Acute Kidney Injury Post-op: Kidney attack

1. Acute Kidney InjuryPost-op: Kidney attack Kianoush Kashani 5th Anesthesia and Critical Care Conference Kuwait 2013

4. Outlines Definition Epidemiology/outcome Pathophysiology Diagnosis Management Vs treatment

6. RIFLE Criteria GFR criteria Urine output criteria Increased creatinine x1.5 or GFR decrease >25% UO <0.5 mL kg-1h-1 x6 hr Risk High sensitivity Increased creatinine x2 or GFR decrease >50% UO <0.5 mL kg-1h-1 x12 hr Injury Increased creatinine x3 or GFR decrease >75% or creatinine 4 mg/100 mL (acute rise of 0.5 mg/100 mL dL) UO <0.3 mL kg-1h-1 x24 hr or anuriax12 hr Oliguria Failure High specificity Persistent ARF = complete loss of renal function >4 weeks Loss End-stage renal disease ESRD

7. AKIN Definition for AKIAKIN Conference, Vancouver 2006 • Inc Scr 0.3 mg/dL or >150-200% from baseline Stage I <0.5 mL/kg/hr for >6 hr • Inc Scr >200-300% from baseline Stage II <0.5 mL/kg/hr for >12 hr • Inc Scr >300% • Scr >4 with acute min rise of 0.5 mg/dL • Need for RRT • <0.3 mL/kg/hr for 24 hr • Anuria for 12 hr Stage III

9. Reasons for  incidence Age Comorbid conditions CKD More sensitive criteria Incidence of AKI % Year Hou et al: Am J Med 74:243, 1983 Nash et al: JASN 7:376, 1996 Nash et al: AJKD 39:930, 2002

11. AKI and Mortality 0.01 0.01 0.01 0.1 0.1 0.1 1 1 1 10 10 10 100 100 100 Mortality Risk vs Non-AKIRR (random)95% CI Mortality Injury vs Non-AKIRR (random)95% CI Mortality Failure vs Non-AKIRR (random)95% CI Study or subcategory 01 General ICU (Cr and UO criteria) Abosaif Ahlstrom Cruz Hoste 02 General ICU (without UO criteria) Lopes (HIV) Lopes (sepsis)Ostermann 03 Cardiosurgery Kuitunen Lin 04 Other ICU Coca Lopes (bmt) Lopes (burns) 05 Not confined to ICU Uchino Ricci Z: Kidney Int 73:538, 2008

12. AKI and Long-Term Mortality No AKI AKIN I AKIN II Cumulative probabilityof survival (%) AKIN III Number at risk 782,222 601,772 443,730 296,128 138,820 No AKI 52,338 37,234 25,798 16,441 7,758 AKIN I 19,771 13,692 9,210 5,712 2,633 AKIN II 10,602 7,173 4,639 2,723 1,200 AKIN III Follow-up (years) Lafrance et al: JASN 21(2):345, 2010

13. ESRD After AKI No AKI or CKD CKD only AKI only AKI and CKD P<0.0001, DF=1 AKI Probability of ESRD Probability of ESRD P<0.0001, DF=3 No AKI Days from hospital discharge Days from hospital discharge

14. RRT epidemiology (NEFROINT data) Piccinni et al. Minerva anestheiology 2011; 77:1-2

16. Etiology of Hospital-Acquired AKI % Comprehensive Clinical Nephrology, Johnson 3rd edition

17. Ischemia induced AKI Abuelo et al, NEJM 2007, 357 (8)

19. Symptoms Polyuria Oliguria/anuria Hematuria Dysuria Azotemia Mental status changes Acidosis ( respiratory rate) Hypervolemia/hypertension Hyperkalemia Pericarditis

20. Urinary Index PrerenalLaboratory test azotemia ATN Urine osmolality (mOsm/kg) >500 <400 Urine sodium level (mEq/L) <20 >40 Urine/plasma creatinine ratio >40 <20 Fractional excretion of sodium (%) <1 >2 Fractional excretion of urea (%) <35 >35 Urinary sediment Normal; Renal tubular occasional hyaline epithelial cells; or fine granular granular and casts muddy brown casts Schrier: J Clin Invest 114(1):5, 2004

21. FeNa Less than 1% Decreased renal perfusion Decreased intravascular volume NSAID ACE inhibitor/ARB Pigmenturia Hepatorenal syndrome Acute contrast nephropathy Acute (early) GN Early obstruction Acute embolic event

22. FeNa More than 3% Tubular dysfunction ATN Chronic renal disease Diuretics/concentrating defects

23. Urinary Sediments Sediment Differential diagnosis Normal or few Prerenal azotemia Red blood cells Arterial thrombosis or embolism White blood cells Preglomerular vasculitis HUS or TTP Scleroderma crisis Postrenal azotemia Granular casts ATN (muddy brown) Glomerulonephritis or vasculitis Interstitial nephritis Red blood cell casts Glomerulonephritis or vasculitis Malignant hypertension Rarely interstitial nephritis White blood cell casts Acute interstitial nephritis or exudative glomerulonephritis Severe pyelonephritis Marked leukemic or lymphomatous infiltration Eosinophiluria (>5%) Allergic interstitial nephritis (antibiotics > NSAIDs) Atheroembolic disease Crystalluria Acute urate nephropathy Calcium oxalate (ethylene glycol toxicity) Acyclovir Indinavir Sulfonamides Radiocontrast agents Brenner and Rector: The Kidney, 8th edition

24. Ultrasonography in AKI Observation Clue to diagnosis of Shrunken kidneys Chronic kidney disease Normal size kidneys Echogenic Acute GN Normal Echo Prerenal Acute renal artery occlusion Enlarged kidneys Malignancy, renal vein thrombosis, diabetic nephropathy, HIV Hydronephrosis Obstructive nephropathy Comprehensive Clinical Nephrology, Johnson 3rd edition

25. Pathology

26. Pathology

27. Renal Angina • Hazard Tranche 1 • Very high risk patients • Increase in 0.1 mg/dL over baselineor • 1 hour of oliguria in a appropriately resuscitated subject • Hazard Tranche 2 • High risk patients • Increase in 0.3 mg/dL over baselineor • 3 hours of oliguria in a appropriately resuscitated subject • Hazard Tranche 3 • Moderate risk patients • Increase in 0.4 mg/dL over baselineor • 5 hours of oliguria in a appropriately resuscitated subject Renal Angina Threshold Hazard Tranche#1 Hazard Tranche#2 Hazard Tranche#3 Hazard Tranche#1 Hazard Tranche#2 Hazard Tranche#3  serum creatinine (mg/dL) Oliguria (hr) Risk of developing acute kidney injury Risk of developing acute kidney injury Goldstein et al: cJASN 5:943, 2010

28. Biomarkers Cystatin C Functional marker in blood Tubular marker in urine NGAL In plasma less sensitive/specific than urine Others IL-18 Kim-1 L-FABP Netrin-1 Vimentin Stay tunednew markers are on the way

29. Risk prediction

30. Risk prediction

31. Risk prediction

32. Management

33. KDIGO guidelines KI supplement, March 2012

34. Aydin, Z. et al. NDT. 2007 22:342-346

35. شكراً “The best interest of the patient is the only interest to be considered”

36. Questions & Discussion