objectives understand why aki matters natural history associated risk be able to recognise aki do...
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Objectives
Understand why AKI matters
Natural history
Associated risk
Be able to recognise AKI
Do small changes in creatinine/eGFR really matter?
Be confident about what to do
Be confident about when to refer
KIDNEYS
Understand why AKI matters
NICE Guidance 28th August 2013
The National Confidential Enquiry into Patient Outcome and Death found that only half of patients with AKI had received 'good' care
Up to 30 per cent of cases of AKI can be prevented - that equates to at least 12,000 unnecessary deaths per year
Inadequate assessment of risk factors in 24% of patients admitted with AKI
Commonest risk factors not assessed were medication, co-morbidity and hypovolaemia
Understand why AKI matters: Natural history
Acute kidney injury results most often from ‘external’ insults threatening glomerular perfusion
Exacerbated by ‘toxic’ insults
Often in setting of ‘damaged’ kidneys
Significant biochemical changes have no ‘immediate’ clinical correlate but are ‘red flags’ for potentially significant ongoing insult/s to kidneys
If the insult is not corrected kidney injury will progress and reversible injury may become irreversible
Understand why AKI matters: Associated risk
AKI is associated with increased mortality
Degree of change directly proportional to increased risk
CKD≥3 is associated with increased mortality
AKI may be irreversible or only partially reversible resulting in CKD
‘Angina of the kidneys’
Need to stop becoming MI
(N=1,120,295)
1.0
1.4
2.0
2.8
3.4
Ha
zard
ra
tio fo
r C
V e
ven
t
0
1
2
3
4
Reduced kidney function is associated with a higher risk of CV events
≥60 45-59 30-44 15-29 <15
eGFR (mL/min/1.73 m2)
Go et al. N Engl J Med 2004 351: 1296–1305 Tonelli et al. J Am Soc Nephrol 2006 17: 2034–2047Eeg-Olofsson et al. J Internal Medicine 2010 268: 471–482 Khaw Nature Reviews Endocrinology 2009 5: 130-131
8.0-8.9
9.0-9.9
CKD3
Be able to recognise AKI: Classification
A rise in serum creatinine of ≥26.5 μmol/L in 48 hoursA rise in serum creatinine of ≥50% in 7 days
AKI stage 1: a rise in creatinine of ≥26.5 μmol/L or 1.5-1.9 × baseline
AKI stage 2: a rise in creatinine of 2.0-2.9 × baseline
AKI stage 3: a rise in creatinine of ≥3 × baseline or increase in creatinine to ≥353 μmol/L
Be able to recognise AKI: Small changes
A rise in serum creatinine of ≥26.5 μmol/L in 48 hoursA rise in serum creatinine of ≥50% in 7 days
AKI stage 1: a rise in creatinine of ≥26.5 μmol/L or 1.5-1.9 × baseline
AKI stage 2: a rise in creatinine of 2.0-2.9 × baseline
AKI stage 3: a rise in creatinine of ≥3 × baseline or increase in creatinine to ≥353 μmol/L
Be able to recognise AKI: Change from baseline
140
120
100
140
120
100
Hemmelgarn BR. Kidney International 2006: 29: 2155
10,184 community-dwelling subjects aged 66 or over
Decline in eGFR greatest in diabetics (2.1 and 2.7 ml/min/1.73m2/year in F and M respectively)
Decline in eGFR in non-diabetics: 0.8 and 1.4 ml/min/1.73m2/year in F and M respectively
Decline more likely if baseline eGFR <30
Decline of GFR in elderly people
RRT
60
50
40
30
20
10
eGFR
CKD3
CKD4
X
Be able to recognise AKI: Is it really CKD?
Do not ignore eGFR 30-59ml/min until know
direction of travel and significant causes ruled
out
Direction of travel is everything
Haematuria and proteinuria are flags for further investigation
Risk factors for AKI include age >65, diabetes, CVD and ACEI/ ARB
Infection is a trigger for AKI in at risk patients even if not involving urinary tract
Summary
What to do
Recognise at risk patient
Identify and treat reversible insults irrespective of kidney function
Document kidney function
What to do: Medications
ACEI/ARB StopLoop Diuretics StopMetformin StopSUs ReviewMetiglinides No changeGliptins No changeStatins No changeAspirin No changeNSAIDs Stop/AvoidTrimethoprim Avoid
When to refer
AKI 1: Can be managed in primary care if cause treatable and kidney function stabilises
AKI 2: Refer general medicine
AKI 3: Refer nephrology
NB Obstruction and rapidly progressive glomerulonephritis should be referred to specialist unit directly whatever level of kidney function
Challenges: A lot of work for no return?
Need baseline defined in all at risk patients and technology to allow interpretation
Rapid turn round of creatinine in at risk patient with acute illness
Urinalysis
Patient education: sick day rules for kidneys
Recognition and Prevention of AKI
Is this an at risk patient?Age >65 yearsVascular diseaseDMACEI/ARBCKD
Is glomerular perfusion threatened ?Hypotension or sepsisNSAID/COXi/COX-2i
Kidney medicine in primary care: 7 minutes
Recognising the at risk patient: ACEI
ACEI/ARB essential part of managing IHD and preventing progression of CKD
ACEI/ARB, IHD and CKD are important risk factors for AKI
48 yr old man. Routine health check. Found to have eGFR of 35ml/minReferred for investigation of his “CKD 3”
No previous eGFRProtein ++++ No haematuriaBP 122/74
Case 1
Renal biopsy demonstrated FSGS
Mrs MA 74 year old eGFR 46ml/min/1.73m2
USS demonstrated ‘normal’ size kidneys
Serum electrophoresis revealed a paraprotein with urinary BJP
Case 2
Dipstick of urine revealed + protein
Mr PS 80 year old ‘Stable’ IHD Not diabetic No ACEI
Acutely SOB with possible rigor
Few crackles L base
Clarithromycin prescribed
Case 3
24 hours later confused and hypotensive
Emergency admission
Treated as CAP according to hospitalprotocol
Rx Vancomycin 1g x 2Gentamicin 160mg x 2
Case 3 continued
48 hours later AKI diagnosedBaseline eGFR 42ml/min/1.73m2
4 week hospital admission
Probably avoidable with recognition that patient likely to have CKD and risk conferred by this CKD
Admission eGFR 22ml/min/1.73m2
‘48h’ eGFR 12ml/min/1.73m2
Case 3 continued
74 year old male with 12 year history of T2DM presents to casualty unwell with lower abdominal pain. Known to have diverticular disease
Most recent HbA1c 7.4%
First thoughts?
Case 4
Rx Ramipril 5mg daily and Metformin 500mg bd
74 year old male with 12 year history of T2DM presents to casualty unwell with lower abdominal pain. Known to have diverticular disease
Rx Ramipril 5mg daily and Metformin 500mg bd
Pyrexial. BP 130/74. Euvolaemic
WCC 10.6x109/l CRP 48ng/ml
eGFR 42ml/min with a potassium of 4.2mmol/l
Case 5
92 year old is seen in clinic having been found by GP to have ‘CKD4’
She is well with an eGFR of 26ml/min
Rest of biochemistry is safe, urine reveals neither blood nor protein
What do I do?
Case 6
USS shows echobright kidneys of 8.2cm and 8.4cm with no evidence of obstruction
eGFR was 28ml/min in 2008
Case 7
A 36 yr old woman who has been previously fit and well and who rarely attends the surgery presents complaining of increased tiredness. She is an active sportswoman who has noticed reduction in exercise tolerance over 3 weeks such that she has struggled on hills when jogging. For 3 days she has had a sore throat, ‘painful’ fingers and noticed a few ‘red spots’ on her right thigh. On examination you confirm that she has a palpable non-blanching purpuric rash on her thigh. BP is 164/90 but examination is otherwise unremarkable.
What do I do?
Case 7
A 36 yr old woman who has been previously fit and well and who rarely attends the surgery presents complaining of increased tiredness. She is an active sportswoman who has noticed reduction in exercise tolerance over 3 weeks such that she has struggled on hills when jogging. For 3 days she has had a sore throat, ‘painful’ fingers and noticed a few ‘red spots’ on her right thigh. On examination you confirm that she has a palpable non-blanching purpuric rash on her thigh. BP is 164/90 but examination is otherwise unremarkable.
What do I do
Dipstick of urine revealed blood ++ and protein ++
78 year old with stable CKD3. Rx Ramipril 5mg daily
eGFR June 2011 47ml/min April 2014 41ml/min
Cares for terminally ill husband therefore deferred R hip replacement
What pain killers would you recommend?
Case 8
Pharmacist recommended Ibuprofen 400mg daily
4th July 2014 16ml/min
Stopped ibuprofen
14th July 2014 39ml/min
Slides and more info available at www.clinimeded.co.uk
https://www.thinkkidneys.nhs.uk
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ClinicalAcute Kidney Injury
Quiz: http://www.doctors.net.uk
More information available at
Objectives
Understand why AKI matters
Natural history
Associated risk
Be able to recognise AKI
Do small changes in creatinine/eGFR really matter?
Be confident about what to do
Be confident about when to refer