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ACUTE KIDNEY INJURY (AKI)

BY

DR I. O. MBAH (MB;BS(Nig), FWACP)

Consultant Nephrologist/ Snr Lecturer Bingham University, JOS, Nig.

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APPRECIATION

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INTRODUCTION

  • AKI has now replaced ARF

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  • A universal defn / staging system proposed
  • Why? To Allow earlier detection / Mx of Kd Inj

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  • This new terminology AKI enables healthcare professsionals to see the dse as a spectrum of injury
  • Which extends from less severe inj to more adv injury when RRT is reqd (ARF)

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HISTORY OF AKI

  • B4 advancement of modern med AKI was ref to as uremic poisoning

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  • Uremia was contamination of blood with urine

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  • 1847 uremia came to be used ↓ in urine output (oliguria)

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  • It was thought to be urine mixing with blood instead of passing thru the ureter / urethra

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ACUTE KIDNEY INJURY

  • Abrupt cessation of renal function
  • Presentation often as unexplained acute uraemic emergencies
  • Several definitions (RIFLE, AKIN) but we prefer the KDIGO definition
  • KIDNEY DISEASE IMPROVING GLOBAL OUTCOMES

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KDIGO AKI DEFINITION

Stage

Serum creatinine

Urine output

1

1.5-1.9 times baseline or >=26.5μmol/L increase

<0.5ml/kg/hr for 6-12 hours

2

2-2.9 times baseline

<0.5ml/kg/hr for >12 hours

3

3.0 times baseline OR

Increase in serum creatinine to >=353.6 µmol/L OR initiation of dialysis

<0.3ml/kg/hr for>24 hours or anuria for >12 hours

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ADQI 2001

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AKIN 2007

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KDIGO Clinical Pract Guideline

  • FXNAL CRITERIA; ↑SCr by 50% within 7days or ↑SCr by 0.3mg/dl (26.5umol/l) within 2days or Oliguria = AKI

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  • STRUCTURAL CRITERIA ---Nil

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EARLY DETECTION

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AETIOPATHOGENESIS

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Pre-Renal, Renal & Post-Renal

  • Before the Kidneys

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  • Intrinsic (Inside the Kidneys)

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  • After the Kidneys

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PRE-RENAL

  • Hypovolemia
  • ↑ Sweating (Hot climate)
  • Xsive Vomiting / Diarrhoea
  • Vasodilation from sepsis
  • Cirrhosis (3rd space loss

Cardiogenic shock

  • CCF, MI, Pericardial tamponade

Haemorrhage, APH, PPH, RTA

Bilateral RAS

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Bilateral RAS

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RENAL

  • AGN
  • AIN (infections)
  • Herbs
  • Drugs (NSAIDs, Gentamycin, Radio-contrast)
  • Malaria
  • Haemolytic crisis
  • Snake bite
  • G6PD Def
  • Illegal abortions, Unsafe deliveries, Crush injury

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Trauma / Crush Injury

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POST-RENAL

  • Obstruction to flow of urine (extrinsic or intrinsic)

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  • Damping back pressure

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  • ↓ GFR

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  • ↑ Accumulation to uremic toxins

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STOOP causes of AKI

  • Sepsis and hypoperfusion
  • Toxicity-drugs and contrast
  • Obstetric
  • Obstruction
  • Parenchymal kidney disease- glomerulonephritis, malignancy

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Clinical Presentation

  • Age (Younger age group)
  • Hx of Risk Factors ( CCF, CLD,DM,APH, PPH, GE, )
  • Use of Nephrotoxic agents (Hg soap, creams, Exposure to Pb in paints
  • Skin rash, Use of Herbs
  • Reduction in urine out put
  • Coke coloured urine
  • Uraemic syndrome (N /V,/D, Hiccups, asterixis etc)

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LABORATORY INVESTIGATION

  • Urine

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  • Blood (FBC, ESR, SEUC, )

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  • ECG

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  • Radiology (USS, CXR, CT, MRI)

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QUICK LAB CHECK

  • URINALYSIS can provide impt clinical info on AKI pts
  • Proteinuria(3+, 4+→ Intrinsic)
  • Haematuria (Intrinsic Glom Dse)
  • Pyuria (AIN,Pyelo,AGN)
  • Crystalluria → Poisoning (oxalate crystals in ethylene glycol, Tumor lysis syndr ARV, Acyclovir, Sulfonamides)
  • Urine Osm, urine/plasma Cr & urea ratios, Urinary Na, FENa, FEurea, Cr Clearance

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TREATMENT

  • ADEQUATE VOL REPLACEMENT ( Use crystalloids instead of colloids)
  • TREAT SEPSIS/ HAEMORRHAGE
  • AVOID/ STOP NEPHROTOXIC AGENTS
  • Olyguria to Non-Oliguria
  • Watch out for Polyuric phase (↑Na +↓ K)
  • Pharm Rx not helpful? (loop diuretic, Dopamine,) BUT
  • Fenoldopam a selective dopamine A-1 receptor agonist

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RRT (Indications : Clinical & Biochemical)

  • Uraemic Syndr
  • Uraemic encephalopathy
  • Uraemic pericarditis
  • Recalcitrant Oedema / HBP
  • Severe Azotaemia
  • Hyperkalemia

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RRT

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Warning sign scores

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TEAM WORK IS IT!

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THANK YOU FOR LISTENING