Acute Kidney Injury tAKIng the piss

1. Acute Kidney InjurytAKIng the piss Evie Donna Ricky, Frederique Brigham, Francis Collett-White, Jessica Bell, Luke Simonds, Michael Brittain, Sam Cook, Sarah Garthwaite.

2. CASE: 1

3. Retired Postman 81 PC: Diarrhoea & Vomiting 10/7 Bilateral leg swelling PMHx: Ischaemic Heart Disease (IHD) Type II Diabetes Mellitus PolyarteritisNodosa (PAN) COPD DVT &PE Dx: Salbutamol Beclomethasone Prednisolone Furosemide O/E: HR: 108 bpm RR: 18 bpm BP: 120/75 JVP: ↑ Chest: Some base crackles, slight wheeze. Bilateral tender pitting oedema to the knees and ecchymosis to anterior shins. Urine output <400ml over 24 hours. (Catheterised)

4. Test Results FBC and U&E Hb 9.4 ↓ K 7.7 ↑ Urea 20.6 ↑ Creatinine 238 ↑ (Baseline 128) Albumin 30 ↓ ABG pH 7.31 ↓ Base Excess - 4.0↓ Lactate 1.7 ↑ HCO₃ 20.5 ↓ CRP 127 ↑ PT 16.2 ↑

5. Investigations • ECG: Sinus tachycardia (poor quality) • CXR: Hyperinflated lungs, nil focal, calcification of aortic arch • ECHO: Normal for age, with evidence of slight TR, MR and mildly thickened AV leaflets. PAP of 34 mmHg. • US: Normal • URINE DIPSTICK: Proteinuria

6. Differential Diagnosis • PolyarteritisNodosa • Hypovolaemia • Congestive Cardiac Failure • Urinary obstruction • Renal vein thrombosis

7. AKI secondary to hypovolaemia • Definition of Hypovolaemia: A diminished volume of circulating blood, caused by: • Blood loss • Dehydration from D&V, burns, decreased fluid intake. • Drugs: diuretics, vasodilators • Hypovolaemia causes Acute Tubular Necrosis due to Ischemic injury. • Common in the elderly, particularly those admitted to hospital! Stop presciribing drugs in those at risk, maintain a good fluid balance.

8. But why is there oedema in this hypovolaemic patient? PAN and nephrotic syndrome cause leaking of fluid into extravascular spaces even when a patient is hypovolaemic. Why is this patients JVP still raised even though he is hypovolaemic? It is due to Tricuspid Regurgitation. What part does PAN have to play in this patients diagnosis? PAN causes leaking and inflammation of medium sized vessels, which results in swelling and reduced blood flow to the kidneys, exacerbating the ischaemia.

9. CASE: 2

10. 22 Chinese Student • Haematuria PC: 3/7 Sore Throat and Fever 1/7 Macroscopic Haematuria with left flank pain HxPC: Recurrent Haematuria every summer in China for the last two years FHx: Grandma and Aunt – Recurrent Haematuria O/E: No abnormalities on examination Urine dipstick: Blood +++ Protein ++

11. Differential Diagnosis • Neoplasia • Glomerular Nephritis • Tubulointerstitial Nephritis • Polycystic Kidney Disease • Infection • Trauma

12. IgA Nephropathy – aka Berger’s Disease IgA deposits in the glomerular mesangium. Immunofluorescence scan for IgA in the glomerulus It typically presents as recurrent haematuria (macroscopic or microscopic), and proteinuria after an upper respiratory tract infection. IgAN may cause no loss of renal function (5-30%), however end stage renal failure, ESRF, develops in 25% after 20 years.

13. IgA Nephropathy Demographics IgAN is a rare disease but the commonest cause of GN worldwide. The typical patient is 28 year old (mean age) man (2♂ :1♀) from south Asia or southern Europe with a family history of IgAN. Treatment Nothing ACE-i and ARB Tonsillectomy, steroid therapy and fish oil. If the patient presents with rapidly falling renal function (RPGN) steroids, cytotoxic drugs and plasmapherisis is given

14. CASE: 3

15. 77 Afro-carribbean ethnicity PC: Suprapubic pain Lower abdominal fullness HxPC: Urinary retention Dysuria Haematuria PMHx : Schizophrenia Dx: Olanzapine Procyclidine Depoxil O/E: Tender lower abdomen PR – Small, smooth non-nodular prostate

16. Investigations & Results Urine dipstick: ++ blood + protein Bloods: Urea 9.8 mmol/L ↑ (2.7 – 7.5) Cr 232 µmol/L ↑ (50 – 150) Baseline 158 µmol/L eGFR 23.8 ml/min ↓ (>90) Others: PSA 1.6 ng/ml (0-4) Cholesterol 6.8 mmol/L (<5) MSU negative

17. Differential Diagnosis Renal USS Markedly distended bladder Bilateral hydronephrosis Cystoscopy Proximal urethral stricture Urinary tract infection Bladder tumour Prostatitis Benign prostatic hyperplasia His drugs (anticholinergics, antipsychotics)

18. Diagnosis and Explanation Prostate moderately enlarged & indenting bladder base • Benign Prostatic hyperplasia • Causes • Age • Androgens, growth factors • Presentation • Hesitancy • Frequency • Nocturia • Complications • Infections • Bladder stones • Hydronephrosis

19. Management Choices include: • Long term indwelling catheter • Intermittent Self Catheterization • Transurethral Resection of the Prostate (TURP)

20. What happened next? • 10 days self catheterization • Haematuria • Multiple blockages in the catheter • Infections • Proteus sensitive to Amoxicilin, co-amoxiclav and cephalexin Management: • Emergency catheterization • Antibiotics • TURP

21. Diagnosis, Management and Treatment of AKI

22. Diagnosis History and exam Dipstick urine and MSU Routine bloods Extra bloods – bicarbonate, CK, CRP, blood cultures ECG CXR Renal USS Immunology screen Renal USS & biopsy

23. Management • Treat/remove the cause or exacerbating factors: • Prerenal • Intrinsic • Postrenal

24. Treat the complications • Hyperkalaemia • Look for ECG changes – Give calcium gluconate • Insulin + dextrose • Salbutamol nebs • Correct fluid balance • Pulmonary oedema • SOD Off

25. Indications for Renal Replacement Therapy Refractory hyperkalemia >7mmol/L Serious fluid overload (Refractory pulmonary oedema) Established oliguria Serious complications of uraemia (encephalopathy, pericarditis) Refractory acidosis – pH <7.2

26. References • Patient.co.uk • Medicinenet.com • Accuracy of prostate weight estimation by digital rectal examination versus transrectalultrasonography. J Urol. 2005 Jan;173(1):63-5. • IgA nephropathy – Chapter 277 Harrison’s Principles of Internal Medicine 17th edition • Dr Wright’s wonderful lecture on AKI – “It’s like Love”

27. Thank you