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Acute Kidney Injury. Pamela Pride, MD, FHM Cathryn Caton, MD, MS June 5, 2012 MUSC. Objectives. Define Acute Kidney Injury (AKI) Define the significance of AKI in a hospitalized patient Differentiate pre/intra/post renal injury

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Acute kidney injury

Acute Kidney Injury

Pamela Pride, MD, FHM

Cathryn Caton, MD, MS

June 5, 2012

MUSC


Objectives
Objectives

  • Define Acute Kidney Injury (AKI)

  • Define the significance of AKI in a hospitalized patient

  • Differentiate pre/intra/post renal injury

  • Utilize history, physical exam and appropriate diagnostic tests to determine etiology of AKI


Acute kidney injury what is it
Acute Kidney Injury – What is it?

  • An abrupt or rapid decline in renal filtration function

  • Marked by

    • rise in serum creatinine

    • azotemia

  • Patients may be

    • Oliguric

    • Non - oliguric


Importance of aki
Importance of AKI

OR 1.7; 95% CI, 1.2 to 2.6

Green bars unadjusted

Blue Bars age and gender adjusted

Gray bars are multivariable adjusted


Common causes of aki
Common Causes of AKI

OUTPATIENT

INPATIENT

  • ACE-I when vomiting

  • ACE-I + NSAID

  • BPH

  • Stones

  • ATN

    • Sepsis

    • Drugs

  • Contrast

  • Rhabdomyolysis


Approach to a patient with aki
Approach to a Patient with AKI

  • Think three broad categories

    • Pre-renal

    • Intrinsic renal

    • Post-renal


Evaluation of aki
Evaluation of AKI

  • HPI

  • Past Medical History –

    • ?CKD

    • ?DM

    • ?Proteinuria

    • ?HTN

  • Family History

  • Social History –

    • IVDA

    • Hepatitis

    • HIV risks

  • Medications – review all medications

  • Physical Exam


Physical exam
Physical Exam

  • Pre-Renal

    • Orthostatic hypotension

    • Tachycardia

    • Decreased skin turgor

    • Signs of heart failure

  • Post-renal

    • Palpable bladder


Physical exam1
Physical Exam

  • Intrinsic renal

    • ATN – volume overload

    • Glomerulonephritis – variable

    • Vasculitis – purpura

    • Atheroembolic disease – livedoreticularis, blue toes

    • Interstitial nephritis – rash, fever, +/- eos


Laboratory data
Laboratory Data

  • BMP

  • CBC

  • UA

  • Urine sediment – look for muddy brown casts

  • FeNa

  • Renal Ultrasound or Computed tomography


Interpreting fena
Interpreting FeNa

  • Non-pre-renal with low FeNa

    • Contrast

    • Rhabdo

    • Early sepsis

    • Obstruction

    • Acute glomerulonephritis

  • Pre-renal with high FeNa

    • Diuretic use

    • Pre-existing CKD


Pre renal
Pre-Renal

  • Hypoperfusion

  • Hypovolemia

  • Decreased cardiac output

  • Decreased effective circulatory volume

    • CHF

    • Cirrhosis

  • Impaired renal hemodynamics

    • NSAIDs

    • ACE

    • ARB


Intrinsic aki
Intrinsic AKI

  • Essentially ruled out pre-renal, post-renal

  • No good reason for ATN

  • Check complement levels – C3, C4

  • ANCA, antiGBM

  • ANA

  • LDH, haptoglobin – hemolysis, thrombotic microangiopathy


Post renal aki
Post-Renal AKI

  • Obstruction

    • BPH

    • Stone


Interpreting urinary sediment
Interpreting urinary sediment

Granular cast

RBC cast


Interpreting urinary sediment1
Interpreting urinary sediment

Tubular Epithelial Cells

WBC vs Epithelial Cell


Interpreting urinary sediment2
Interpreting urinary sediment

Oval Fat Bodies

WBC Cast


References
References

  • Chertow GM, Burdick E, Honour M, et. Al. Acute Kidney Injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol, 16: 3365-70, 2005.

  • Wald R, Quinn RR, Luo J et. al. Chronic dialysis and death among survivors of acute kidney injury requiring dialysis. JAMA, 302: 1179-85, 2009.

  • Blantz RC. Pathophysiology of pre-renal azotemia. Kidney Int, 53: 512-23, 1998.

  • Friedrich JO, Adhikari N, Herridge MS, et. al. Meta-analysis: low dose dopamine increases urine output but does not prevent renal dysfunction or death. Ann Intern Med, 142: 510-24, 2005

  • Steiner RW: Interpreting the fractional excretion of sodium. Am J Med, 77: 699-702, 1984


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