acute kidney injury
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Acute Kidney Injury

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. 49 year old man was a single vehicle MVC in which he was ejected. His injuries include:Left temporal epidural hematomaLeft hemo/pneumothoraxLiver lacerationBilateral open compound femur fracturesHe is brought to the ICU postop after an urgent craniotomy for the epidural.A chest tube is in p

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49 year old man was a single vehicle MVC in which he was ejected. His injuries include:
    • Left temporal epidural hematoma
    • Left hemo/pneumothorax
    • Liver laceration
    • Bilateral open compound femur fractures
  • He is brought to the ICU postop after an urgent craniotomy for the epidural.
  • A chest tube is in place but the fractures are only splinted.
6 hours after admission, the nurse calls because the urine output has fallen.
  • On assessment, he is sedated and intubated with both legs in traction.
  • He is hemodynamically stable, BP 168/86, pulse 96, no vasopressors and afebrile.
  • There is about 200 mL of dark urine in the foley bag (emptied upon arrival to ICU).
Is there a problem with the urine output?
  • The patient weighs about 75 kg and is known to have some renal insufficiency with a baseline creatinine of 200. Creatinine on admission was 305.
  • Is there a problem with the urine output?
RIFLE Criteria
    • Risk
      • 1.5X increase in creatinine or UO < 0.5 ml/kg for 6 hours
    • Injury
      • 2X increase in creatinine or UO < 0.5 ml/kg for 12 hours
    • Failure
      • 3X increase in creatinine or UO < 0.5 ml/kg for 24 hours or anuria for 12 hours
    • Loss
      • Complete loss of function for more than 4 weeks
    • ESRD
      • Complete loss of function for more than 3 months
Where is the patient in the RIFLE criteria?
  • List some possible causes for the renal dysfunction in this case.
    • Volume depletion
    • Radiocontrast dye
    • Myoglobinuria
    • Acute on chronic renal insufficiency
Categorize the different causes of acute renal insufficiency.
    • Prerenal: volume depletion and relative hypotension
    • Vascular: Consider vasculitis, TTP, nephrosclerosis, renal artery stenosis
    • Glomerular: Consider the nephritic and nephrotic syndromes
    • Tubular/interstitial: Consider ATN, drugs, PCKD, myeloma, autoimmune disorders
    • Obstructive: Consider prostate disease, stones, metastatic cancer
What are the most likely causes in hospitalized patients?
    • ATN (45%)
    • Prerenal (21%)
    • Acute on chronic kidney disease (13%)
    • Obstruction (10%)
    • Glomerulonephritis or vasculitis (4%)
    • Acute interstitial nephritis (2%)
    • Atheroemboli (1%)
6 hours later, the patient’s urine output has been a total of 350 mL since admission. The creatinine has risen to 455.
  • What RIFLE criteria is the patient now?
  • What investigations could be ordered to identify the cause of the acute kidney injury?
  • What are the implications on morbidity and mortality when renal failure occurs in the ICU?
The urine sodium is 125 mmol/L, urine osmolarity is 247 mOsm/L, serum osmolality is 315 mOsm/L, CK 98035, and urine myoglobin 15035.
  • It is now 24 hours since admission and there has only been another 100 mL of urine with no urine for the last 12 hours.
  • What is the RIFLE criteria now?
What treatments could have been started to mitigate the development of acute kidney failure?
  • What are the indications for renal replacement therapy in the critical care setting?
  • How do you choose between continuous versus intermittent hemodialysis?
After inserting a femoral dialysis catheter, the patient is started on hemodialysis.
  • He is currently has a MAP of 65 requiring levophed 12 ug/min with a FiO2 of 85% (increased since starting fluid boluses.
  • Will this patient tolerate an intermittent run of dialysis? Why or why not?
  • How does hemodialysis work?