M A R I A S M Y R L I - N E P H R O L O G Y R E S I D E N T

G N A “ O E U A G G E L I S M O S ”

TREATMENT ANDMONITORING OF AKI

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Pubmed articles about acute kidney injury/failure through the ages

WHY SO IMPORTANT?

• Acute kidney injury (previously known as acute renal failure) covers a wide spectrum of injury to the kidneys, not just kidney failure

• Up to 18% of all hospital admissions have AKI

• Inpatient AKI-related mortality is between 25 and 30%

• Between 20 and 30% of cases of AKI are preventable. Prevention could save up to 12,000 lives each year

• NHS costs related to AKI are between £434 and £620 million per year

CLASSIFICATION OF AKI

R-I-F-L-E

criteria

Acute Dialysis Quality Initiative 2004

CLASSIFICATION VOL 2

AKIN

criteria

Time becomes more important!

FINAL CLASSIFICATION

KDIGO Definition of Acute Kidney Injury (AKI)

Referral to

Urologist

Kidney Int Rep. 2017 Jul; 2(4): 544–558

HIGH RISK PATIENTS

• Chronic kidney disease (or history of)

• Diabetes

• Heart failure

• Sepsis

• Hypovolaemia

• Age 65 years or over

• Use of drugs with nephrotoxic potential (for

example, NSAIDs, ACE inhibitors)

• Liver disease

• Limited access to fluids, e.g. via neurological

impairment

• Symptoms or history of urological obstruction

PREVENTION (1)

Community Acquired Patients

• eGFR < 60 mL/min/1.73m2 )

• patients who are treated with

ACEi or ARB

Prevention and Management of Acute Kidney Injury.John Harty. Ulster Med J

2014;83(3):149-157.

PREVENTION (2)

Perioperative AKI

Recognition of patients who are at risk will allow measures to be undertaken to

reduce exposure to renal insults and maximize renal recovery should

AKI occur.

• Optimization of fluid balanceFluid volume status should be carefully assessed with respect to both fluid depletion

and fluid overload. Patients at risk of dehydration due to prohibited or poor oral

intake should be prescribed maintenance IV fluids.

• Optimization of blood pressureHypotension systolic blood pressure (SBP) < 110 mmHg / mean arterial pressure (MAP)

< 65 mmHg) needs urgent assessment and treatment with IV fluid challenges and

vasopressor agents where indicated.

Prevention and Management of Acute Kidney Injury.John Harty. Ulster Med J

2014;83(3):149-157.

PREVENTION (3)

The Renal Association, British Cardiovascular Intervention Society and The Royal

College of Radiologists 2017

After prevention and diagnosis, what?

AKI

nephrologist

There is no definitive therapy for AKI,

supportive care is the mainstay of

management regardless of etiology

Check your patient’s volume status!!!!

Which fluid?

• 2,278 ICU patients were randomized to receive PlasmaLyte 148 vs 0.9% saline. There

was no significant difference

Effect of a buffered crystalloid solution vs saline on acute kidney injury among patients in the intensive care unit: the

SPLIT randomized clinical trial. JAMA. 2015

• 15,802 randomized patients received 0.9% saline vs a buffered crystalloid solution in

five ICUs at one center. Significant reduction in the risk of major adverse kidney events within 30 days in the group of patients treated with buffered solutions

Conflicting data

Balanced crystalloids versus saline in critically ill adults. The Isotonic Solutions and Major Adverse. Renal Events Trial

(SMART)2018

• 13,347 non critically ill patients admitted to the hospital from the ED those who

received buffered solution while in the ED had a similar rate of death at 28 days compared with those who received saline

Balanced crystalloids versus saline in non critically ill adults. N Engl J Med. 2018. Saline against Lactated Ringer’s or

Plasma-Lyte in the Emergency Department [SALT-ED] trial)

September 2019 Volume 156, Issue 3, Pages 594–603

In the absence of hemorrhagic shock, we suggest using isotonic crystalloids

rather than colloids (albumin or starches) as initial management for

expansion of intravascular volume in patients at risk for AKI or with AKI. (2B)

We recommend the use of vasopressors in conjunction with fluids in patients

with vasomotor shock with, or at risk for, AKI. (1C)

Kidney International Supplements (2012) 2, 37–68;

Management principles

Optimization of hemodynamics

Correction of fluid and electrolyte imbalances

Discontinuation of nephrotoxic medications

Dose adjustment of administered medications

Management of life-threatening complications

Diagnosis and specific management of underlying cause

Mnemonic

Diuretics

ACEi/ARBs

Metformin

NSAIDS

What about diuretics?

25

Theory• ↑intrarenal production of vasodilative prostaglandins

• ↓ sodium retention

• ↓ free water production

• ↓ energetic needs of the cells

3.4.1: We recommend not using diuretics to prevent AKI. (1B)

3.4.2: We suggest not using diuretics to treat AKI, except in the management of volume overload.

(2C)

5.2.2: We suggest not using diuretics to enhance kidney function recovery, or to reduce the

duration or frequency of RRT. (2B)

There is no evidence that the use of diuretics reduces the incidence

or severity of AKI.

To dialyse or not?IF yes, when?

Dialysisis indicated when medical management fails to control (refractory*):

a. Volume overload*

b. Electrolyte disorders (K>6,5meq/l,

Na<115, Na>160meq/l)

c. Anuria*

d. Severe metabolic acidosis*

e. Severe complications of uremia

(pericarditis , neuropathy ,unexplained

decline in mental status, uremic

bleeding)

f. Overdose with a dialyzable drug/toxin

Lameire N et al. The Lancet 2005

Modes of RRT

• Intermittent hemodialysis (IHD)

• Peritoneal dialysis (PD)

• Continuous renal replacement therapy (CRRT) (CVVH,

CVVHDF,SCUF,CVVHD)

The choice of modality is often dictated by the AVAILABLE

technology

AND

Expertise of medical staff

Intermittent Hemodialysis

• The most common form of RRT for

AKI

• Employed intermittently (3-

4hr/day, 3-4/wk)

• Vascular access

• Low cost

• Acute correction of electrolytes

and fluid overload

Disadvantage: Hypotension and cerebral edema

Continuous renal

replacement (CRRT)

a. Hemodynamic instability

b. Critical ill patients

c. Severe brain injury/

elevated intracranial

hypertension

Disadvantage: high cost, need for anticoagulants

What Are the Nutritional

Requirements in Patients With AKI?

4.1. We recommend enteral nutrition support be started as early as possible to

prevent malnutrition.

4.2. We recommend prescribing 25 to 30 kcal/kg per

day intake of calories.

4.3. We recommend prescribing 0.8 to 1.0 g/kg per day

of protein intake for AKI without RRT and/or in

the noncatabolic state.

4.4. We recommend prescribing 1.5 to 2.0 g/kg per day

of protein intake for AKI with RRT and/or in the

hypercatabolic state.

Prevention and Therapy of Acute Kidney Injury in the Developing World

Vijay Kher et al .Kidney Int Rep (2017) 2, 544–558

FOLLOW UP CARELOST IN TRANSITION……

• those who survive an AKI episode have a 2X risk of death, a 3X risk of ESRD,

and a 10X risk of developing either incident or progressive CKD

• 75% of patients see a primary care physician within 3 months of discharge

37% and 13% see a cardiologist or nephrologist, respectively.

• patients seen by a nephrologist at 12 months after an AKI hospitalization is still only

19%.

• Follow-up by a nephrologist also remains low in patients with preexisting CKD

(23% at 12 months) and diabetic nephropathy (29% at 12 months

Intensive Care Med (2017) 43:855–866

PROGNOSIS

• Mortality of AKI remains

about 50%

• Preneral azotemia, and

postrenal azotemia carry a

better prognosis than most

cases of intristic AKI

• Olirugic AKI, developing in a surgical setting or in older

patients, carries a higher

mortality than other forms

ΑΚΙ is not innocent

but

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