AKI and CKD
By ,
DARSHAN

AKI
• Approximately 7% of all hospitalized patients and 20% of acutely ill
patients develop AKI
• In uncomplicated AKI; mortality is low even when RRT is required
• In AKI associated with sepsis and multi-organ failure, mortality is 50-
70%
CKD
• Prevalence of CKD stages 3-5 in many countries is around 5-7%
• More prevalent in people aged 65 years and older
• Substantially higher in the patients with HTN, DM and vascular diseases
2

AKI: Definition
AKI is defined as –
Increase in Serum Cr by 0.3 mg/dl within 48 hours
OR
Increase in Serum Cr to 1.5 times of baseline, which
is known or presumed to have occurred within the
prior 7 days
OR
Urine volume <0.5 ml/kg/h for 6 hours.

Causes

Clinical Features
•Asymptomatic
• elevations in the plasma
creatinine
• abnormalities on urinalysis
•Signs and symptoms resulting from loss of kidney function:
•decreased or no urine output, flank pain, edema,
hypertension, or discolored urine

Clinical Features
•Symptoms and/or signs of renal failure:
•weakness
•easy fatiguability (from anemia)
•vomiting, mental status changes or
•Seizures
•edema
•Systemic symptoms and findings:
•fever
•Joint pain

Diagnosis
•Detailed history
•Blood urea nitrogen and serum creatinine
•CBC, peripheral smear, and serology
•Urinalysis
•Urine electrolytes
•Ultrasonography, CT
•Serology: Anti DNA, HBV, HCV, cryoglobulin, urinary
Myoglobulin, HBsAG

Complications of AKI
1) Uraemia
2) Hyper / hypovolemia
3) Hyponatremia
4) Hyperkalemia
5) Hyperphosphatemia / hypocalcemia
6) Metabolic acidosis
7) Bleeding
8) Infection risk
9) Cardiac –pericarditis, arrhythmia &pericardial effusion
10)Malnutrition

Treatment
•Optimization of hemodynamic and volume status
•Avoidance of further renal insults by medications
•Optimization of nutrition
• If necessary, institution of renal replacement therapy

CKD: Definition (criteria)
•Kidney damage for >= 3 months, as defined by
structural or functional abnormalities of the kidney,
with or without decreased GFR, manifest by either:
•Pathological abnormalities or
•Markers of kidney damage, including
abnormalities in the composition of blood and
urine, or abnormalities in the imaging tests
•GFR <60 ml/min/1.73m2 for >=3 months, with or
without kidney damage

Staging
Stage Description GFR (ml/min/1.73m2)
I Kidney damage with normal or increased
GFR
>=90
II Kidney damage with mild decrease in GFR 60-89
III Kidney damage with moderate decrease in
GFR
30-59
IV Kidney damage with severe decrease in GFR 15-29
V Kidney failure <15 (or dialysis)

Causes

Clinical features
•Most asymptomatic till GFR falls below 30 ml/min
•GFR < 20 ml/min- affect almost all systems
•Tiredness, breathlessness- anemia, fluid overload
•Itching, weight loss, nausea, vomiting and
hiccups
•Advanced renal failure- metabolic acidosis,
muscular twitching, drowsiness and coma

Investigations
16

Management
•Aims of management in CKD are
•To monitor renal function
•To prevent or slow further renal damage
•To limit complications of renal failure
•To treat risk factors for cardiovascular diseases
•To prepare for RRT, if appropriate

Management
Conservative
⚫Slowing the Progession
⚫Limiting the adverse
effects
⚫Preparing for Renal
Replacement Therapy
Definitive
RENAL REPLACEMENT
THERAPY (RRT)
• Dialysis:
• Hemodialysis
• Peritoneal Dialysis
• Renal Transplantation
• Live
• Cadaveric

Limiting the adverse effects of CKD
•Anemia
•Fluid and electrolyte balance
•Acidosis
•Cardiovascular disease and lipids
•Renal Osteodystrophy
•Infection

Anaemia
⚫Defined as Hemoglobin < 13.5 g/dl in males
< 12 g/dl in females
⚫Normocytic normochromic anaemia – as early as in
Stage III CKD or universally by Stage IV CKD
⚫Primary cause : insufficient production of
Erythropoetin

Other factors causing anemia
• Iron deficiency/Folate and Vit B12 deficiency
• Chronic inflammation
• Hyperparathyroidism / bone marrow fibrosis
• Decreased erythropoiesis
• Decreased RBC survival
• Increased blood loss
• Occult gastrointestinal bleeding
• Platelet dysfunction
• Blood loss during hemodialysis
• Blood sampling

Anemia - goals
⚫Target Hb : not more than 11.5g/dl
⚫Check Hb monthly while on ESAs (Erythropoeisis
stimulating agents)
⚫Iron studies monthly when started on ESA
⚫On stable ESA Therapy : Iron studies can be done 3times in
a monthl

Anemia – treatment options
⚫Oral iron
⚫IV Iron Dextran
⚫IV Iron Sucrose
⚫IV Sodium Ferric Gluconate Complex
⚫Folic acid and Vitamin B 12 supplements
⚫Erythropoetin Stimulating Agents : Epoetin alfa*
Epoetin beta Darbepoetin alfa
⚫Epoetin alfa / beta : 50 -100 IU / Kg SC per week
⚫Darbepoetin alfa : 40 mcg SC every 2 weeks

Bone disorder (CKD-MBD)
•Renal bone disease – significantly increase mortality in
CKD patients
•Hyperphosphatemia – one of the most important
risk factors associated with cardiovascular disease
in CKD patients

Preparation for Renal Replacement
Therapy
⚫Patients of CKD Stage IV approaching Stage V should be referred for
Vascular access ifhemodialysis is preferred
Peritoneal dialysis catheter placement if peritoneal dialysis is
preferred
⚫AVF is most preferred access for HD patients
Ideally created 6 months prior to start of HD
Non dominant upper extremity
And that arm is to be preserved – no iv lines
⚫AVG : 3-6 weeks prior to start of HD
⚫PD Catheter : 2 weeks prior to start of HD

Differences between AKI & CKD

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