Acute Kidney Injury

Datuk Dr Sethu Nagappan.ASDK;PGDK:

MBBS;MD(Int Med); MRCP (UK)
FRCP(IREL);FRCP(LOND);FRCP(EDIN);FAMM
Assoc Professor, Dept of Medicine
International Medical University,KL
• Excretion Of Toxic Wastes
• Maintenance of Fluid, Electrolytes and Acid base constancy
• Promotes Erythropoisis –Erythropoietin
• Controls Blood Pressure – RAAS
• Prevents Bone Osteoporosis – Vit D
• Clinical Markers of Renal Function

Retention of Nitrogenous wastes

Urine output
• Pre Renal

• Intrinsic Renal

• Post Renal
Hypovolaemia
Low cardiac output
Renal vasoconstriction
• Pre Renal

• Intrinsic Renal

• Post Renal
Glomerular
Interstitial
Tubular
Vascular
ACUTE KIDNEY INJURY
• RedCast = Glemerular nephrotis
• White+ interstitial
• = tubular
• If ideformed rred cell , come from higher u p, if natact red cell,
Clinical classification of AKI

• Reversible AKI
Hypoperfusion Incipient stage –
Half way house

Self limited AKI-

ac tubular necrosis

Irreversible AKI -
Cortical necrosis
• Pre Renal

• Intrinsic Renal Stones

Stricture
• Post Renal Tumour
Prostate
Renal Failure indices

• Spot Urine Na
• Urine to plasma urea ratio
• Urine to plasma creatinine ratio
• Urine osmolality
• Fractional excretion of Na
• Renal failure index
Biomarkers of Ac Kidney injury
New markers ; NGAL , Cystatin, KIM-1, IL 18
complications

• Uremia
• Hypervolemia and hypovolemia
• Hyponatremia ,Hyperkalemia,Hypocalcemia,Hyper Po4
• Acidosis
• Bleeding
• Infections
Management
ac renal failure
• Step 1
confirm renal shutdown-urine output
Bu/Se/creat
• Step 2
assess the hydration clinically
urinary diagnostic indices
• Step 3
rule out obstruction by abd exam
and ultrasound
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 Management
Ac renal failure
• Fluid challenge
normal saline till CVP is 0 to 5
• Diuretic challenge
iv furosemide 40 mg, 160 mg, and 240 mg,
increasing doses at hourly intervals,
caution-ototoxicity
• Dopamine and verapamil infusions
• Dialysis

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General issues

• Optimization of systemic and renal haemodynamics through volume

resuscitation and judicious use of vasopressors
• Elimination of nephrotoxic agents
• Initiation of renal replacement therapy
 Renal replacement therapies

• Peritoneal dialysis

• Haemodialysis

• Haemofiltration / Haemodiafiltration

• Ultrafiltration

• High Flux dialysis

Dialysis prescription

• Intermittent dialysis ( PD or HD )

• Continuous RRT ( HF or HDF )

• SLEDD / SLEDD f ( HD or HDF )

Peritoneal dialysis
Peritoneal dialysis

• inexpensive and readily available

• not so efficacious
• infection
• mortality up to 5o%
 Haemodialysis
• - expensive and needs trained staff
• - stable BP for procedure to be safe
• - precipitous drop in BP during dialysis
• - short daily sessions
• - acetate
• vs
bicarbonate
Haemodialysis
CRRT
Continuous renal replacement therapies

• Highly trained staff, access to large vessels, large volumes of fluids

and anticoagulation.
• Labour oriented and time consuming

• Air embolism and bleeding complications

 When the BP is low, options are either CRRT
or PD

• Haemofiltraton and Peritoneal dialysis in

infection associated acute renal failure in Vietnam
-------------------------------------------------
Nguyen Hoan Phu et al N Engl J Med
Vol347,No12,Sep 19,2002
ts and conclusions

• Mortality rate
CRRT -- 15%
PD -- 47%
• Resolution of acidosis and
Decline in serum creatinine
twice faster in CRRT compared to PD
• Haemofiltration is superior to PD in ARF
CRRT

• Technically demanding
• Continuous anticoagulation
• Workload 24hours per day
• Expensive sterile substitution solution
Metaanalysis has not shown superior survival results
Hybrid therapies - SLEDD

• Sustained low efficiency daily dialysis

conceptual and technical hybrid of CRRT and IHD
reduced rate of ultrafiltration for optimized
haemodynamic stability
low efficiency solute removal to minimize solute
disequilibrium
sustained treatment duration to maximise
dialysis dose
intermittency for convenient access to patients
for out of unit diagnostic procedures
Comparison of techniques
IHD SLED CRRT
Time 4 hours 5 – 18 h 24 hours
Blood flow 250ml/ hr 70 to 100 100 ml / hr
Dialysate 500 ml / hr < 100 ml/h < 200 ml/h
flow
Fluid 750 ml / hr i50 ml / hr 62.3 ml/h
removal. (10 hrs /d)
Eg 3 L
Solute 200 ml/mt 60 ml / mt 40 ml / mt
clearence
eg urea
Catch word

• Match the therapy to the pt s haemodynamics at different stages

• Continuum of care
 Renal failure –clinical subsets
• RF without an oliguric phase but with steadily increasing
creatinine -- PD
• RF with anuria but with stable haemo-
• Dynamics -- intermittent HD
• Pulmonary oedema is a majo r risk and is often associated
-- Ultrafiltration
• When associated with jaundice, hypoglycaemia and
severe metabolic acidosis,
BP drops suddenly andPt becomes comatose , needing
circulatory, respiratory and renal support –MODS – poor
prognosis
• Next

• Chronic Kidney disease