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Acute Kidney Injury. Do we know what we mean?. Definition of AKI. There are more than 35 definitions of AKI (formerly acute renal failure) in literature!

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acute kidney injury

Acute Kidney Injury

Do we know what we mean?

definition of aki
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; 14:2178-2187.
definition of aki3
Definition of AKI
  • RIFLE classification
  • AKIN classification
rifle classification
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; 8:R204-R212.

akin classification
AKIN classification
  • Modification of the RIFLE classification by Acute Kidney Injury Network (AKIN).
  • Recognizes that small changes in serum creatinine (>0.3 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; 50:712-720.

akin classification6
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.

definition of aki7
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 < 0.5 mL/kg/hr for > 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.

epidemiology
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; 39:930-936.

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; 10:R73.

Osterman M, Chang R: Acute Kidney Injury in the Intensive Care Unit according to RIFLE. Critical Care Medicine 2007; 35:1837-1843.

mortality according to rifle
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; 10:R73.

Chertow G, Levy E, Hammermeister K, et al.: Independent association between acute renal failure and mortality following cardiac surgery. American Journal of Medicine 1998; 104:343-348.

Uchino S, Kellum J, Bellomo R, et al.: Acute renal failure in critically ill patients: A multinational, multicenter study. JAMA 2005; 294:813-818.

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; 50:712-720.

diagnosis
Diagnosis
  • Serum Creatinine
  • Urine Output
  • Time
limitations of scr
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; 38:261-275.

common causes of aki in icu
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; 294:813-818.

common causes of aki in icu13
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; 38:261-275.

nephrotoxins
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; 38:261-275.

prevention of aki in icu
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; 38:261-275.

prevention of contrast induced nephropathy
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; 38:261-275.

prevention of aki in hepatic dysfunction
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; 341:403-409.

Gines P, Tito L, Arroyo V, et al.: Randomised comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis. Gastroenterology 1988; 94:1493-1502.

Gluud L, Kjaer M, Christensen E: Terlipressin for hepatorenal syndrome. Cochrane Database Systematic Reviews 2006; CD005162.

management of aki in icu
Management of AKI in ICU
  • Maintain renal perfusion
  • Correct metabolic derangements
  • Provide adequate nutrition
  • ? Role of diuretics
maintaining renal perfusion
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.

maintaining renal perfusion20
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; 33:780-786.

volume resuscitation which fluid
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.

volume resuscitation how much fluid
Volume resuscitation – how much fluid?
  • Fluid conservative therapy decreased ventilator days and didn’t 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; 354:2564-2575.

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.

which inotrope vasopressor
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; 38:261-275.

renal vasodilators
Renal vasodilators?
  • “Renal” dose dopamine doesn’t 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; 69:1669-1674.

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; 33:1327-1332.

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