ACUTE KIDNEY INJURY (AKI)

(Cedera Ginjal Akut)

Another term : Acute Renal Failure

Many references / literatures still use this term

DEFINITION :
AKI is an abrupt (less then 7 days) and sustained decrease in
kidney function.
changes in blood biochemistry : increased of serum
creatinine, blood urea nitrogen
decreased of urine out put in 80-90% cases (10-20%
normal or increase) or both
kidney function used to be normal
When the patient has a previous episode of kidney disease,
the term is : Acute on Chronic Kidney Injury (ACKI)
CLASIFICATION
AKI classified according to degree and outcome of renal
function by RIFLE criteria
R = Risk I = Injury F = Failure
L = Loss E = End Stage

1. Risk of Renal Dysfunction (R)

serum creatinine increased 1.5 fold, or
GFR decreased by more than 25%
Less than 0.5 ml/kg/h of urine production for 6 hours
2. Injury of the Kidney (I)
doubling of serum creatinine or
GFR decreased by more by 50% or
urine production less than 0.5 ml/kg/h in 12 hours
3. Failure of Kidney Function
serum creatinine increased 3 fold, or
GFR decreased by more than 75%
less than 0.3 ml/kg/h of urine for 24 hours
4. Loss of Kidney Function
Complete loss of kidney function for longer
than 4 weeks
5. End Stage Renal Disease
The need for dialysis for longer than 3 month
 GFR Criteria AND/OR Urine output Criteria

Risk of renal 50% decrease in creatinine Urine output < 0.5 ml/kg/hr for
dysfunction or > 25% decrease in GFR at least 6 hours

Two-fold increase in Urine output < 0.5 ml/kg/hr for

Injury to the creatinine or > 50% at least 12 hours
kidney decrease in GFR

Three-fold increase in creatinine Urine output < 0.3

Failure of or > 75% decrease in GFR or ml/kg/hr for 24 hours (or
creatinine > 350 (acute rise) anuria for 12 hours)
kidney function

Loss of kidney Loss of kidney function > 4 weeks

function but < 3 months

ERF Established renal failure (loss of

function > 3 months)

Acute renal failure (ARF) classified according to degree and outcome by RIFLE criteria
CAUSES OF AKI
Causes of AKI divided into three matter :
1. Prerenal :
Decreased of renal perfusion (hypoperfusion)
2. Renal (Intrinsic)
Damage of parenchyma of the kidney (glomeruli,
tubules, intra-renal vasculature, interstitial nephritis)
3. Post-renal
Obstruction of urinary tract
PRERENAL CAUSES OF AKI
1. Shock :
cardiogenic ahock
distributive shock (e.g.sepsis, anaphylactic)
2. Hypovolemia hypovolemic shock
haemorhage
gastrointestinal loss (vomiting, diarrhea)
cutaneous losses (e.g.burns)
3. Renal hypoperfusion
renal artery stenosis
hepatorenal syndrome
4. Changes of water distribution (oedema)
congestive heart failure
hepatic failure
nephrotic syndrome
RENAL / INTRINSIC CAUSES OF AKI
1. Glomerular disease
glomerulonephritis
2. Tubular injury
prolonged renal hypoperfusion
toxin (snake venom), drugs (aminoglycosides),
3. Vascular
vasculitis
arterial or venous thrombosis
4. Interstitial nephritis
infiltrative malignancy
toxin (alcohol, metal)
infection (leptospiral)
POST-RENAL CAUSES OF AKI
Obstruction :
stone
urethral stricture
prostate hypertrophy
pelvic tumor
retroperitoneal fibrosis
DIAGNOSTIC
1. History of disease
gastroenteritis, bleeding ?
heart disease
toxin ? post infection ?
stone disease ?
2. Investigation
A. Physical examination.
blood pressure (hypotension/shock)
anemic, dehydration
renal colic, ballotment, full vesica urinaria
B. Blood chemistry
haemoglobine, white blood cell
blood ureum, serum creatinine
potassium (K), sodium (Na)
blood gas analysis
C. Radiology
plain photo abdomen
ultrasonography
COMPLICATIONS
1. Volume overload
acute pulmonary oedema

acute left heart failure

2. Metabolic acidosis

3. Electrolyte imbalance
hyperkalemia
MANAGEMENT
A. Manage the initial causes / initial disease properly
B. Patient must be hospitalized and admit in
Intensive Care Unit
water, electrolyte and acid-base balance
antibiotic
C. Renal Replacement Therapy
dialysis
ultrafiltration
PREVENTION
Identify and treat patients most at risk
gastroenteritis
bleeding
hearth failure
pre- operation
drugs / toxin
infection
 Deferential diagnosis between
Acute Kidney Injury (AKI) and
Acute on Chronic Kidney Injury (ACKI) :

AKI ACKI
History of kidney disease No/unknown Yes

Physical examination
- hypertension rare mostly
- oedema rare mostly
Blood biochemistry :
- anaemic rare mostly
- hyperphosphatemia (PO4) rare mostly
Ultrasonographic normal small kidney