1. Perioperative Acute Kidney Injury Biomarkers, Physicians, and the Surgical Abdomen Dr. Andrew Ferguson Department of Anaesthetics & Intensive Care Medicine Craigavon Area Hospital

4. Perioperative AKI is NEVER benign!

5. “ Predictable and avoidable AKI should never occur ” “ Post-operative AKI is avoidable in the elderly and should not occur ”

6. How do we diagnose & stage AKI? Cruz DN et al. Critical Care 2009; 13 : 211

8. All grades of AKI matter! Cruz DN, et al. Critical Care 2009; 13 : 211 Ricci Z, et al. Kidney International 2008; 73: 538-546 Clec ’h C, et al. Crit Care 2011; 15 : R128 Mandelbaum T, et al. Crit Care Med 2011; 39 : Epub ahead of print AKIN

10. Incidence - emergency surgery N = 61, mean age 75, unpublished audit data

11. Incidence – elective surgery 1. Thakar CV, et al. Clin J Am Soc Nephrol 2007 ; 2 : 426-430 2. Kheterpal S, et al. Anesthesiology 2007 ; 107 : 892-902 3. Abelha FJ, et al. Crit Care 2009; 13 : R79 4. Kheterpal S, et al. Anesthesiology 2009; 110 : 505-515 5. Molnar AO, et al. J Am Soc Nephrol 2011; 22 : 939-946 Study Population AKI definition AKI incidence Thakar 1 Retrospective 504 patients – gastric bypass > 50% rise in creatinine or need for HD 8.5% Kheterpal 2 Prospective , observational major non-cardiac surgery 15,102 patients creatinine clearance > 80 ml/min Creatinine clearance < 50 ml/min within 7 days of surgery 0.8% Abelha 3 Retrospective , 1,166 patients baseline creatinine < 140 major non-cardiac surgery AKIN stage 1 7.5% Kheterpal 4 Retrospective US national dataset 75,952 general surgery patients creatinine rise of > 167  mol/L from baseline or need for HD 1% (6+ risk factors: 9%) Molnar 5 Retrospective database cohort Major elective surgery including cardiac in 213,347 over 65 ’s Database coding as AKI 1.9%

13. Biomarkers – the renal crystal ball?

16. Biomarker time-course Time (hours) 0 3-6 24 48 NGAL KIM - 1 Cystatin C Creatinine McIlroy DR, Wagener G, Lee HT. Anesthesiology 2010; 112 : 998-1004   Therapeutic window  

19. Challenges in perioperative AKI Needs surgery NOW ! Can we keep up?

20. AKI Triggers & Perpetuators

21. AKI hurts other organ systems Grams ME, Rabb H. Kidney International 2011; advance online publication, 3 August 2011

24. Fluid overload & adverse outcome 1 Grams ME, et al. Clin J Am Soc Nephrol 2011; 6 : 966-973 2 Boyd JH, et al. Crit Care Med 2011; 39 : 259-265 3 Sutherland SM, et al. Am J Kid Dis 2010; 55 : 316-325 4 Bouchard J, et al . Kidney Int 2009; 76 : 422-427 5 Payen D, et al. Crit Care 2008; 12 : R74 6 Wiedemann HP, et al. N Engl J Med 2006; 354 : 2564-2575 7 de-Madaria E, et al. Am J Gastroenterol 2011. Epub 30/08/2011 Population N Design Results ARDS + AKI 1 306 Retrospective analysis of RCT Strong association + ve balance and mortality Septic shock 2 778 Retrospective analysis of RCT + ve balance correlated with increased mortality AKI 3 297 Prospective cohort More + ve balance associated with mortality AKI 4 618 Prospective cohort More + ve balance associated with mortality ICU 5 1,120 Prospective cohort More + ve balance associated with mortality ARDS 6 1,000 RCT Conservative balance = shorter ventilation time Pancreatitis 7 247 Prospective cohort More + ve balance associated with increased organ failures

25. Fluid overload causes tissue oedema Prowle JR, et al. Nat Rev Nephrol 2010; 6 : 107-115 Cerebral Altered mental status Myocardial Arrhythmia, diastolic/systolic dysfunction Pulmonary Impaired gas exchange, increased work Hepatic Cholestasis Renal Decreased RBF & GFR, venous congestion Gut Ileus, anastomotic breakdown Tissue Poor healing, pressure ulcers, infections