perioperative aki

8/3/2019 Perioperative AKI

1/31

Periopera(ve

AcuteKidneyInjury

Biomarkers,Physicians,andtheSurgicalAbdomen

Dr.AndrewFergusonDepartmentofAnaesthe?cs&IntensiveCareMedicine

CraigavonAreaHospital


2/31

Disclosures

Noconflictsofinteresttodeclare


3/31

Outline

WhyAKImaJerstous Diagnos?candstagingcriteriaforAKI AKIriskfactorsinperiopera?vepa?ents NovelbiomarkerswhatdotheyofferClinicalchallengesimpactoffluidoverload

Take-homepoints


4/31

Periopera(veAKIisNEVERbenign!


5/31

PredictableandavoidableAKI

shouldneveroccur

Post-opera(veAKIisavoidablein

theelderlyandshouldnotoccur


6/31

Howdowediagnose&stageAKI?

CruzDNetal.Cri?calCare2009;13:211


7/31

NgKP,etal.QMed2011,advanceaccessAugust222011

ThegrimrealityofrealworldAKI

In222non-ICUAKIpa?entsrequiringRRT

29%ofpa?entsdiedwithin30days

37.6%diedwithin90days

51.4%diedwithinoneyear

34.9%ofsurvivorsRRTdependentat1year55%ofsurvivorsoffRRTby90dhadeGFR


8/31

AllgradesofAKImaSer!

CruzDN,etal.Cri?calCare2009;13:211

RicciZ,etal.KidneyInterna?onal2008;73:538-546

ClechC,etal.CritCare2011;15:R128

MandelbaumT,etal.CritCareMed2011;39:Epubaheadofprint

AKIN


9/31

coringPeriopera(veAKIRisk

Age>56years Malegender Ac?veCHF Ascites Hypertension MildtomoderateCKD DiabetestreatedwithOHAorinsulin Emergencysurgery Intra-peritonealsurgery

Riskfactors Hazardra(o0-2 1

3 3.1

4 8.5

5 15.4

6 46.2

KheterpalS,etal.Anesthesiology2009;110:505-515


10/31

Incidence-emergencysurgery

N=61,meanage75,unpublishedauditdata


11/31

Incidenceelec(vesurgery

tudy Popula(on AKIdefini(on AKIincidence

Thakar1Retrospec(ve504pa?entsgastricbypass

>50%riseincrea?nineor

needforHD 8.5%

Kheterpal2Prospec(ve,observa?onalmajornon-cardiacsurgery15,102pa?ents

crea?nineclearance>80ml/min

Crea?nineclearance


12/31

Earlydiagnosisthecrea(nineissue

Varia?onwithmusclemass&ageetc. Insensi?vetorapidchangesinrenalfunc?on Insensi?vetolesserdegreesofdysfunc?on FrequentlyabsentbaselineLag?melostopportunityfortherapy

Alteredbyfluidshi^sandfluidbalance1

Posi?vebalancecanhideAKI1LiuKD,etal.CritCareMed2011;39:Epubaheadofprint(uly2011)


13/31

Biomarkerstherenalcrystalball?


14/31

Renalbiomarkercandidates

Kidneyinjurymolecule1(KIM-1) Cysta?nC Interleukin18(IL-18) Andothers

Neutrophilgela(nase-associatedlipocalinNGAL)


15/31

NGAL-whatisit?

25kDaproteinup-regulatedinrenalinjury PresentinurineandplasmainAKI Levelrisesasearlyas2hoursaercellinjury Fallswithsuccessfultherapy(animalmodels)

PredictsAKI

PredictspooroutcomesRRT/death)

Allowsmonitoringoftherapy

HaaseM,etal.CurrOpinCritCare2010;16:526-532


16/31

Timehours)03-62448

NGAL

KIM-1

Cysta(nC

Crea(nine

McIlroyDR,WagenerG,LeeHT.Anesthesiology2010;112:998-1004

Biomarker(me-course

Therapeu(cwindow


17/31

0

2

4

6

8

10

12

14

1618

20

NGAL-/

Creat-

NGAL+/

Creat-

NGAL-/

Creat+

NGAL+/

Creat+

RRT

Hospdeath

Composite

NGALandsubclinicalAKI

NGALriseonly=similaroutcomestoNGAL&crea?ninerise Retrospec?vepooleddesignHaaseM,etal.AmCollCardiol2011;57:1752-1761

%


18/31

Biomarkers-unresolvedissues

Bedsidevs.laboratorytes?ng Lackofreal-worldassayvalida?on Timing/frequencyoftes?nguncertain Lackofevidenceforwhatsbesttodonext Impactoftes?ngonoutcomesunclear


19/31

Challengesinperiopera(veAKI

Needssurgery

NOW!

Canwekeepup?


20/31

AKITriggers&Perpetuators

AKIHypotension

Hypovolaemia

Drugs,toxins,

contrast

Cardiacdysfunc(on

Tissueoedema

Abdominalhypertension

Microvasculardysfunc(on

epsis

Fluidoverload


21/31

AKIhurtsotherorgansystems

GramsME,RabbH.KidneyInterna?onal2011;advanceonlinepublica?on,3August2011


22/31

Generalmanagement

Op?misehaemodynamics

Appropriatefluidchallenges+/-inotrope/pressor(dobutamine/dopamine)

Stopnephrotoxins&adjustdrugdoses Treatunderlyingsepsis/obstruc?on Physiologicalsurveillance/management

EscalatetoHDU/ICUCRRT NephrologyconsultIHD


23/31

Problemareas-fluidoverload

Fluidsdonotreversevasodilatoryhypotension Associatedwithpooroutcomes Causesorgan/?ssueoedema Causesvenousconges?on Worsens?ssueperfusion Intraabdominalhypertension


24/31

Fluidoverload&adverseoutcomePopula(on N Design Results

ARD+AKI1 306 Retrospec(veanalysisofRCT trongassocia(on+vebalanceandmortality

Sep?cshock2 778 Retrospec?veanalysisofRCT+vebalancecorrelatedwith

increasedmortality

AKI3 297 Prospec(vecohortMore+vebalanceassociated

withmortality

AKI4 618 Prospec(vecohortMore+vebalanceassociated

withmortality

ICU5 1,120 Prospec?vecohortMore+vebalanceassociated

withmortality

ARDS6 1,000 RCT Conserva?vebalance=shorterven?la?on?me

Pancrea??s7 247 Prospec?vecohortMore+vebalanceassociated

withincreasedorganfailures

1GramsME,etal.ClinAmSocNephrol2011;6:966-9732BoydH,etal.CritCareMed2011;39:259-265

3SutherlandSM,etal.AmKidDis2010;55:316-325

4Bouchard,etal.KidneyInt2009;76:422-4275PayenD,etal.CritCare2008;12:R74

6WiedemannHP,etal.NEnglMed2006;354:2564-25757de-MadariaE,etal.AmGastroenterol2011.Epub30/08/2011


25/31

Fluidoverloadcauses(ssueoedema

Cerebral Alteredmentalstatus

Myocardial Arrhythmia,diastolic/systolicdysfunc?on

Pulmonary Impairedgasexchange,increasedwork

Hepa(c Cholestasis

Renal DecreasedRBF&GFR,venousconges?on

Gut Ileus,anastomo?cbreakdownTissue Poorhealing,pressureulcers,infec?ons

ProwleR,etal.NatRevNephrol2010;6:107-115


26/31

Fluidoverloadworsens(ssueperfusion

Sheddingofendothelialglycocalyx

Triggeredbyhypervolaemia(ANP)&inflamma?on1 Lossofvascularintegrity=>leak Leukocyte/plateletadhesion=>microthrombi

1BrueggerD,etal.BasicResCardiol2011;19 thulyOnlineFirst


27/31

Microvascularresponsestofluid

Differsfromthemacro-haemodynamicresponse ImprovementinCOandBPdonotguaranteeimprovementinmicrovascularperfusion

Posi?vemicrovascularresponsetofluidbolusdiminishessignificantlyover?me

PoJecher,etal.IntensiveCareMed2010;36:1874

Ospina-TasconG,etal.IntensiveCareMed2010;36:949-955

HarroisA,etal.CurrOpinCritCare2011;17:303-307


28/31

Intra-abdominalhypertension

NormalIntra-AbdominalPressure75mmHg

APP=Meanarterialpressure(MAP)IAP Renalfiltra?ongradient=MAP2*IAP

DecreasedRBF,increasedvenouspressures

Impairedgutbloodflow&guttransloca?on IAP>20+organfailure=compartmentsyndrome


29/31

owhatshouldwedo?

THINKbeforefluidsandMONITORaer Earlyfluidresuscita?onisappropriate Usuallyleadstoearlyposi?vebalance Maketheswitch

Evenbalanceby48hours,nega?vebeyondthisDiure?csorUFEarliermovetoinotropes/pressors

Makeitpartofdailyprac?ce


30/31

Take-homepoints

AnydegreeofAKI=worseoutcome Riskrecogni?onandtailoredjourney

Morehaemodynamicop?misa?on

EarlierrecoursetoHDU/ICU Biomarkers=earlierinterven?on Fluid?mingandbalancearecri?cal Renalrescuebundles


31/31

Poisonisineverything,

andnothingiswithoutpoison.

Thedosagemakesiteitherapoisonoraremedy

PhilippusAureolusTheophrastusBombastusvonHohenheim

Paracelsus(1493-1541)

perioperative aki

Documents