1 / 65

Acute Kidney Injury

Acute Kidney Injury. Outline: Acute Kidney Injury. Anatomy Epidemiology Mortality & Cost Diagnosis, Assessment, & Management Treatment Limitations and Unmet Clinical Needs. Anatomy. Renal System Anatomy.

jasminc
Télécharger la présentation

Acute Kidney Injury

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Acute Kidney Injury

  2. Outline: Acute Kidney Injury • Anatomy • Epidemiology • Mortality & Cost • Diagnosis, Assessment, & Management • Treatment • Limitations and Unmet Clinical Needs

  3. Anatomy

  4. Renal System Anatomy • The urinary tract consists of kidneys, adrenal glands, ureters, bladder, urethra and all associated blood vessels. • Kidneys are often donated. • It is not uncommon for an individual to be able to live without one kidney. ADRENAL GLANDS KIDNEYS URETERS BLADDER 4 URETHRA

  5. Kidney Anatomy • The kidney is supplied with blood by the renal artery. CORTEX • Each renal artery branches and eventually the blood feeds into the medulla and the nephrons, or functional units of the kidney. RENAL MEDULLA RENAL ARTERY RENAL VEIN RENAL PELVIS URETER 5

  6. Nephron • A tubular structure called the nephron filters blood to form urine. URINE FORMATION Blood Flow • The glomerulus is a group of capillaries that perform the first step of filtering blood. Efferent Arteriole Afferent Arteriole FILTRATION • A glomerulus and its surrounding Bowman's capsule constitute a renal corpuscle, the basic filtration unit of the kidney. Glomerulus Renal Corpuscle REABSORPTION Solutes and Waste NEPHRON • Blood is filtered through the glomerulus into the Bowman's capsule which empties into a tubule that is also part of the nephron. SECRETION Additional Waste Renal Tubule EXCRETION

  7. Epidemiology

  8. Acute Kidney Injury Mehta RL, Kellum JA, Shah SV et al. Crit Care. 2007;11(2):R31. • Acute kidney injury (AKI) is a rapid loss of kidney function including: • Rapid time course (less than 48 hours) • Rise in serum creatinine • Reduction in urine output (oliguria)

  9. Number of AKI Hospitalizations: 1979 to 2002 45,000,000 700,000 40,000,000 600,000 35,000,000 500,000 30,000,000 400,000 25,000,000 20,000,000 300,000 15,000,000 200,000 10,000,000 100,000 5,000,000 0 0 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 1980 1982 All Hospitalizations AKI National Center for Health Statistics, National Hospital Discharge Survey.Centers for Disease Control and Prevention.

  10. A Dramatic Rise in Kidney Injury 60 50 40 30 20 10 0 Total (all types) Chronic Unspecified Acute Rate (Per 10,000 Population) 1980 1985 1990 1995 2000 2005 Year Adapted from International Classification of Diseases, 9th Rev., Center for Disease Control and Prevention. 2008.

  11. Patients at Risk for Kidney Injury • Adults with diabetes or hypertension are at an increased risk of developing chronic kidney disease (CKD) or injury. • Other risk factors include cardiovascular disease, obesity, elevated cholesterol, and a family history of CKD.   Overall 20-44 Years 45-65 Years 65+ Years Male Female Non-Hispanic White Non-Hispanic Black Mexican American 0 10 20 30 40 50 Percent (%) National Chronic Kidney Disease Fact Sheet 2010. U.S. Department of Health and Human Services. Centers for Disease Control and Prevention.

  12. AKI Risk Factors Dennen P, Douglas IS, Anderson R. Crit Care Med. 2010;38:261-75.Kidney Disease: Improving Global Outcomes (KDIGO). 2008. Sepsis Age > 65 years Presence of infection Low cardiac output Major surgery Trauma Cancer Hypervolemia (fluid overload) Cirrhosis Certain medications

  13. AKI Causes

  14. AKI Causes: Sepsis ICU LENGTH OF STAY HOSPITAL LENGTH OF STAY 6 5 4 3 2 1 0 25 20 15 10 5 0 Non-Septic AKISeptic AKI Non-Septic AKISeptic AKI Days Days None Risk Injury Failure None Risk Injury Failure RIFLE Category RIFLE Category Sepsis accounted for 32.4% of all hospitalized patients with AKI. Over 42% of all sepsis diagnoses also had an AKI diagnosis. Sepsis is the most common cause of AKI in the ICU. Bagshaw SM, George C, Bellomo R et al. Crit Care. 2008;12:R47.

  15. AKI Causes: Ischemia INFLAMMATORY MEDIATORS OF ISCHEMIC AKI • Ischemia can lead to AKI through the induction of inflammatory mediators that induce cell death in the kidney tubules • Reactive oxygen species • Cytokines • Chemokines • Macrophages Endothelium Neutrophils Adhesion Molecules Lymphocytes Interstitium Vasoconstrictors Cytokines Chemokines Dendritic Cells ROS Macrophages Tubular Urinary Lumen Apoptosis, Cell Injury, Oxidative Stress Proximal Tutules Adapted from Aiello S and Noris M. Kidney Int. 2010;78:1208-10.

  16. AKI Causes: Physiological INTRINSIC (RENAL) POST-RENAL PRE-RENAL Damage to the kidney itself Urinary tract obstruction Decreased blood flow to the kidney • Low blood pressure • Low blood volume • Heart failure • Arterial changes leading to kidney • Glomerulonephritis • Acute tubular necrosis (ATN) • Acute interstitial nephritis (AIN) • Benign prostatic hyperplasia • Kidney stones • Obstructed urinary catheter • Bladder stone • Bladder, ureteral or renal malignancy Thadhani R, Pascual M, Bonventre JV. N Engl J Med. 1996;334(22):1448-60.

  17. AKI Causes: Unknown CONSIDER RENAL BIOPSY

  18. Definitions of AKI, CKD, and AKD GFR assessed from measured or estimated GFR. Estimated GFR does not reflect measured GFR in AKI as accurately as in CKD. Kidney damage assessed by pathology, urine, or blood markers, imaging, and – for CKD – presence of a kidney transplant. AKD, acute kidney diseases and disorders; AKI, acute kidney injury; CKD, chronic kidney disease; GFR, glomerular filtration rate; NKD, no known kidney disease; SCr, serum creatinine. Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2012; Volume 2, Issue 1:1–126.

  19. Chronic Kidney Disease • CKD is a slow loss of kidney function over time. • Many elderly patients have CKD despite creatinine values that are “normal” (~1.0). 1 2 3 4 ESRD * Kidney damage is defined as pathological abnormalities or markers of damage, including abnormalitiesin blood or urine test or imaging studies.

  20. CKD vs. AKI CKD CKD AKI ESRD ESRD Adapted from Dear JW and Yuen PST. Kidney Int. 2008;74:7-9. • AKI can occur on top of CKD • Many patients have CKD at baseline • AKI can increase severity of CKD

  21. AKI With or Without Chronic Kidney Disease • AKI can be diagnosed in patients with chronic kidney disease (CKD). • AKI can also increase the incidence of CKD. Insult 100 80 60 40 20 0 Full Recovery AKI to CKD Renal Function AKI on CKD AKI to ESRD Time Cerda´ J, Lameire N, Eggers P et al. Clin J Am Soc Nephrol. 2008;3:881-6.

  22. Cumulative Incidence of CKD by Exposure Status (Recovered AKI vs. Controls) in Patients With Normal Baseline Kidney Function 1.0 0.8 0.6 0.4 0.2 0 AKIControls Proportion of Patients Without CKD 0 6 12 18 24 30 36 42 48 54 60 66 72 Months Since Index Hospitalization Bucaloiu ID, Kirchner HL, Norfolk ER et al. Kidney Int. 2012 Mar;81(5):477-85.

  23. Additional Comorbid Pathologies • Diabetes mellitus • Ischemic heart disease • Congestive heart failure • Hypertension MOST COMORBID CONDITIONS ARE INFLAMMATORY OR CARDIOVASCULAR Bagshaw SM. Nephrol Dial Transplant. 2008;23(7):2126-8.

  24. Mortality & Cost

  25. AKI Increases Hospital Length of Stay and Associated Costs AKI = INCREASING COST AND LENGTH OF STAY

  26. AKI Associated Length of Stay (LOS) RRT, renal replacement therapy; MICU, medical intensive care unit; NROF, non-renal organ failure. Barrantes F, Tian J, Vazquez R, Amoateng-Adjepong Y et al. Crit Care Med. 2008;36:1397-403.

  27. AKI Associated Length of Stay (LOS) RRT, renal replacement therapy; MICU, medical intensive care unit; NROF, non-renal organ failure. Barrantes F, Tian J, Vazquez R, Amoateng-Adjepong Y et al. Crit Care Med. 2008;36:1397-403.

  28. AKI Cost by Creatinine Level ↑ SCr ≥ 0.5 + baseline SCr < 2.0 mg/dl N = 2892, 1236, 351, 105, 4060, 1967, 714, 352, and 1160 for respective AKI criteria. Results are relative to those without the change indicated. Multivariable analyses were adjusted for age, gender, DRG weight, and ICD-9-CM categories of cardiovascular, respiratory, malignant, and infectious diseases. Chertow GM, Burdick E, Honour M et al. J Am Soc Nephrol. 2005;16:3365–70.

  29. AKI Costs Can Increase Following Surgery INCREASING SEVERITY FOLLOWING CARDIAC SURGERY Dasta JF, Kane-Gill SL, Durtschi AJ et al. Nephrol Dial Transplant. 2008;23:1970-74.

  30. Mortality Associated With Changes in SCr N = 2892, 1236, 351, 105, 4060, 1967, 714, 352, and 1160 for respective AKI criteria. Results are relative to those without the change indicated. Multivariable analyses were adjusted for age, gender, DRG weight, and ICD-9-CM categories of cardiovascular, respiratory, malignant, and infectious diseases. Chertow GM, Burdick E, Honour M et al. J Am Soc Nephrol. 2005;16:3365–70.

  31. Morbidity and Mortality ICU MORTALITY1 ICU MORTALITY2 60 50 40 30 20 10 0 60 50 40 30 20 10 0 Percent Percent No AKI AKI Sepsis Sepsis + AKI • Clermont G, Acker CG, Angus DC et al. Kidney Int. 2002;62(3):986-96. • Hoste EA, Lameire NH, Vanholder RC et al. J Am Soc Nephrol. 2003;14(4):1022-30.

  32. Diagnosis, Assessment, & Management

  33. Traditional Methods of Measurement

  34. Creatinine and GFR • Creatinine • Breakdown product of creatine • Exclusively filtered out by the kidneys (no resorption) • Estimates renal function • GFR • Glomerular filtration rate • Volume of creatinine cleared per unit time • Some equations also take age and sex into account eGFR Value 0 15 60 120 Kidney Failure Kidney Disease Normal

  35. AKI Diagnosis Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2012; Volume 2, Issue 1:1–126.

  36. Estimated Baseline SCr Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2012; Volume 2, Issue 1:1–126.

  37. AKI Staging Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2012; Volume 2, Issue 1:1–126.

  38. GFR/SCr Algorithm GFR/SCr Is GFR decreased or is serum creatinine increased? Yes < 3 months Yes > 3 months No NKD AKD CKD Is SCr increasing or GFR decreasing? No Yes-D Yes-I No Yes-D Yes-I No Yes-D Yes-I NKD AKD without AKI AKI AKD without AKI AKD without AKI AKI CKD CKD + AKD without AKI CKD + AKI Yes-D, change in SCr meets AKD criteria but not AKI criteria CKD + AKD without AKI CKD + AKI AKD without AKI AKI Does the decrease in GFR or increase in SCr resolve within 3 months? RRT, renal replacement therapy; MICU, medical intensive care unit; NROF, non-renal organ failure. Yes Yes Yes Yes No No No No CKD worse CKD stable CKD worse CKD stable CKD new NKD CKD new NKD AKD, acute kidney disease/disorder; AKI, acute kidney injury; CKD, chronic kidney disease; GFR, glomerular filtration rate; NKD, no known kidney disease; SCr, serum creatinine Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2012; Volume 2, Issue 1:1–126.

  39. GFR Over the Course of AKI • Prerenal azotemia can progress to kidney injury. Prerenal Azotemia Injury • After the initial sharp drop in GFR, there is further injury from secondary effects. Diagnosis (Future with Biomarkers) GFR Diagnosis (2011) • Early immune response can be maladaptive and contribute to further injury. Time (Days) • After injury, GFR does not recover immediately after return of renal blood flow. Maladaptive Response Repair Response Winterberg PD and Lu CY. Am J Med Sci. 2011 Aug 3.

  40. Other Methods of Diagnosis • Serum • Urea nitrogen • Urine • Fractional excretion (sodium, urea), protein/creatinine ratio, sediment (casts, WBCs, eosinophils), enzyme activity • Imaging • Ultrasound, CT, MRI, nuclear renal scan • Pathology • Kidney biopsy

  41. Physicians Can Take Action With Early Assessment of AKI KDIGO Initiative to Set Guidelines KDIGO AKI Guidelines • KDIGO is a global non-profit foundation dedicated to improving the care and outcomes of kidney disease patients worldwide. • Assembled working group of eighteen thought leaders to establish global clinical practice guidelines for AKI • New guidelines just published. High Risk 1 2 3 Discontinue all nephrotoxic agents when possible Ensure volume status and perfusion pressure Consider functional hemodynamic monitoring Monitor serum creatinine and urine output Avoid hyperglycemia Consider alternatives to radiocontrast procedures Check for changes in drug dosing Consider Renal Replacement Therapy Check for changes in drug dosing Consider Renal Replacement Therapy Consider ICU admission Avoid subclavian catheters Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2012; Volume 2, Issue 1:1–126.

  42. Physicians Can Take Action With Early Assessment of AKI High Risk 1 2 3 Discontinue all nephrotoxic agents when possible Ensure volume status and perfusion pressure Consider functional hemodynamic monitoring Monitor serum creatinine and urine output Avoid hyperglycemia Consider alternatives to radiocontrast procedures Check for changes in drug dosing Consider Renal Replacement Therapy Check for changes in drug dosing Consider Renal Replacement Therapy Consider ICU admission Avoid subclavian catheters if possible KDIGO AKI Guidelines Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2012; Volume 2, Issue 1:1–126.

  43. Current Thinking • Focus is now on inflammation-mediated organ injury in addition to renal blood flow. • New terminology • AKI rather than acute renal failure (ARF) • Injury vs. decreased filtration • AKI leads to progressive injury and a spectrum of functional kidney problems. • Serial AKI leading to CKD

  44. Key Findings in Assessment of AKI Care • The care of patients with acute kidney injury is very poor. • Patients are dying from predictable and avoidable renal failure. • The failings in the care of patients are largely clinical. • Poor assessment of risk • Inadequate basic intervention • Missed complication • Acutely unwell patients are not being recognized. • Education about acute kidney injury must improve. Hussein HK, Lewington AJP, Kanagasundaram NS. Brit J Hosp Med. 2009;70:M104–7. Stewart JAD. Brit J Hosp Med. 2009;70(7):372-3.

  45. Deficiencies in the Diagnosis and Care of AKI Patients FINDINGS FOR ADMITTED PATIENTS THAT DIED FROM HOSPITAL ACQUIRED AKI Acute Kidney Injury: Adding Insult to Injury. NCEPOD. 2009.

  46. Lack of AKI Recognition Resulted in Inadequate Consultations FINDINGS FOR ADMITTED PATIENTS THAT DIED FROM COMMUNITY AND HOSPITAL ACQUIRED AKI Acute Kidney Injury: Adding Insult to Injury. NCEPOD. 2009.

  47. Many Omissions in AKI Management Acute Kidney Injury: Adding Insult to Injury. NCEPOD. 2009.

  48. Classification and Assessment No AKI Risk (Minor AKI)Cr x 1.5 or GFR decreases > 25% or UO < 0.5 ml/kg/hr x 6 hr Injury (Moderate AKI)CR x 2.0 or GFR decreases > 50% or < 0.5 ml/kg/hr x 12 hr Failure (Severe AKI)Cr x 3.0 or GFR decreases > 75% or Cr ≥ 4 mg/dl or < 0.3 ml/kg/hr x 24 hr or anuria x 12 hr LossOn dialysis > 1 month ESRDOn dialysis > months Bellomo R, Ronco C, Kellum JA et al. Crit Care. 2004;8(4):R204–12. • RIFLE • Classifies AKI into three levels of severity (Risk, Injury, and Failure) and includes two clinical endpoints (Loss and End-stage renal disease) • Severity is determined from the increase in CR and decrease in UO

  49. Classification and Assessment No AKI Stage 1Cr x 1.5 or ≥ 0.3 mg/dl or UO < 0.5 ml/kg/hr x 6 hr Stage 2CR x 2.0 or UO < 0.5 ml/kg/hr x 12 hr Stage 3Cr x 3.0 or UO < 0.3 ml/kg/hr x 24 hr or anuria x 12 hr NOT in AKIN classification NOT in AKIN classification Mehta RL, Kellum JA, Shah SV et al. Crit Care. 2007;11(2):R31. • Acute Kidney Injury Network (AKIN) • Stage 1 is similar to RIFLE-R but includes abrupt reduction in function. • RIFLE-I and F are the same as stages 2 and 3. • Stage 3 includes patients who need any renal replacement therapy.

  50. Classification and Assessment No AKI Stage 1Cr ≥ 26 μmol/L within 48 hrs or ≥ 1.5 to 1.9 or UO < 0.5 mL/kg/hr for > 6 hr Stage 2CR ≥ 2 to 2.9 or UO < 0.5 ml/kg/hr x 12 hr Stage 3Cr ≥ 354 μmol/L or ≥3 or UO < 0.3 ml/kg/hr x 24 hr or anuria x 12 hr NOT in KDIGO classification NOT in KDIGO classification Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2012; Volume 2, Issue 1:1–126. • Kidney Disease: Improving Global Outcomes (KDIGO) • Similar to AKIN • Adds values to creatinine levels as well as fold increase • Stage 3 also includes patients who need renal replacement therapy.

More Related