acute kidney injury - seton.net · 50% - 70% in severe aki requiring rrt ... can diagnose aki...
TRANSCRIPT
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Acute Kidney Injury
Ali Salim, MD
Professor of Surgery
Chief, Division of Trauma, Burns, Surgical Critical Care, and Emergency General Surgery
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Disclosures
I have nothing to disclose
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Acute Kidney Injury
Incidence
Definition
Causes
Treatment
RRT Controversies
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Acute Kidney Injury
Sudden decline in kidney function
Due to:
Loss in small solute clearance
↓ GFR
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Acute Kidney Injury
Sudden decline in kidney function
Disturbances in :
Fluid
Electrolytes
Acid base balance
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Acute Kidney Injury
Sudden decline in kidney function
Spectrum of disease
Subclinical injury
Complete organ failure
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Acute Kidney Injury
Common in ICU
7% of hospitalized patients
36% to 67% of critically ill patients
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Acute Kidney Injury
↑ morbidity
↑ cost
↑ length of stay
↑ mortality
Mortality ↑ proportionately with ↑ severity
50% - 70% in severe AKI requiring RRT
Independent risk factor for in-hosp mortality
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Acute Kidney Injury
↑ development of chronic kidney disease
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Definitions
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Definitions
RIFLE
AKIN
KDIGO
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RIFLE
R -risk
I - injury
F - failure
L – loss
E – end stage kidney disease
Uses serum creatinine and UOP
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RIFLE SCr Criteria UOP Criteria
R ↑ SCr x 1.5 < 0.5 ml/kg/hr x 6
hrs
I ↑ SCr x 2 < 0.5 ml/kg/hr x 12
hrs
F ↑ SCr x 3, or SCr ≥ 4
w/ an acute rise of at
least 0.5
< 0.5 ml/kg/hr x 24
hrs, or anuria x 12 hrs
L Persistent loss of
kidney function > 4
weeks
E Persistent loss of
kidney function > 3
months
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AKIN
A - acute
K - kidney
I - injury
N - network
Even very small changes in SCr (≥ 0.3mg/dl)
adversely impact outcome
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AKIN Stage SCr Criteria UOP Criteria
1 ↑ SCr ≥ 0.3 or ↑1.5 to
2 fold from baseline
< 0.5 ml/kg/hr > 8
hrs
2 ↑ SCr > 2 to 3 fold
from baseline
< 0.5 ml/kg/hr > 12
hrs
3 ↑ SCr > 3 fold from
baseline, or SCr ≥ 4
w/ an acute rise of at
least 0.5
< 0.5 ml/kg/hr x 24
hrs, or anuria x 12 hrs
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KDIGO
K - Kidney
D - disease
I – improving
G - global
O - outcomes
Merging of RIFLE and AKIN
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KDIGO
AKI
SCr ↑ ≥ 0.3 in 48 hours; or
SCr ↑ ≥ 1.5 times baseline within 7 days; or
UOP < 0.5 ml/kg/hr for 6 hours
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Biomarkers
Replace or complement serum creatinine
Can diagnose AKI earlier
May provide information regarding etiology
Cystatin C is used in some hospitals
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Causes of AKI
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Top 5 Causes of AKI
Sepsis – up to 50% of cases
Major surgery
Low cardiac output
Hypovolemia
Medications
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Medications
NSAIDS
Antimicrobials
Aminoglycosides
Amphotericin
Penecillins
Acyclovir
Chemotherapeutic agents
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Other Causes
Hepatorenal syndrome
Trauma
Cardiopulmonary bypass
Abdominal compartment syndrome
Rhabdomyolysis
Obstructive Uropathy
Radiocontrast dye
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Management of AKI
Optimizing hemodynamics
Maintain renal perfusion
Avoid hyperglycemia
Avoid nephrotoxins
Diuretics for volume overload
Adequate nutrition
RRT
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Management of AKI
Optimizing hemodynamics
Maintain renal perfusion
Avoid hyperglycemia
Avoid nephrotoxins
Diuretics for volume overload
Adequate nutrition
RRT
Only treatment option for AKI
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Management of AKI
No other supportive measures available
Best therapy is avoidance of further injury
Early intervention appears to be beneficial
Ideal intervention still under debate
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Indications for RRT
No current consensus on indications
“Absolute” indications
Severe hyperkalemia
Clinically apparent signs of uremia
Severe acidemia
Volume overload
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Renal Replacement Therapy
Choice of modality??
Timing of intervention??
Dose/Intensity of treatment??
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Choice of Modality
Continuous versus intermittent
Continuous
SCUF
CVVH
CVVHD
CVVHDF
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Choice of Modality
Continuous more closely approximate
normal physiology
Slow correction of metabolic derangements
Slow removal of fluid
Better tolerated in critically ill and
hemodynamically unstable
Data??
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Intensity of Renal Support
Intensive renal support:
No decrease in mortality
Did not improve recovery of kidneys
Did not reduce rate of nonrenal organ failure
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Zhang et al Am J Kid Dis 2015;66:322-330
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Zhang et al Am J Kid Dis 2015;66:322-330
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Zhang et al Am J Kid Dis 2015;66:322-330
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Continuous versus Intermittent
No difference in outcome
Choice is influenced by:
Individual site availability
Resources
Cost
Clinician bias
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Renal Replacement Therapy
Choice of modality??
Timing of intervention??
Dose/Intensity of treatment??
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Timing of RRT
Early intervention seems to be important
When to start when conventional indications
are absent?
How early is early?
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2011
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2011
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Earlier appears to be better
Heterogeneous studies
Definitive recommendation cannot be
made…
2011
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2016
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KDIGO stage 2
SCr ≥ 2 times baseline or
UOP < 0.5 ml/kg/hr ≥ 12 hrs
Plasma neutrophil gelatinase-associated
lipocalin > 150
2016
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Early – within 8 hours of diagnosis
N=112
Delayed – within 12 hours of stage 3 AKI or
upon an absolute indication
N=119
2016
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Early initiation
↓ mortality (39.3% vs 54.7%, p=0.03)
↑ renal recovery (53.6% vs. 38.7%, p=0.02)
↓ RRT duration (9 days vs. 25 days, p=0.04)
↓ hospital stay (51 days vs. 82 days, p<0.001)
2016
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2016
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AKIKI Study
KDIGO stage 3
Mechanical ventilation; or
Catecholamine infusion
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AKIKI Study
Early
Immediately after randomization
Late
If at least one criteria met
Severe hyperkalemia
Metabolic acidosis
Pulmonary edema
BUN > 112
Oliguria > 72 hours
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AKIKI Study
Early
N=311
Within 2 hours after randomization
Late
N=308
Within 57 hours after randomization
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2016
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Delayed:
No difference in mortality
Averted need of RRT in many
2016
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Timing
Question of timing remains unanswered
Still need definition of “early”
More studies warranted
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Renal Replacement Therapy
Choice of modality??
Timing of intervention??
Dose/Intensity of treatment??
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Dose/Intensity of Treatment
Intensities range from intensive to less
intensive with respect to CRRT
Can also have variable intensities with
intermittent dialysis
What is best??
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No difference in outcome between
intensive renal support and less-intensive
support
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2016
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Cochrane Review - 2016
Compared less intense (range 20-25
ml/kg/hr) to more intense (35-48 ml/kg/hr)
No difference:
Mortality
Renal recovery
Postsurgical AKI
High intensity appears to reduce risk of death
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Acute Kidney Injury
Incidence
Definition
Causes
Treatment
RRT Controversies
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