Acute Kidney

Injury
What this presentation covers
 Background
 Definitions
 Etiology
 Pathophysiology
 Management
 Recommendations
Background
• Acute kidney injury (previously known as acute renal
failure) covers a wide spectrum of injury to the
kidneys, not just kidney failure

• Up to 18% of all hospital admissions have AKI

• Inpatient AKI-related mortality is between 25 and 30%

• Between 20 and 30% of cases of AKI are preventable.

Prevention could save up to 12,000 lives each year

• NHS costs related to AKI are between £434 and £620

million per year
Definition

 An abrupt (within hours) decrease in

kidney function, which encompasses
both injury (structural damage) and
impairment (loss of function)
 Rapid impairment in renal function
resulting in raised plasma urea/creatinine,
fluid and/or acid-base imbalance which
is reversible

Makris K. Acute Kidney Injury: Definition, Pathophysiology and

Clinical Phenotypes. Clin Biochem Rev 37 (2) 2016
Profound reduction of the blood flow to the outer
stripe of the outer medulla as indicated in B

Basile, David P et al. “Pathophysiology of acute kidney

injury” Comprehensive Physiology vol. 2,2 (2012): 1303-53.
Risk factors: adults
• Chronic kidney disease (or history of)
• Diabetes
• Heart failure
• Sepsis
• Hypovolaemia
• Age 65 years or over
• Use of drugs with nephrotoxic potential (for example,
NSAIDs, ACE inhibitors)
• Use of iodinated contrast agents within past week
• Oliguria
• Liver disease
• Limited access to fluids, e.g. via neurological impairment
• Deteriorating early warning scores
• Symptoms or history of urological obstruction
Risk factors: children and young people

As for adults, with the following additional risks:

• Abnormal or deteriorating paediatric early
warning score
• Young age, disability or cognitive impairment with
dependency on carers for access to fluids
• Severe diarrhoea, especially bloody diarrhoea
• Signs or symptoms of nephritis (for example,
oedema or haematuria)
• Haematological malignancy
• Hypotension
KDIGO criteria

Makris K. Acute Kidney Injury: Definition, Pathophysiology and

Clinical Phenotypes. Clin Biochem Rev 37 (2) 2016
Staging RIFLE Criteria

 Proposed by ADQI

 Severity (Stage 1-3)

 Risk: GFR decrease >25%, serum creatinine increased 1.5 times OR
urine production of <0.5 ml/kg/hr for >6 hours
 Injury: GFR decrease >50%, doubling of creatinine OR urine
production <0.5 ml/kg/hr for 12 hours
 Failure: GFR decrease >75%, >tripling of creatinine or creatinine >355
μmol/l (>4 mg/dl) OR urine output below 0.3 ml/kg/hr for 24 hours
 Outcome
 Loss: persistent AKI or complete loss of kidney function for more than 4
weeks
 End-stage renal disease: need for renal replacement therapy (RRT)
for more than 3 months Bellomo R, et.al. Acute renal failure – definition, outcome
measures, animal models, fluid therapy and information
technology needs: the Second International Consensus
Conference of the Acute Dialysis Quality Initiative (ADQI)
Group. Crit Care. 2004; 8(4): R204–R212.
 Etiology
• Pre renal
prerenal etiologies account for 25–
60%

• Renal
renal etiologies account for
35–70% of AKI cases

• Post Renal
Postrenal etiologies generally
account for <5%

1. http://www.medicalassessmentonline.net/terms.php?R=3
2. Basille DP, et.al. Pathophysiology of Acute Kidney Injury. Compr Physiol. 2012
April ; 2(2): 1303–1353. doi:10.1002/cphy.c110041.
Pathophysiology
 Basile, David P et al. “Pathophysiology of acute kidney
injury” Comprehensive Physiology vol. 2,2 (2012): 1303-53.
Presentation

Symptoms Signs
 Malaise  Hypertension

 Anorexia, Nausea and  Fluid overload:

Vomiting peripheral oedema,
SOB/ bibasal
 Pruritis
crackles/raised JVP
 Dehydration
 Dehydration: postural
 Confusion, convulsions hypotension, poor urine
output (palpable
bladder)
Workup
1. Complete blood count (CBC)
2. Serum biochemistries
 Myoglobin or free hemoglobin - Eg, pigment nephropathy
 Increased serum uric acid level - Eg, tumor lysis syndrome
 Serum lactate dehydrogenase (LDH) - Eg, renal infarction
3. Urine analysis with microscopy
4. Urine electrolytes
5. Kidney Function Studies (BUN and creatinine)
6. Ultrasonography
7. Nuclear Scanning (Radionuclide imaging with technetium-
99m-mercaptoacetyltriglycine (99m Tc-MAG3),99m Tc-
diethylenetriamine penta-acetic acid (99m Tc-DTPA), or
iodine-131 (131I)-hippurate)
Workup

8. Aortorenal Angiography
9. Renal Biopsy
10. Furosemide Stress Testing
In early AKI, urine output after a furosemide stress test
(FST) can predict the development of stage 3 AKI
Treatment and Management

• Conservative management

• Relieving urological obstruction

• Referral
Conservative
Management
1. Correction of fluid overload with furosemide
2. Correction of severe acidosis with bicarbonate
administration, which can be important as a bridge
to dialysis
3. Correction of hyperkalemia
4. Correction of hematologic abnormalities (eg,
anemia, uremic platelet dysfunction) with measures
such as transfusions and administration of
desmopressin or estrogens
5. All nephrotoxic agents (eg, radiocontrast agents,
antibiotics with nephrotoxic potential, heavy metal
preparations, cancer chemotherapeutic agents,
nonsteroidal anti-inflammatory drugs [NSAIDs])
should be avoided
Relieving urological obstruction
 Refer all patients with upper tract urological obstruction to
a urologist.

 Immediate referral if one or more of following present:

 Pyonephrosis

 Obstructed single kidney

 Bilateral upper urinary tract obstruction

 Complications of AKI secondary to urological

obstruction
 When nephrostomy or stenting required – undertake as
soon as possible and within 12 hours of diagnosis
Referral
Nephrology:
Discuss AKI management with a nephrologist/paediatric nephrologist as
soon as possible (and within 24 hours) if one of the following is present:
Potential diagnosis requiring AKI with no clear Inadequate treatment
specialist treatment (for example, cause response
vasculitis or glomerulonephritis)
Complications associated with AKI Stage 3 AKI eGFR is less than < 30
ml/min/1.73 m2 after
AKI episode
Patients with renal transplant and CKD stage 4 or 5
AKI
Renal replacement therapy:
Refer adults, children and young people immediately for RRT if any of the
following are not responding to medical management:
Hyperkalaemia Metabolic Symptoms or complications Fluid overload
acidosis of uraemia such as +/- pulmonary
pericarditis or oedema
encephalopathy
Thank
You