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Aki march 2015
1. Acute Kidney Injury
Dr. Amit Agarwal
MD, FIPNA,FISPN (AIIMS)
Consultant Pediatric Nephrologist
2. Acute Kidney Injury
Acute renal failure
Sudden loss of renal function, over hr-days, with
deranged fluid balance, acid base & electrolytes
Detect early AKI
Avoid nephrotoxic agents; prevent further injury
Fluid overload predicts mortality
Associated with prolonged hospital stay
KDIGO Clinical Practice Guidelines for Acute Kidney Injury: Kidney International 2012
3.
4.
5. Serum creatinine vs. Urine output
Serum creatinine: pitfalls
Varies: age, gender, muscle
Rises after 50% function lost
Tubular secretion
overestimates function
AKI: does not depict
function immediately
Methods of estimation
Easily dialyzed
Urine output is important
Duration & episodes
have prognostic value
Enables early diagnosis
Improves management
Useful chiefly in PICU
Canary in the coal mine
7. Emphasis on early recognition
Increase in Cr by ≥0.3 mg/dl within 48 hr
Increase in Cr to ≥1.5 times baseline, known
or presumed to have occurred within prior 7 d
Urine volume <0.5 ml/kg/hr for 6 hr
Any of the following
9. Severity of AKI determines outcome
AKI affects PICU mortality
Nat Rev Nephrol 2010;6:393
10. RIFLE & stepwise increase in mortality
KI 2008; 73, 538–546
24 studies (2004-07); 71000 patients
AKI level RR [95% CI] mortality
Risk 2.40 [1.9, 3.0]
Injury 4.15 [3.1, 5.5]
Failure 6.37 [5.1, 7.9] P <0.0001; vs. non-AKI
11. Distant effects of AKI
Disrupted BBB
IL-6 mediated
Changes in
Organ function
Vascular inflammation
Cellular apoptosis
Transporter activity
Transcriptional changes
Oxidative stress
12. Etiology of AKI (%)
1972-79
N=142
1981-88
N=205
1991-2005
N=266
Diarrhea 35 17 10
HUS - 36 24
Infections 25 19 38
GN 30 13 8
Obstruction 3 3 6
Causes vary with age; determine mortality
Incident AKI 15%
AKI @ admission 5.5%
HUS
Septicemia
Rapidly progressive GN
Dehydration
2008
N=514 screened
Indian J Pediatr 1980,17:405; Indian J Med Res 1990,92:404
Indian Pediatr 2012;49: 537-42
13. March 2008; 4:138-53
Developed nations: AKI chiefly in ICU; older
kids; multiorgan failure & sepsis; high mortality
Developing world: AKI in the young; single
diseases [gastroenteritis, malaria, sepsis,
leptospirosis, HUS, enzyme deficiencies]
16. Fluids in sepsis: Avoid early under
treatment; late overload
Early goal directed
therapy: prevents AKI
Saline & albumin as good
Hexastarch & AKI
Persistent overload:
hypoxia, ARDS
Judicious fluid removal
EGDT (6 hr of dx)
MAP >65 mm Hg
CVP 8-12 mm
Venous saturation 80%
Urine output >0.5 ml/kg/h
Surviving Sepsis Campaign. Crit Care Med 2004;32:858
Management of sepsis. N Engl J Med 2006;355:1699
17. Prevent nephrotoxicity
Aminoglycosides
Use suitable, less nephrotoxic alternatives
Administer as single dose daily regimen
Drug levels if multiple doses or single-daily dose for >48-hr
Use topical or local route, when feasible
Amphotericin
Use lipid formulations rather than conventional
Azoles and/or echinocandins, if equal efficacy assumed
Dose modification in renal failure
18.
19. Prevent contrast nephropathy
High- ∼2000 mOsm/kg
Low- 600-800
Iso-osmolal 290; less toxic
Minimum contrast volume
Saline/bicarbonate based @
1.0 ml/kg/h for 3–12 h before &
6–24 h after contrast exposure
Urine output (1.5 ml/kg/h)
20. Frusemide: Not associated with benefits for prevention
& treatment of AKI
Do not improve survival, recovery of renal function
Loop diuretics for AKI
Recommend not using diuretics to prevent AKI
Suggest not using diuretics to treat AKI, except for
volume overload
Suggest not using diuretics to enhance recovery, or
reduce duration or frequency of RRT
High doses: Ototoxicity
21. Renal vasodilators
Low dose Dopamine
Increases RBF & GFR
Does not prevent/alter course
Tachycardia, myocardial &
tissue ischemia
No role in preventing AKI
Fenoldopam
Reduced RRT (OR 0.4);
mortality (OR 0.5)
Lower creatinine; less AKI
[than dopamine]
Recommend not using dopamine to prevent or treat AKI (1A)
Suggest not using fenoldopam to prevent or treat AKI (2C)
Meta-analysis. Ann Intern Med 2005;142:510
The myth. JAPI 2002; 50: 571–575
Meta-analysis. J Cardiothor Vasc Anesth 2008;22: 27
Blinded RCT. Crit Care Med 2005; 33: 2451
Fenoldopam vs. dopamine. Crit Care Med 2006;34:707
Suggest not using atrial natriuretic peptide
22. Maintaining nutrition: a challenge
Intake >20–30 kcal/kg/d
Avoid restricting proteins to prevent/delay RRT
Administering protein @
0.8–1.0 g/kg/d in patients not on dialysis
1.0–1.5 g/kg/d in patients with AKI on RRT
1.0-1.7 g/kg/d in those on CRRT, hypercatabolic
Nutrition preferably by enteral route
High catabolism & energy needs; dialysis losses
23. Begin renal replacement therapy early
Uremia
Late initiation urea >150: risk of
dying
CJASN 2006;5:915
CVVH dosing requirements
Early initiation: better outcome
Lancet 2000; 356:26
Fluid overload
116 patients; 39% sepsis
<20% overload: 59% survival
>20% overload: 40% survival
P<0.002
PRISM similar
Goldstein, ppCRRT. KI 2005; 67: 653
Fluid overload >15%
Independent risk factor for mortality
Fluid overload = fluid in (L) – fluid out (L) x 100
weight @ admission (kg)
24. Manage complications & plan dialysis
Fluid overload
Pulmonary edema
Hypertension
Metabolic acidosis
Hyperkalemia
Hyponatremia
Severe anemia
Hyperphosphatemia
25. Initiate RRT emergently if life-threatening fluid,
electrolyte and acid-base imbalance exist
Consider broad clinical context, the presence of
conditions that can be modified with RRT & trends of
laboratory tests — when making the decision to start
RRT
Early initiation of dialysis
Intermittent vs. continuous therapies
27. Peritoneal dialysis: Continuous
solute & fluid clearance
Less expertise, equipment
Surgically placed
Tenckhoff, short-term
catheters
Stiff catheters still used
Successful in most
Not efficient: severe fluid
overload, lactic acidosis
Pulmonary compromise;
abdominal surgery
Manual PD: labor intensive
If done correctly, PD achieves
adequate solute & water clearances
30. Choice of RRT depends on
clinical features & local expertise
Peritoneal dialysis: prefer if isolated ARF;
universally available
Hemodialysis: efficient; nursing expertise
Hemofiltration: increasingly used in PICU;
enables nutrition; risks of bleeding
32. Patients with AKI need follow up
Evaluate patients @ 3-mo after AKI
Manage CKD as per guidelines
Consider patients without CKD as being @ increased risk
33. Children should not die of AKI
Recognize patients @ risk; maintain volume, perfusion
Discontinue nephrotoxic agents; avoid radiocontrast
Dosage of most medications will change
Limited role of pharmacological interventions
Prompt renal replacement (not mode, nor dose)
determines outcome
Need prolonged follow up
Do what you do well and improve the care
of patients with AKI …. Tim Bunchman
34. 0 By 25
• Thousands of people are still dying in
vain of AKI, especially in less developed
or emerging countries. AKI should no
longer be a death sentence for these
people. Nobody should die of
preventable and treatable Acute Kidney
Injury (AKI) by 2025!
G. Remuzzi, ISN President
35. Goals
• To address the current lack of data on
the global burden of AKI, especially in
low and middle-income countries. We
hope to establish AKI as a contributor
to the Global Burden of Disease
36. • To raise awareness of AKI across the
global healthcare community including
among healthcare professionals,
patients and, more widely, among
governments and public health
institutions and the private sector
37. • To contribute to developing a
sustainable infrastructure by
implementing “need driven” approaches
in selected areas for education and
training and care delivery
