Download
acute kidney injury n.
Skip this Video
Loading SlideShow in 5 Seconds..
Acute Kidney Injury PowerPoint Presentation
Download Presentation
Acute Kidney Injury

Acute Kidney Injury

247 Views Download Presentation
Download Presentation

Acute Kidney Injury

- - - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript

  1. Acute Kidney Injury Dr Andrew Lewington Consultant Renal Physician/Honorary Clinical Associate Professor Leeds Teaching Hospitals

  2. What is AKI?

  3. Functions of the Kidney maintenance of body composition osmolality, electrolyte content, acidity excretion of metabolic end products urea, drugs secretion of erythropoietin maturation of erythrocytes secretion of activated form of vitamin D3 calcium and phosphate balance renin secretion angiotensinogen→angiotensin I

  4. Stage 1 eGFR ≥ 90 • Kidney damage, normal or increased GFR • Stage 2 eGFR 60-89 • Kidney damage, mildly reduced GFR • Stage 3A eGFR 45-59 • Moderately reduced GFR ± other evidence of kidney damage • GFR < 60 ml/min for ≥ 3 months ± kidney damage • Stage 3B eGFR30-44 • Stage 4 eGFR 15-29 • Severely reduced GFR ± other evidence of kidney damage • Stage 5 eGFR< 15 • Established kidney failure • Kidney damage (presence of structural abnormalities and/or persistent haematuria, proteinuria or microalbuminuria) for ≥ 3 months Stages of CKD

  5. The UK eCKD Guide - Renal

  6. What is Acute Kidney Injury?

  7. Acute Kidney Injury Term encompasses all forms of AKI rapid reduction in kidney function occurs over hours to days no specific symptoms exception – stones failure to regulate fluid and electrolyte balance acid/base balance failure to excrete some drugs

  8. Acute Kidney Injury • Most commonly associated with acute illness (hypoperfusion) • recovery usual if patient recovers from primary cause • severe AKI may progress to chronic kidney disease • Rarer forms • require rapid recognition for specific therapy

  9. Increased mortality associated with changes inserumcreatinine Chertow et al: JASN 2005

  10. New Definitionswww.renal.org

  11. Definition of AKI – Kidney Disease Improving Global Outcomes • Serum creatinine rise ≥26 µmol/L within 48 hours or • Serum creatinine rise ≥1.5 fold from the baseline value, which is known or presumed to have occurred within one week or • Urine output is <0.5 mL/kg/hr for >6 consecutive hours

  12. AKI Staging – KDIGO

  13. Epidemiology

  14. Epidemiology • based on old definitions • 5% of hospital admissions • 30% of ICU admissions • based on new definitions • 18% of hospital admissions • 30-80% of ICU admissions

  15. Aetiology

  16. Aetiology • essential to establish aetiology • aetiology determines treatment • not all AKI is secondary to ischaemia /reperfusion injury • important to identify rarer causes

  17. AKI is a Syndrome Pre-renal AKI • Sepsis • Hypovolemia Intrinsic AKI • Acute tubular injury • Tubulointerstitial injury • Glomerulonephritis • Vasculitis Post-renal AKI • Kidney stones • Prostatic hypertrophy • Retroperitoneal fibrosis

  18. Clinical Presentation of AKI

  19. Clinical Presentation of AKI • Risk factors for AKI (some) • chronic kidney disease • cardiac failure • peripheral vascular disease • diabetes mellitus (with proteinuria) • liver disease • myeloma

  20. Clinical Presentation • poor fluid intake • nausea, vomiting • ↓ functional capacity • excessive fluid losses • fever • diuretics • diarrhoea • high stoma output • haemorrhage • burns

  21. Clinical Presentation • drug history • nephrotoxic drugs • radiocontrast media • urinary tract symptoms • prostatic disease • renal calculi

  22. Clinical Presentation • volume status • core temperature • heart rate • JVP • postural hypotension • cardiovascular status • peripheral perfusion • BP • heart rate and rhythm

  23. Clinical Presentation • palpable bladder • prostatic hypertrophy • carcinoma of cervix • bruits/absent pulses • renovascular disease • rash • vasculitis • interstitial nephritis

  24. Complications

  25. Complications of AKI • metabolic • hyperkalaemia • cardiovascular • pulmonary oedema, arrhythmias, pericarditis • gastrointestinal • nausea, vomiting, gastritis, ulceration, malnutrition

  26. Complications of AKI • neurological • seizures, mental status changes • infectious • haematological • anaemia, bleeding

  27. Investigations

  28. Investigations • Full Blood Count and clotting • U&Es and bicarbonate (previous renal function) • Liver Function Tests and bone • urinalysis (prior to urinary catheter) • immunological screen – if vasculitis suspected

  29. Investigations • ultrasound of renal tract within 24hrs if • obstruction suspected • isoteric cause suspected requiring a kidney biopsy • consider blood film, LDH • (if ↓ Hb and ↓ Pl) • consider creatine kinase • (rhabdomyolysis)

  30. Management

  31. No Specific Therapy For Most Forms of AKI

  32. Prevention of AKI is Essential • Risk of complications • increased length of stay • increased mortality • chronic kidney disease • Cost • £1.2 Billion

  33. Prevention • identify risk factors • > 75 years • pre-existing chronic kidney disease • vascular disease • diabetes mellitus (with proteinuria) • cardiac failure • hypovolaemia • sepsis • nephrotoxins • drugs • contrast media

  34. Prevention • treat sepsis promptly • optomise volume status • stop/avoid • nephrotoxic medications • minimise volume of contrast

  35. Treatment

  36. Treatment of AKI dependent upon the cause • supportive therapy • stabilise haemodynamics • treat complications • renal replacement therapy - dialysis • avoid further renal insults • nephrotoxins • Hypotension • Hold antihypertensives/diuretics

  37. Treatment of AKI • specific therapy • e.g. vasculitis – • Immunosuppression • If suspected – refer immediately

  38. How Good Are We at Caring for Patients with AKI in the UK?

  39. June 11, 2009 Royal Society of Medicine London

  40. Key findings < 50% of AKI care considered good poorassessment of risk factors 43% of post-admission AKI - unacceptable delay in recognition

  41. What is the relevance of AKI to the GP?

  42. Patients with c-AKI sustain more severe AKI than h-AKI • Patients with c-AKI have better short term and long term outcomes than h-AKI

  43. The Context:Addressing vulnerability & Transforming Urgent Care • Provide better support for people to self-care Self-treatment options & care plan to know what to do and who to contact when deterioration • Help people with urgent care needs get right advice in right place, first time • Highly responsive urgent care services outside hospital • People with serious and life threatening emergency care needs receive treatment in centres with facilities and expertise • Connect all urgent and emergency care services

  44. Acute kidney injury: prevention, detection and management up to the point of renal replacement therapy (CG169) • Guidance from the National Institute for Health and Care Excellence • August 2013 • Dr Andy Lewington • Leeds Teaching Hospitals

  45. NICE AKI Guideline • stresses the importance of risk assessment and prevention, early recognition and treatment • it is primarily aimed at the non-specialist clinician, who will care for most patients with AKI in a variety of settings • in view of its frequency and mortality rate, prevention or amelioration of just 20% of cases of AKI would prevent a large number of deaths and substantially reduce complications and their associated costs

  46. NICE AKI Guidelines Rajib Pal (expert adviser) GP Principal, Hall Green Health, West Midlands