Ruolo della clinica e del laboratorio nella diagnosi di IRA

Transcription

1 Ruolo della clinica e del laboratorio nella diagnosi di IRA Antonio Granata Ospedale San Giovanni di Dio - Agrigento Scuola Nazionale Specialistica di Ecografia Nefrologica SIUMB Centro di Riferimento Regionale Malattie Rare di interesse Nefrologico U.O.C. Nefrologia e Dialisi Lecco 6-7 Nov. 2017

2 nella diagnosi di AKI

3 nella diagnosi di AKI The term AKI is intended to encompass the entire spectrum of the syndrome, from minor impairment in renal function to the need for renal replacement therapy. AKI is more than just Acute Renal Failure

4 nella diagnosi di AKI Definizione di AKI

5 nella diagnosi di AKI K/DIGO definition and classification of AKI RIFLE criteria move beyond ARF Patients do not just die from their comorbidities with AKI but die from AKI

6 nella diagnosi di AKI Diagnosis and staging standard for AKI of RIFLE, AKIN, KDIGO, and Cys-C criteria

7 nella diagnosi di IRA Some pts fulfil the AKI definition but do not have AKI, and there are also pts with clear evidence of renal injury who do not meet the s.cr or urine criteria for AKI Limitations of creatinine-based criteria for AKI Limitations of urine-based criteria for AKI

8 nella diagnosi di AKI Potential pitfalls of AKI diagnosis based on s.cr and urine criteria

9 nella diagnosi di AKI Adjunctive diagnostic tools to diagnose AKI In certain circumstances, it may be necessary to use additional tools to diagnose AKI, especially where s.cr and urine values change only slowly, are misleading, or cannot be interpreted accurately. This is particularly relevant for critically ill pts where the presence of fluid overload, muscle wasting, sepsis, and reduced effective circulating volume may completely mask the diagnosis of AKI.

10 nella diagnosi di AKI New AKI biomarkers

11 nella diagnosi di AKI New diagnostic biomarkers of AKI evaluated in human studies

12 nella diagnosi di AKI New criteria for AKI diagnosis Adapted from RIFLE/AKIN criteria ADQI Consensus Conference Ostermann M, et al.: AKI 2016: Critical Care 2016

13 nella diagnosi di AKI New spectrum of AKI Subclinical AKI AKI can be defined by abnormal levels of kidney injury biomarkers even in the absence of oliguria or elevated scr ADQI Consensus Conference

14 nella diagnosi di AKI Diagnosis of acute kidney disease AKI is defined as occurring over 7 days and CKD starts when kidney disease has persisted for more than 90 days. It is clear that some patients have a slow but persistent (creeping) rise in s.cr over days or weeks but do not strictly fulfil the consensus criteria for AKI.

15 nella diagnosi di AKI Diagnosis of acute kidney disease To classify this phase between the early stage of AKI (first 7 days) and the onset of CKD (beyond 3 months), the KDIGO expert group proposed the term acute kidney disease (AKD) and suggested the following criteria: a GFR <60 ml/min/1.73 m 2 for <3 months, a decrease in GFR by 35 %, and an increase in s.cr by >50 % for <3 months or evidence of structural kidney damage for <3 months. These criteria are currently under revision

16 Diagnostic work-up Ruolo della clinica e del laboratorio nella diagnosi di IRA AKI = multiple eziologie ad es. nei pts critici - sepsi, HF, ipovolemia, iatrogena - malattia renali tubulo-interstiziali/glomerulari pre-renal ADQI group renal post-renal functional AKI Endre ZH, et al.: Differential diagnosis of AKI in clinical practice by functional and damage biomarkers: workgroup statements from the tenth Acute Dialysis Quality Initiative Consensus Conference. Contrib Nephrol. 2013;182: kidney damage

17 nella diagnosi di IRA

18 urine dipstick Ruolo della clinica e del laboratorio nella diagnosi di IRA AKI guideline by the NICE recommends performing urine dipstick testing for blood, protein, leucocytes, nitrites, and glucose in all patients as soon as AKI is suspected or detected in order not to miss any potentially treatable glomerular or tubular pathologies. These include: glomerulonephritis (with haematuria and proteinuria) APN (with pyuria/leucocyturia and nitrites in urine) interstitial nephritis (occasionally with eosinophiluria)

19 nella diagnosi di IRA urinary sediment Septic AKI is associated with greater urine microscopy evidence of kidney injury compared with nonseptic AKI, despite similar severity of AKI. A UM 3 correlated with higher ungal and was predictive of worsening AKI. Urine microscopy may have a complementary role for discerning septic from non-septic AKI, discriminating severity and predicting worsening AKI in critically ill patients. Bagshaw SM, et al.: A prospective evaluation of urine microscopy in septic and non-septic acute kidney injury. NDT 2012

20 nella diagnosi di IRA Interpretation of urine microscopy findings Microscopy Example Significance finding

21 nella diagnosi di IRA Interpretation of urine microscopy findings

22 nella diagnosi di AKI Urinary Electrolytes Measurement of urinary electrolytes and fractional excretion of sodium (FENa), urea, or uric acid has not been consistently shown to have clear correlations with clinical and histopathological findings Whereas the presence of low fractional sodium (<1 %), uric acid (<12 %), and urea excretion (<34 %) together with a normal urinary sediment may support the diagnosis of functional AKI, the absence of these typical urinary electrolyte abnormalities would not exclude it

23 nella diagnosi di AKI Urinary Electrolytes A single measurement of urinary electrolytes has a limited role in determining the differential diagnosis of AKI in critically ill patients. Instead, serial monitoring of urinary electrolytes may be more useful as sequential alterations in urine composition have been shown to parallel the development and severity of AKI. However, whether serial measurement of urine electrolytes can also help diagnosing the aetiology of AKI remains unclear.

24 nella diagnosi di IRA Renal Ultrasound

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27 nella diagnosi di IRA Measurement of intra-abdominal pressure In case of suspected AKI due to intra-abdominal compartment syndrome, serial measurement of intra-abdominal pressure should be considered. Those with a pressure rise to >20 mmhg should be suspected of having AKI as a result of intra-abdominal compartment syndrome

28 nella diagnosi di IRA Renal biopsy

29 nella diagnosi di IRA Renal biopsy

30 nella diagnosi di IRA Other laboratory tests Depending on the clinical context, the following tests may be indicated: CPK and myoglobin (in case of suspected rhabdomyolysis) LDH (in case of suspected TTP fragmentocytes (in case of possible TTP/HUS) N-terminal pro-brain natriuretic peptide (NT-proBNP) and troponin (in case of suspected CRS) serum/urine protein electrophoresis (in case of suspected myeloma kidney)

31 nella diagnosi di AKI Challenges of diagnosing AKI in critically ill patients s.creat GFR AKI Until more reliable tests are routinely used in clinical practice it is essential to interpret s.cr results and other diagnostic tests within the clinical context

32 nella diagnosi di IRA Future diagnostic tools New damage markers New imaging techniques

33 nella diagnosi di IRA

34 nella diagnosi di IRA