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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 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.


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Definition of AKI

  • RIFLE classification

  • AKIN classification


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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.


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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.


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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.


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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.


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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.


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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.


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Diagnosis

  • Serum Creatinine

  • Urine Output

  • Time


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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.


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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.


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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.


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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.


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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.


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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.


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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.


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Management of AKI in ICU

  • Maintain renal perfusion

  • Correct metabolic derangements

  • Provide adequate nutrition

  • ? Role of diuretics


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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.


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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.


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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.


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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.


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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.


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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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Avoid nephrotoxins







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