Acute kidney injury l.jpg
This presentation is the property of its rightful owner.
Sponsored Links
1 / 33

Acute Kidney Injury PowerPoint PPT Presentation


  • 200 Views
  • Uploaded on
  • Presentation posted in: General

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!

Download Presentation

Acute Kidney Injury

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Acute kidney injury l.jpg

Acute Kidney Injury

Do we know what we mean?


Definition of aki l.jpg

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 l.jpg

Definition of AKI

  • RIFLE classification

  • AKIN classification


Rifle classification l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

Diagnosis

  • Serum Creatinine

  • Urine Output

  • Time


Limitations of scr l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

Management of AKI in ICU

  • Maintain renal perfusion

  • Correct metabolic derangements

  • Provide adequate nutrition

  • ? Role of diuretics


Maintaining renal perfusion l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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.


Avoid hyperglycemia l.jpg

Avoid hyperglycemia


Correction of acidosis l.jpg

Correction of acidosis?


Any role for diuretics l.jpg

Any role for diuretics?


Avoid nephrotoxins l.jpg

Avoid nephrotoxins


Nutrition l.jpg

Nutrition


Renal replacement therapy l.jpg

Renal replacement therapy


Timing of rrt l.jpg

Timing of RRT


Dosing of rrt l.jpg

Dosing of RRT


Modality of rrt l.jpg

Modality of RRT


  • Login