage the signs and symptoms. such as removing stones or catheterizing the bladder ■ offering nutritional support that provides adequate calories without increasing the protein or sodium load to combat malnutrition and fluid and electrolyte imbalances. causing the following problems throughout the body. such as internal bleeding. Don’t underestimate the importance of urinalysis in helping to determine the cause of ARF. typically affects cardiac function. Prerenal and postrenal ARF can resolve fairly quickly if the cause is known and acted on without delay. Erythropoietin is needed to stimulate RBC production. decreased mentation. and protein metabolism. provide supportive care. Interventions and outcomes The goals of managing ARF are to eliminate the cause. Gastrointestinal • The build-up of wastes in the blood (uremia) causes loss of appetite. is only 60 days. nausea.5 mg/dl. infection. Serum electrolytes may offer additional information about volume status and should be included in the lab workup. tubulointerstitial. Hematologic • Anemia occurs as a result of decreased erythropoietin production by the kidneys and the red blood cells’ (RBCs) shortened lifespan. Renal ultrasound can measure kidney size. • The build-up of urea can cause a metallic taste in the mouth or a foul urine odor to the breath. the RBC lifespan. retrograde leakage of urine from the bladder up the ureters to the renal pelvis. In patients with ARF. It can also identify hydronephrosis. and. a decrease in body mass and muscle.A diagnosis of ARF is made based on increasing levels of creatinine. which is usually 120 days. This can result from reflux. look for tall. Cardiovascular and pulmonary • Fluid overload results in hypertension and peripheral and pulmonary edema. Recovery time may be proMarch/April 2005 Nursing made Incredibly Easy! 23 . • Hyperkalemia causes arrhythmias. BUN is less accurate than creatinine as an indicator of renal function. The far-reaching effects of ARF Acute renal failure (ARF) affects more than the renal system. heart block.

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the medications he’ll be taking after discharge. any fluid restriction. Either of these options requires vascular access via a temporary catheter inserted into a large blood vessel. Acute renal failure.I’m down but not out—although recovery could take up to a year. is sudden. his nutritional needs. Once your patient’s ready for discharge. by definition. such as adverse cardiac and What you can do An accurate record of intake and output. emphasize prevention. making it essential for you to recognize and report abnormal assessments. As the patient’s blood is removed. longed in intrarenal ARF because the functional units of the kidneys may be damaged. the length of the oliguric phase. potassium. and frequent blood pressure measurements are essential when a patient’s been diagnosed with ARF. maintain correct fluid balance. Easier on the body and slower than hemodialysis. and identify patients at greatest risk for developing ARF. but dramatic results take longer. the process allows time for fluids to move into the vasculature from the tissues. and they may also need a longer recovery time. Teach him about the potential signs and symptoms of ARF. Older patients are at higher risk for ARF related to comorbidities. early detection of ARF. Provide emotional support. and other electrolyte levels so you can watch for (and report) any deviation. Highlight the risks from chronic use of NSAIDs and COX-2 inhibitors. You play a key role in prevention and The ins and outs of renal replacement therapy A patient with acute renal failure may rely on one of the following options until normal kidney function returns: • Hemodialysis uses a machine and an artificial kidney to remove excess fluid and waste products from the blood. BUN. and the role of renal replacement therapy (if applicable). Recovery from ARF depends in part on whether the patient has an underlying illness. it rarely causes hypotension. daily weights. and then the blood is returned to the patient. A referral to case management. or other ancillary service can be of great help to the patient and his family. keeping in mind the financial and psychological hardships that may occur as a result of a lengthy recovery. such as edema and weight gain. social services. The blood passes through a porous filter where fluid or solutes are removed. A return to health may take weeks to a year. For optimal recovery. he could develop hypotension from hypovolemia. prevent infection. March/April 2005 Nursing made Incredibly Easy! 25 . an anticoagulant is added. It’s the preferred method when quick removal of water or toxins is indicated and the patient can tolerate the procedure. some patients may not respond well and the disease may progress to chronic renal failure. Also stress the need for regular medical checkups. Driven by the patient’s own blood pressure. and it may have a traumatic impact on the patient and his family. which requires long-term renal replacement therapy. • Continuous arteriovenous hemofiltration is based on a simpler concept. His general health. the patient must regain and maintain a normal fluid and electrolyte balance and must be free of infections or complications. and the degree of nephron damage are important factors in the patient’s recovery. but it doesn’t regulate blood pressure or other renal functions linked to hormonal control. monitor and interpret lab results. Because hemodialysis requires removing a substantial amount of fluid from the patient’s intravascular system. Despite the best care. So is closely monitoring serum creatinine. You’re on the front line of patient care.

This activity is also provider approved by the California Board of Registered Nursing. • No Internet access? Call 1-800-933-6525.Stages of kidney disease Stage 1 2 3 4 5 Glomerular filtration rate (GFR) (ml/min/1. How acute renal failure puts the brakes on kidney function. and therapy. JAMA. Mo. don’t fail me now! Instructions • Read the article beginning on page 18. and Iowa and holds the following provider numbers: AL #ABNP0114.).73 m2) ≥90 60 to 89 30 to 59 15 to 29 ≤15 diabetes and chronic renal insufficiency. Accessed December 27. Mosby. • We offer special discounts for as few as six tests and institutional bulk discounts for multiple tests. • Within 3 to 4 weeks after your CE enrollment form is received. N.. This means that your certificate of earned contact hours is valid no matter where you live. January 2001. Nursing2003. http://www. Minimizing factors that can predispose them to renal failure is essential. January 2003. If you fail. pathogenesis. 6th edition. the primary goals are to quickly restore renal perfusion and manage the underlying pathology. 26 Nursing made Incredibly Easy! March/April 2005 . • Questions? Contact Lippincott Williams & Wilkins: 646-6746617 or 646-674-6621. 76:67-74. and those with low muscle mass. Registration Deadline: April 30. Mayo Clinic Proceedings. such as older individuals with multiple comorbidities. et al. 2003. 6621. IA #75. CERP Category A). et al. Each question has only one correct answer. Schrier RW. • Complete registration information (Section A) and course evaluation (Section C). Nursing management of acute renal failure and chronic kidney disease.. and interference with the effectiveness of ACE-Is. diagnosis. you have the option of taking the test again at no additional cost. • Mail completed test with registration fee to: Lippincott Williams & Wilkins. CE Group. Singri N. • If you pass. Call 1-800-933-6525. It’s showing up in hospitalized patients more often because of an older patient population and an increased survival rate of sicker patients. for other rush service options. July 2004.htm. Acute renal failure: A practical update. 333 7th Ave. Holechek MJ. • A passing score for this test is 11 correct answers. 19th Floor.com for immediate results. 6621. The Journal of Clinical Investigation. 6617 or ext. By recognizing patients who are at increased risk. recording your answers in the test answers section (Section B) of the CE enrollment form on page 42. LWW is also an approved provider of CNE in Alabama. 33(1):59-63. ext. which is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center’s Commission on Accreditation and by the American Association of Critical-Care Nurses (AACN 00012278. FL #FBN2454. 114(1):5-14. 2004. St. If the disease isn’t preventable.. New York. 10001. 289(6):747-751. 6617 or ext. ext.75 from the price of each test. Acute renal failure. et al. worsening hypertension. other CE activities. • Need CE STAT? Visit http://www. Payment and Discounts • The registration fee for this test is $17. et al (ed. you may deduct $0. Campbell D. Inc. Florida.5 contact hours. All of its home study activities are classified for Texas nursing continuing education requirements as Type I. Acute renal failure. • Take the test.com/med/topic1595. and your personalized CE planner tool. • If you take two or more tests in any nursing journal published by LWW and send in your CE enrollment forms together. for more information. Provider Number CEP 11749 for 2.95. you will be notified of your test results. Learn more about it Albright RC. you will receive a certificate of earned contact hours and an answer key. February 2003. Minimizing the risk Acute renal failure is a significant problem. many instances of ARF can be avoided. Mahendra A. Your certificate is valid in all states. Louis.5 contact hours is provided by Lippincott Williams & Wilkins. Acute renal failure: Definitions. Medical Surgical Nursing: Assessment and Management of Clinical Problems. ■ gastrointestinal effects. 2007 Provider Accreditation This Continuing Nursing Education (CNE) activity for 2.Y. patients with chronic illnesses such as CE Test Kidneys. emedicine. Lewis S.nursingcenter.

. b. prerenal ARF. Mrs. except the a. Prerenal failure is caused by a. The classic sign of ARF is urine output of less than a.4 mg/dl on Monday and 1. 400 ml/day. 2. c. mild renal failure. 15. NSAIDs. whose creatinine clearance level was 90 ml/min on Monday and 60 ml/min on Tuesday b. c. the importance of taking nonsteroidal antiinflammatory drugs (NSAIDs) to decrease nephron inflammation. c. C.. severe renal failure. His health care provider would appropriately prescribe a.5 ANCC/AACN CONTACT HOURS Kidneys. decreased blood flow to the kidneys. you need to make sure she knows a. Mrs.. 600 ml/day. whose serum creatinine level was 1. c. 10. c. 4. Renal calculi can cause prerenal failure. hemodialysis. S. you’ll be able to: 1.4 mg/dl on Monday and 1. c. the glomerular filtration rate is between 120 ml/min and 125 ml/min. acute tubular necrosis. Mr. an ACE-I. intrinsic ARF. Mrs. Turn to page 42 for the CE Enrollment Form. patient with chronic angina who’s taking a beta-blocker. b. All of the following patients are at high risk for ARF. Based on the creatinine clearance value. b. a potassium-sparing diuretic. ARF occurs when a. and specific nursing interventions to treat the disease and prevent its development. the signs and symptoms of renal failure. patient with renal calculi. A. c. 5. Mrs. Explain nursing interventions and patient teaching to manage and prevent ARF. there’s a major build-up of RBCs. c.3 mg/dl on Tuesday 8. postrenal ARF. ARF can always be cured with proper drug therapy. The serum blood urea nitrogen level is less accurate than the serum creatinine level as an indicator of renal function. excessive erythropoietin production. b. 800 ml/day. During discharge teaching. the importance of increasing fluid intake to at least 3 L/day. March/April 2005 Nursing made Incredibly Easy! 27 . c. Mrs. electrolyte and acid-base abnormalities. 12.5 mg/dl on Tuesday c. b. Based on the serum creatinine level. 3. c. Ready? Just go with the flow! 14. 3. renal calculi. is recovering from ARF and is ready for discharge.C E 2. O. which of the following patients is most likely to have ARF? a. Accurately assess for risks and manifestations associated with ARF. which of the following patients is most likely to have ARF? a. Which of the following statements is true? a. a contrast medium. Which of the following statements is true? a. half of the nephrons lose their ability to function. Describe recommended treatments for ARF. b. b. collapse of the immune system. Administering aminoglycosides to at-risk patients can prevent ARF. 6. b. its current diagnostic measures and treatments. 7. b. moderate renal failure.. N. renal calculi. 13.1 mg/dl on Tuesday b. b. 2. Acute tubular necrosis can be caused by a. 11. c. b. Daily weights aren’t helpful in monitoring a patient with ARF. Patients with ARF develop a. b. decreased blood flow from shock. c. b. D. Drugs with a renal protective effect include a. M. 1. Mr.. R’s creatinine clearance level is 72 ml/min. trauma patient with severe blood loss. whose serum creatinine level was 1..4 mg/dl on Monday and 2. Mrs. whose creatinine clearance level was 90 ml/min on Monday and 85 ml/min on Tuesday c. whose creatinine clearance level was 90 ml/min on Monday and 95 ml/min on Tuesday 9. whose serum creatinine level was 1. Mr. c. aminoglycosides. don’t fail me now! GENERAL PURPOSE: To identify the risk factors for and manifestations of acute renal failure (ARF). R. is in ARF with severe acid-base imbalance. LEARNING OBJECTIVES: After reading the article and taking this test. The sooner ARF is recognized and treated the less likely that chronic renal failure will occur. Hydronephrosis is an example of a. This lab value is consistent with a. angiotensin-converting enzyme inhibitors (ACE-Is).