acute kidney injury › wp-content › uploads › 2020 › 03 › ... · acute kidney injury -...
TRANSCRIPT
Acute Kidney Injury“Laying Siege to Life”
2020 NURSING SYMPOSIUM
DisclosuresRelevant Financial Relationships:◦ None
Relevant Non-Financial Relationships:◦ Medical Director at a Fresenius Kidney Care Center
2020 NURSING SYMPOSIUM
Acute kidney injury - Facts
Complicates 5% of hospital admissions
Affects 30-50% of intensive care patients
Prerenal failure is most common etiology
Hospital mortality as high as 20-25%
Death remains high in the first year after hospitalization (28% in a study from Ontario, CA)
2020 NURSING SYMPOSIUM
2020 NURSING SYMPOSIUM
BMJ 2015;351:h5639
Risk of postoperative acute kidney injury in patients undergoing orthopaedic surgery—development and validation of a risk score and effect of acute kidney injury on survival: observational cohort study
2020 NURSING SYMPOSIUM
Acute kidney injury - Facts
2020 NURSING SYMPOSIUM
Average duration of AKI is 7 to 21 days - although
highly variable
Recurrent AKI is associated with higher
risk of CKD and/or death
AKI is associated with a higher mortality
Acute Kidney Injury may lead to CKDRisk factors that may increase risk of chronic injury:◦ Preexisting chronic kidney disease
◦ Prolonged ischemia
◦ Repeated injuries
◦ Older age
◦ Heart or liver failure
◦ Albuminuria
2020 NURSING SYMPOSIUM
Acute kidney injury after cardiac surgery in eastern Saudi Arabia
2020 NURSING SYMPOSIUM
EMHJ, 2011, 17(6): 495-500
Acute Kidney Injury IncreasingAging of the population
More interventions (chemotherapy, surgery, contrast procedures)
Rising incidence of co-morbid conditions (heart failure, diabetes)
Rising awareness of kidney injuries
2020 NURSING SYMPOSIUM
Acute vs Chronic Kidney InjuryCharacteristic AKI CKD
Duration Short Permanent
Onset Recent Slow and Prolonged
Progression Rapid Gradual
SymptomsFrequent and driven by rapid
changesFew, unless driven by
associated disease
Recovery Common Uncommon
2020 NURSING SYMPOSIUM
2020 NURSING SYMPOSIUM
2020 NURSING SYMPOSIUM
Acute Kidney Injury – Blood FlowOrgan Blood flow rate Percent of Cardiac Output
Kidneys 1200-1300 ml/min 25%
Brain 750 ml/min 15%
Intestines 500-1750 ml/min 10-35%
Skeletal muscles 1000 ml/min (rest) to 4000 ml/min
20-80%
2020 NURSING SYMPOSIUM
AKI Evaluation
Laboratory Data◦ BUN and creatinine *◦ Urine analysis *◦ Others (Hgb, PTH, uric acid, CK, sodium, CO2)
Imaging studies◦ IV contrast given◦ Structural analysis
Symptoms *
Vitals and Urine output *
Medication *
2020 NURSING SYMPOSIUM
2020 NURSING SYMPOSIUM
2020 NURSING SYMPOSIUM
2020 NURSING SYMPOSIUM
ATN41%
PRERENAL19%
OBSTRUCTION9%
NEPHRITIS6%
AKI w/ CKD12%
OTHER13%
AKI CAUSES
ATN PRERENAL OBSTRUCTION NEPHRITIS AKI w/ CKD OTHER
2020 NURSING SYMPOSIUM
Important Factors in AKI
Insufficient renal circulation (hypotension, hemorrhage)
Medication (RAS inhibitors, NSAIDS, PPI drugs, chemotherapy)
Iodinated contrast agents
Obstruction
Inflammation◦ Muscle damage
◦ Cellular injury (uric acid)
◦ Autoimmune conditions (lupus, scleroderma, vasculitis)
◦ Infection (sepsis, thrombotic microangiopathy)
2020 NURSING SYMPOSIUM
2020 NURSING SYMPOSIUM
2020 NURSING SYMPOSIUM
2020 NURSING SYMPOSIUM
Acute Kidney Failure
Vasocontrictors Vasodilators
Angiotensin II Nitric Oxide
Endothelin I Prostaglandin E2
Thromboxane A2 Prostacyclin
Adenosine Atrial natriuretic peptide
Sympathetic nerve activity
2020 NURSING SYMPOSIUM
Pre-Renal Injury◦ Unable to optimize filtration efficiency◦ Reduces waste clearance◦ Reversible◦ Since tubular function is intact, urinary sodium will be low – the
kidney is trying to restore intravascular volume◦ Clinically, patient may have hypovolemia, euvolemia, or
hypervolemia◦ “Effective renal blood flow” may be decreased◦ Treatment is directed at restoring glomerular blood flow to enable
filtration
2020 NURSING SYMPOSIUM
2020 NURSING SYMPOSIUM
2020 NURSING SYMPOSIUM
2020 NURSING SYMPOSIUM
Acute Tubular Injury Treatment
Eliminate Threats◦ Correct blood pressure or eliminate obstruction
◦ Stop offending medication
Avoid new insults (iodinated contrast, hypotension)
Optimize renal perfusion◦ Restore central volume
◦ Support systemic blood pressure (pressors, reduce afferent arteriolar vasocontriction)
Loop diuretics◦ Mainly used to augment urine, but may help with dislodgement of intratubular casts
Eliminate triggers (Treat infections)
2020 NURSING SYMPOSIUM
AKI Treatment◦ Atrial natriuretic peptide (block tubular reabsorption of sodium,
vasodilate afferent arterioles, and inhibit the renin-angiotensin system)
◦ Dopamine (or Fenoldopam – selective dopamine-1 agonist)◦ N-acetylcysteine◦ Vasopressin◦ Steroids◦ Statins◦ Sodium bicarbonate
2020 NURSING SYMPOSIUM
2020 NURSING SYMPOSIUM
Acute Kidney Injury - TreatmentManage AKI
condition (dialysis, fluids,
nutrition)
Make an underlying diagnosis
2020 NURSING SYMPOSIUM
2020 NURSING SYMPOSIUM
Acute Kidney Injury - DialysisStart dialysis – “when the risks of dialysis are less than the risks of observation”◦ Hypervolemia
◦ Metabolic acidosis
◦ Uremia symptoms
◦ Electrolyte derangement (hyperkalemia, hyponatremia)
Other considerations:◦ Poisoning (ethylene glycol, lactic acidosis)
◦ CK levels in patients with rhabdomyolysis
◦ Urine output
◦ Weekends and evenings
2020 NURSING SYMPOSIUM
Dialysis Risks
2020 NURSING SYMPOSIUM
Line insertion with risk of bleeding, discomfort, or infection
Dialysis might prolong or compound tubular injury
Hypotension or arrythmias may occur during or after a dialysis session
Dialysis vs CRRT
Hemodialysis CRRT
Clearance √√√√ √√
Hemodynamic Stability √ √√√
Volume Removal √ √√√
Cost √√ √√√√
2020 NURSING SYMPOSIUM
When to Stop Renal Replacement◦ Improving urine output
◦Creatinine not rising much between dialysis sessions
◦Creatinine falling spontaneously
◦Creatinine is below 3.5 mg/dl pre-dialysis
2020 NURSING SYMPOSIUM
6.1
4.6 4.7
4.6 4.2
Special Circumstances
2020 NURSING SYMPOSIUM
AKI in renal allograft
Hepatorenal syndrome
Rhabdomyolysis
NSAIDS
Allograft AKIAdditional prerenal conditions◦ Loss of afferent arteriole parasympathetic influence
◦ Continual calcineurin inhibitor (CNI) mediated vasocontriction
Initial ischemia (donor type, donor age, donor circulation)
Viral infection (polyoma BK, CMV)
Acute rejection (antibody-mediated rejection, cellular rejection)
Recurrence of primary renal disease (diabetes, FSGS, mesangial GN, membranoproliferative GN, lupus, crescentic GN)
Older donor age may be associated with greater sensitivity to CNI drugs
2020 NURSING SYMPOSIUM
2020 NURSING SYMPOSIUM
Allograft AKI
If creatinine is over 25% of baseline level:
• Adjust CNI dose if necessary
• Correct additional prerenal conditions
• Repeat lab including CNI level in 5-7 days
• If GFR not improved, then perform renal biopsy
2020 NURSING SYMPOSIUM
Hepatorenal syndrome (HRS)◦ In the late 19th century, reports noted an association among advanced liver
disease, ascites, and oliguric renal failure in the absence of significant renal histologic changes
◦ Underlying mechanism of kidney failure is peripheral and splanchnic arterial vasodilation – combined with intense renal vasoconstriction mediated by renal sympathetic stimulation
◦ HRS kidneys work when transplanted – also kidney function may recover after liver transplantation
◦ Elevated nitric oxide synthesis particularly in splanchnic circulation
◦ Depressed prostaglandin synthesis
2020 NURSING SYMPOSIUM
Frequent HRS Triggers
Bacterial infection
Large volume paracentesis
GI hemorrhage
Acute alcoholic hepatitis
2020 NURSING SYMPOSIUM
Renal Circulatory Conditions
2020 NURSING SYMPOSIUM
Hepatorenal syndrome
• Prerenal syndrome with internal derangement of renal autoregulation
Cardiorenal syndrome
Edematous conditions
• Severe pulmonary hypertension
• Severe venous insufficiency
• Abnormal capillary permeability (diabetes, sepsis, burns, trauma,
• Medication (NSAIDS, glucocorticoids, glitazones, insulin, estrogens, tamoxifen, vasodilators, calcium channel blockers, gabapentin, pregabalin, pramipexole)
• Lymphatic obstruction
• Nephrotic syndrome
Rhabdomyolysis
2020 NURSING SYMPOSIUM
Crush injuries or direct muscle trauma
Exertional (non-traumatic) injury
• extreme exercise
• heat
Hyperkinetic conditions
• seizures
• amphetamine use
• delirium tremens
Metabolic causes
• carnitine palmitoyltransferase deficiency
• phosphorylase deficiency (McArdle disease)
Drugs
• cocaine, alcohol, amphetamines
• statins, colchicine, volatile anesthetic agents
NSAIDS and the KidneyInhibit prostaglandins, thus leads to abnormal afferent arteriole autoregulation
If present during a period of hypoperfusion, then risk for acute tubular injury is much greater
May cause an interstitial nephritis
Associated with a glomerular disorder (minimal change nephropathy)
Impairs tubular potassium excretion and may cause a type IV renal tubular acidosis
Leads to sodium and water retention
May cause hyponatremia
2020 NURSING SYMPOSIUM