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Acute Kidney Injury

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Do we know what we mean? There are more than 35 definitions of AKI (formerly acute renal failure) in literature! Mehta R, Chertow G: Acute renal failure definitions ... – PowerPoint PPT presentation

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Title: Acute Kidney Injury


1
Acute Kidney Injury
  • Do we know what we mean?

2
Definition of AKI
  • There are more than 35 definitions of AKI
    (formerly acute renal failure) in literature!
  • Mehta R, Chertow G Acute renal failure
    definitions and classification Time for change?
    Journal of American Society of Nephrology 2003
    142178-2187.

3
Definition of AKI
  • RIFLE classification
  • AKIN classification

4
RIFLE classification
  • Bellomo R, Ronco C, Kellum J, et al. Acute
    renal failure-definition, outcome measures,
    animal models, fluid therapy and information
    technology needs The Second International
    Consensus Conference of the Acute Dialysis
    Initiative (ADQI) Group. Critical Care 2004
    8R204-R212.

5
AKIN classification
  • Modification of the RIFLE classification by Acute
    Kidney Injury Network (AKIN).
  • Recognizes that small changes in serum creatinine
    (gt0.3 mg/dl) adversely impact clinical outcome.
  • Uses serum creatinine, urinary output and time.
  • Coca S, Peixoto A, Garg A, et al. The
    prognostic importance of a small acute decrement
    in kidney function in hospitalized patients a
    systematic review and meta-analysis. American
    Journal of Kidney Diseases 2007 50712-720.

6
AKIN classification
Patients needing RRT are classified stage 3
despite the stage they were before starting
RRT Mehta R, Kellum J, Shah S, et al. Acute
kidney Injury Network Report of an Initiative to
improve outcomes in Acute Kidney
Injury. Critical Care 2007 11 R31.
7
Definition of AKI
  • AKI is an abrupt (within 48 hrs) reduction in
    kidney function currently defined as an absolute
    increase in serum creatinine of 0.3 mg/dL (
    26.4 µmol/L), a percentage increase in serum
    creatinine of 50, or a reduction in urine
    output (documented oliguria of lt 0.5 mL/kg/hr for
    gt 6hrs.
  • Mehta R, Kellum J, Shah S, et al. Acute kidney
    Injury Network Report of an Initiative to
    improve outcomes in Acute Kidney Injury.
    Critical Care 2007 11 R31.

8
Epidemiology
  • AKI occurs in
  • 7 of hospitalized patients.
  • 36 67 of critically ill patients (depending on
    the definition).
  • 5-6 of ICU patients with AKI require RRT.
  • Nash K, Hafeez A, Hou S Hospital-acquired renal
    insufficiency. American Journal of Kidney
    Diseases 2002 39930-936.
  • Hoste E, Clermont G, Kersten A, et al. RIFLE
    criteria for acute kidney injury are associated
    with hospital mortality in critically ill
    patients A cohort analysis. Critical Care 2006
    10R73.
  • Osterman M, Chang R Acute Kidney Injury in the
    Intensive Care Unit according to RIFLE. Critical
    Care Medicine 2007 351837-1843.

9
Mortality according to RIFLE
  • Mortality increases proportionately with
    increasing severity of AKI (using RIFLE).
  • AKI requiring RRT is an independent risk factor
    for in-hospital mortality.
  • Mortality in pts with AKI requiring RRT 50-70.
  • Even small changes in serum creatinine are
    associated with increased mortality.
  • Hoste E, Clermont G, Kersten A, et al. RIFLE
    criteria for acute kidney injury are associated
    with hospital mortality in critically ill
    patients A cohort analysis. Critical Care 2006
    10R73.
  • Chertow G, Levy E, Hammermeister K, et al.
    Independent association between acute renal
    failure and mortality following cardiac surgery.
    American Journal of Medicine 1998 104343-348.
  • Uchino S, Kellum J, Bellomo R, et al. Acute
    renal failure in critically ill patients A
    multinational, multicenter study. JAMA 2005
    294813-818.
  • Coca S, Peixoto A, Garg A, et al. The
    prognostic importance of a small acute decrement
    in kidney function in hospitalized patients a
    systematic review and meta-analysis. American
    Journal of Kidney Diseases 2007 50712-720.

10
Diagnosis
  • Serum Creatinine
  • Urine Output
  • Time

11
Limitations of SCr
Dennen P, Douglas I, Anderson R, Acute Kidney
Injury in the Intensive Care Unit An update and
primer for the Intensivist. Critical Care
Medicine 2010 38261-275.
12
Common causes of AKI in ICU
  • Sepsis
  • Major surgery
  • Low cardiac output
  • Hypovolemia
  • Medications (20)
  • Uchino S, Kellum J, Bellomo R, et al. Acute
    renal failure in critically ill patients A
    multinational, multicenter study. JAMA 2005
    294813-818.

13
Common causes of AKI in ICU
  • Hepatorenal syndrome
  • Trauma
  • Cardiopulmonary bypass
  • Abdominal compartment syndrome
  • Rhabdomyolysis
  • Obstruction
  • Dennen P, Douglas I, Anderson R, Acute Kidney
    Injury in the Intensive Care Unit An update and
    primer for the Intensivist. Critical Care
    Medicine 2010 38261-275.

14
Nephrotoxins
  • NSAIDs
  • Aminoglycosides
  • Amphotericin
  • Penicillins
  • Acyclovir
  • Cytotoxics
  • Radiocontrast dye
  • Dennen P, Douglas I, Anderson R, Acute Kidney
    Injury in the Intensive Care Unit An update and
    primer for the Intensivist. Critical Care
    Medicine 2010 38261-275.

15
Prevention of AKI in ICU
  • Recognition of underlying risk factors
  • Diabetes
  • CKD
  • Age
  • HTN
  • Cardiac/liver dysfunction
  • Maintenance of renal perfusion
  • Avoidance of hyperglycemia
  • Avoidance of nephrotoxins
  • Dennen P, Douglas I, Anderson R, Acute Kidney
    Injury in the Intensive Care Unit An update and
    primer for the Intensivist. Critical Care
    Medicine 2010 38261-275.

16
Prevention of Contrast-Induced Nephropathy
  • Avoid use of intravenous contrast in high risk
    patients if at all possible.
  • Use pre-procedure volume expansion using isotonic
    saline (?bicarbonate).
  • NAC
  • Avoid concomitant use of nephrotoxic medications
    if possible.
  • Use low volume low- or iso-osmolar contrast
  • Dennen P, Douglas I, Anderson R, Acute Kidney
    Injury in the Intensive Care Unit An update and
    primer for the Intensivist. Critical Care
    Medicine 2010 38261-275.

17
Prevention of AKI in hepatic dysfunction
  • Intravenous albumin significantly reduces the
    incidence of AKI and mortality in patients with
    cirrhosis and SBP.
  • Albumin decreases the incidence of AKI after
    large volume paracentesis.
  • Albumin and terlipressin decrease mortality in
    HRS.
  • Sort P, Navasa M, Arroyo V, et al. Effect of
    intravenous albumin on renal impairment and
    mortality in patients with cirrhosis and
    spontaneous bacterial peritonitis. New England
    Journal of Medicine 1999 341403-409.
  • Gines P, Tito L, Arroyo V, et al. Randomised
    comparative study of therapeutic paracentesis
    with and without intravenous albumin in
    cirrhosis. Gastroenterology 1988 941493-1502.
  • Gluud L, Kjaer M, Christensen E Terlipressin
    for hepatorenal syndrome. Cochrane Database
    Systematic Reviews 2006 CD005162.

18
Management of AKI in ICU
  • Maintain renal perfusion
  • Correct metabolic derangements
  • Provide adequate nutrition
  • ? Role of diuretics

19
Maintaining renal perfusion
  • Human kidney has a compromised ability to
    autoregulate in AKI.
  • Maintaining haemodynamic stability and avoiding
    volume depletion are a priority in AKI.
  • Kelleher S, Robinette J, Conger J Sympathetic
    nervous system in the loss of autoregulation in
    acute renal failure. American Journal of
    Physiology 1984 246 F379-386.

20
Maintaining renal perfusion
  • Current studies do not include patients with
    established AKI.
  • The individual BP target depends on age,
    co-morbidities (HTN) and the current acute
    illness.
  • A generally accepted target remains MAP 65.
  • Bourgoin A, Leone M, Delmas A, et al.
    Increasing mean arterial pressure in patients
    with septic shock Effects on oxygen variables
    and renal function. Critical Care Medicine 2005
    33780-786.

21
Volume resuscitation which fluid?
  • SAFE study no statistical difference between
    volume resuscitation with saline or albumin in
    survival rates or need for RRT.
  • Post hoc analysis albumin was associated with
    increased mortality in traumatic brain injury
    subgroup and improved survival in septic shock
    patients.
  • Finfer S, Bellomo R, Boyce N, et al. A
    comparison of albumin and saline for fluid
    resuscitation in the intensive care unit. New
    England Journal of Medicine 2004 350 2247-2256.

22
Volume resuscitation how much fluid?
  • Fluid conservative therapy decreased ventilator
    days and didnt increase the need for RRT in ARDS
    patients.
  • Association between positive fluid balance and
    increased mortality in AKI patients.
  • Wiedeman H, Wheeler A, Bernard G, et al.
    Comparison of two fluid management strategies in
    acute lung injury. New England Journal of
    Medicine 2006 3542564-2575.
  • Payen D, de Pont A, Sakr Y, et al. A positive
    fluid balance is associated with worse outcome in
    patients with acute renal failure. Critical Care
    2008 12 R74.

23
Which inotrope/vasopressor?
  • There is no evidence that from a renal protection
    standpoint, there is a vasopressor agent of
    choice to improve kidney outcome.
  • Dennen P, Douglas I, Anderson R, Acute Kidney
    Injury in the Intensive Care Unit An update and
    primer for the Intensivist. Critical Care
    Medicine 2010 38261-275.

24
Renal vasodilators?
  • Renal dose dopamine doesnt reduce the
    incidence of AKI, the need for RRT or improve
    outcomes in AKI.
  • It may worsen renal perfusion in critically ill
    adults with AKI.
  • Side effects of dopamine include increased
    myocardial oxygen demand, increased incidence of
    atrial fibrillation and negative
    immuno-modulating effects.
  • Lauschke A, Teichgraber U, Frei U, et al.
    Low-dose dopamine worsens renal perfusion in
    patients with acute renal failure. Kidney 2006
    691669-1674.
  • Argalious M, Motta P, Khandwala F, et al.
    Renal dose dopamine is associated with the risk
    of new onset atrial fibrillation after cardiac
    surgery. Critical Care Medicine 2005
    331327-1332.

25
Avoid hyperglycemia
26
Correction of acidosis?
27
Any role for diuretics?
28
Avoid nephrotoxins
29
Nutrition
30
Renal replacement therapy
31
Timing of RRT
32
Dosing of RRT
33
Modality of RRT
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