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Acute Kidney Injury

Acute Kidney Injury. Pamela Pride, MD, FHM Cathryn Caton, MD, MS June 5, 2012 MUSC. Objectives. Define Acute Kidney Injury (AKI) Define the significance of AKI in a hospitalized patient Differentiate pre/intra/post renal injury

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Acute Kidney Injury

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  1. Acute Kidney Injury Pamela Pride, MD, FHM Cathryn Caton, MD, MS June 5, 2012 MUSC

  2. Objectives • Define Acute Kidney Injury (AKI) • Define the significance of AKI in a hospitalized patient • Differentiate pre/intra/post renal injury • Utilize history, physical exam and appropriate diagnostic tests to determine etiology of AKI

  3. Acute Kidney Injury – What is it? • An abrupt or rapid decline in renal filtration function • Marked by • rise in serum creatinine • azotemia • Patients may be • Oliguric • Non - oliguric

  4. Importance of AKI OR 1.7; 95% CI, 1.2 to 2.6 Green bars unadjusted Blue Bars age and gender adjusted Gray bars are multivariable adjusted

  5. Common Causes of AKI OUTPATIENT INPATIENT • ACE-I when vomiting • ACE-I + NSAID • BPH • Stones • ATN • Sepsis • Drugs • Contrast • Rhabdomyolysis

  6. Approach to a Patient with AKI • Think three broad categories • Pre-renal • Intrinsic renal • Post-renal

  7. Evaluation of AKI • HPI • Past Medical History – • ?CKD • ?DM • ?Proteinuria • ?HTN • Family History • Social History – • IVDA • Hepatitis • HIV risks • Medications – review all medications • Physical Exam

  8. Physical Exam • Pre-Renal • Orthostatic hypotension • Tachycardia • Decreased skin turgor • Signs of heart failure • Post-renal • Palpable bladder

  9. Physical Exam • Intrinsic renal • ATN – volume overload • Glomerulonephritis – variable • Vasculitis – purpura • Atheroembolic disease – livedoreticularis, blue toes • Interstitial nephritis – rash, fever, +/- eos

  10. Laboratory Data • BMP • CBC • UA • Urine sediment – look for muddy brown casts • FeNa • Renal Ultrasound or Computed tomography

  11. Interpreting FeNa • Non-pre-renal with low FeNa • Contrast • Rhabdo • Early sepsis • Obstruction • Acute glomerulonephritis • Pre-renal with high FeNa • Diuretic use • Pre-existing CKD

  12. Pre-Renal • Hypoperfusion • Hypovolemia • Decreased cardiac output • Decreased effective circulatory volume • CHF • Cirrhosis • Impaired renal hemodynamics • NSAIDs • ACE • ARB

  13. Intrinsic AKI • Essentially ruled out pre-renal, post-renal • No good reason for ATN • Check complement levels – C3, C4 • ANCA, antiGBM • ANA • LDH, haptoglobin – hemolysis, thrombotic microangiopathy

  14. Post-Renal AKI • Obstruction • BPH • Stone

  15. Interpreting urinary sediment Granular cast RBC cast

  16. Interpreting urinary sediment Tubular Epithelial Cells WBC vs Epithelial Cell

  17. Interpreting urinary sediment Oval Fat Bodies WBC Cast

  18. References • Chertow GM, Burdick E, Honour M, et. Al. Acute Kidney Injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol, 16: 3365-70, 2005. • Wald R, Quinn RR, Luo J et. al. Chronic dialysis and death among survivors of acute kidney injury requiring dialysis. JAMA, 302: 1179-85, 2009. • Blantz RC. Pathophysiology of pre-renal azotemia. Kidney Int, 53: 512-23, 1998. • Friedrich JO, Adhikari N, Herridge MS, et. al. Meta-analysis: low dose dopamine increases urine output but does not prevent renal dysfunction or death. Ann Intern Med, 142: 510-24, 2005 • Steiner RW: Interpreting the fractional excretion of sodium. Am J Med, 77: 699-702, 1984

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