Nonspecialist Management of Acute Renal Failure What Do I Need To Know

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Non-specialist Management of Acute Renal
FailureWhat Do I Need To Know?

• Dr Paul Stevens
• Consultant Nephrologist
• East Kent Hospitals University Trust

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Acute Renal Failure

• 'The abrupt transition from functioning kidneys
  to kidney function which is unable to accomplish
  biochemical homeostasis'

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RIFLE Criteria

• Risk
• Injury
• Failure
• Loss
• End stage kidney disease

Sarah Palin - Sniper Kitten Making the world a
better place shot by shot
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Acute Kidney Injury Network Criteria
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Pathogenesis
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Sudden causes affecting
Called
Pre-renal
Renal Perfusion
Parenchymatous (intrinsic)
Parenchymal Structures
Induce ?GFR
Urine output
Post-renal
ARF
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Acute Renal Failure
Postrenal ARF
Intrinsic ARF
Prerenal ARF
Acute vascular syndromes
Acute interstitial nephritis
Acute tubular necrosis
Intratubular obstruction
Acute GN
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What Im Not Going to Talk About

• Vasopressors
• Dopamine agonists
• Natriuretic peptides
• Adenosine agonists
• N-acetylcysteine
• Loop diuretics and osmotic diuretics
• Prophylactic dialysis/HF

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What I Am Going to Talk About

• Everyday life in Margate
• Why does it matter?
• Whats important?
• The real world
• Avoiding ARF

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Everyday Life in Margate

• 37 year old man, depressed
• 1 litre of Brandy, 24 paracetamol, 12 Nurofen
  plus at c. 18.00 hrs
• Vomited, fell asleep against a radiator and woke
  up the following morning
• Left leg was uncomfortable on waking and swollen

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Why Does it Matter?

• AKI is commoner than many realise
• Mortality from AKI remains high
• AKI doubles hospital length of stay
• AKI predicts subsequent mortality
• AKI is costly

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ICNARC AKI Length of Stay
Kolhe, Stevens, Crowe et al Critical Care
200812(Suppl 1)S2 (13 October 2008)
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US National Hospital Discharge Survey

• Projected 29,039,599 hospital admissions, 558,032
  coded as ARF (1.92)

Liangos et al. CJASN 2006 Jan1(1)43-51
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The Effect of AKI on Mortality

• 16,248 radiocontrast media procedures
• 183 subjects with contrast-media associated AKI
• 174 paired subjects (age, procedure, baseline Cr)
• Mortality
• 7 in those without renal failure
• 34 in those with renal failure
• After comorbidity adjustment renal failure
  conferred an odds ratio risk of dying of 5.5

Levy, Viscoli Horwitz. JAMA 19962751489-94
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One Year of ARF in East Kent

• 291 patients, 188 male, 103 female
• Mean age at presentation 73.1 years
• Overall incidence 491 pmp/year
• 81 pmp/year received dialysis

Stevens et al, QJ Med 200194553-560

• Survival to discharge from hospital 53
• Survival at 90 days 32
• Survival at 120 months 14
• In those

Kolhe et al, Unpublished data
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Cost per QALY of ICU Severe AKI
Hamel, M. B. et. al. Ann Intern Med
1997127195-202
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Acute Kidney Injury and Costs

• Consecutive sample of 19,982 adults
• In 1237/9210 (13.4) SCr ? by 44 µmol/L
• 6.5x risk of death, 3.5d increased LOS

Unadjusted
Age and gender adjusted
Multivariably adjusted
Chertow et al. JASN 2005163365-3370
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Whats Important?
ADQI 4th Consensus Conference
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Avoiding Acute Kidney Injury

• Recognise and assess the patient at risk
• Avoid nephrotoxic agents
• Maintain effective circulatory volume
• Recognise and treat hypoxia
• Treat infection, avoid nosocomial infection
• Pharmacological manipulation to maintain RBF,
  perfusion pressure and GFR

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The Patient at Risk From AKI
Cardiovascular Health Study observational
community cohort study 5731 patients 65 yr at
baseline, median follow up 10.2 yr
3.9 developing AKI during follow up
Prevalent CVD doubled the risk of AKI
Hazard ratio
Mittalhenkle et al. Clin J AM Soc Nephrol
20083450-456
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UK Demographics

• 60.2 million people
• Mean age 38.8 years
• 4 Asian
• 2 African -caribbean
• Diabetes 4
• Hypertension 12.5
• Coronary HD 3.7
• Stroke 1.8
• Heart failure 0.8

ONS QMAS data 2005/2006/2007
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UK At Risk Population Characteristics
ACE/ARB prescription in those with hypertension
Stevens et al. Kidney Int 2007 Jul72(1)92-9
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Racking Up The Risk
14 healthy elderly aged 67-78 Single dose of oral
Diclofenac (50mg) or placebo With or without
pre-treatment with Enalapril BFZ


GFR (ml/min)

Juhlin et al, Eur J Heart Fail 200571049-1056
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Assessment of ARF
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Key Assessments All Patients
All 3 Key Assessments
2 of 3 Key Assessments
1 of 3 Key Assessments
No Key Assessments
Stevens et al, QJ Med 200194553-560
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Key Assessments Age 70
All 3 Key Assessments
2 of 3 Key Assessments
1 of 3 Key Assessments
No Key Assessments
Stevens et al, QJ Med 200194553-560
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Key Assessments Age All 3 Key Assessments
2 of 3 Key Assessments
1 of 3 Key Assessments
No Key Assessments
Stevens et al, QJ Med 200194553-560
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Community Acquired ARF

• 163/291 ARF present at time of admission
• 45 were associated with intravascular volume
  depletion and/or hypotension
• 28 were associated with obstruction
• 23 were associated with sepsis
• 23 were drug-related

Stevens et al, QJ Med 200194553-560
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Hospital Acquired ARF

• 125/291 ARF developed after admission
• 55 were associated with intravascular volume
  depletion and/or hypotension
• 34 were drug-related
• 29 were associated with sepsis
• 10 were associated with obstruction

Stevens et al, QJ Med 200194553-560
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Potentially Avoidable ARF 101 of 291
Stevens et al, QJ Med 200194553-560
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Definitely Avoidable ARF 54 of 291
Stevens et al, QJ Med 200194553-560
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Primary Instigating Factors for ARF
Vijayan Miller, Seminars in Nephrology
199818523-32
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Drug-related ARF

• Diuretics 99
• ACEI 75
• NSAIDs 61
• Antibiotics 6
• Contrast 5

• ACEI diuretics 46
• NSAIDs diuretics 24
• ACEIs NSAIDs 15
• ACEIs, NSAIDs diuretics 8

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ARF and Volume Loading

• Korean War
• Incidence of ARF 1200
• Vietnam War
• Incidence of ARF 1600

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Acute Kidney Injury Conceptual Model
Adapted from Himmelfarb et al Clin J Am Soc
Nephrol 20083962-967
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Fluid Balance Lesson for Surgeons

• The body is not analogous to a tank into which
  water can be forced until it finally bursts out
  through the kidneys
• Lattimer, Lancet 1945

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Acute Renal Failure and Sepsis

• ARF occurs in
• 19 culture positive in moderate sepsis
• 23 culture positive in severe sepsis
• 51 culture positive in septic shock
• 70 mortality in sepsis
• and ARF combined

Rangel-Frausto et al. JAMA 1995273117-123
Schrier Wang NEJM 2004351159-69
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ARF in East Kent Initial Assessments
Stevens et al, QJ Med 200194553-560
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Assessment and monitoring physiological
observations

• Initial assessment should include at least
• heart rate
• respiratory rate
• systolic blood pressure
• level of consciousness
• oxygen saturation
• temperature.

Acutely ill patients in hospital NICE clinical
guideline 50
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Change in BP Before Nosocomial AKI

• Non-critically ill patients developing nosocomial
  AKI in hospital
• Exclusions included ICU patients, absolute
  hypotension, renal Tx, AKI within 3 days of
  admission
• Changes in BP prior to maximum stage of AKI
  assessed

mmHg
?SBP
?DBP
SBP
DBP

Liu YL et al. Nephrol Dial Transplant NDT
advance access 3 September 2008
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Avoiding Acute Renal Failure

• Recognise and assess the patient at risk
• Avoid nephrotoxic agents
• Maintain effective circulatory volume
• Recognise and treat hypoxia
• Treat infection, avoid nosocomial infection
• Pharmacological manipulation to maintain RBF,
  perfusion pressure and GFR

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Margate London-By-The-Sea
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Everyday Life in Margate

• Presented to AE 10.30 a.m. seen by Orthopaedic
  SHO, admitted, NBM in case of theatre, Voltarol
  analgesia
• Muddy brown urine (once)
• Reviewed at 18.40 hrs
• Tachycardic, lying BP of 130/80
• Unable to move his left leg, left KJ AJ were
  absent
• Medical SHO called

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Everyday Life in Margate

• Treated with Parvolex, bloods sent
• Results
• Na 138, K 5.2, Urea 19.1, Creatinine 280, Alb 40,
  AST 1738. Clotting was normal, FBC showed WCC
  20.9 (19.3N), Hb 17.8, Plt 247. Paracetamol and
  aspirin levels were below toxic levels
• Medical registrar reviewed him at 23.15 and noted
  severe oedema in the left thigh, sensory and
  motor loss in the left leg and muscle
  fasciculation

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Per Ardua Ad Urinam

• Acknowledgements
• Dr N A Tamimi
• Dr M K Al Hasani
• Dr D I Prosser
• Dr P Carmichael
• Dr N Kohle
• Dr B Klebe