Update in. Acute Kidney Injury. Mark Devonald Consultant Nephrologist. Nottingham AKI Research Group

Transcription

1 Update in Acute Kidney Injury Mark Devonald Consultant Nephrologist

2 If you stay awake you might hear about Why AKI is important Some cases to illustrate some specific points A couple of updates on AKI Comprehensive review of AKI and everything

3 AKI is important because it is: Common Serious Expensive

4 AKI is expensive The Economic Impact of Acute Kidney Injury Marion Kerr NHS Kidney Care

5 AKI is common and serious: mortality RIFLE stage Incidence (%) In-hospital mortality (%) Risk Injury Failure All AKI KDIGO stage Incidence (%) In-hospital mortality (%) D All AKI Uchino et al, Crit Care Med 2006 Porter et al, Nottingham University Hospitals n=20,126 n=140,190

6 AKI is serious: length of stay AKI stage No. of pts Median Age LoS(days) , , , , Porter et al, NDT 2014

7 AKI is serious: effect on renal function Cerdá J et al. CJASN 2008;3: by American Society of Nephrology

8 risk AKI CKD risk

9 Case 1:

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11 Porcine model of IR-AKI Gardner and Devonald, in preparation

12 Sham surgery (control) No AKI Healthy young (7-8/52) pig 5 weeks AKI stage 1 Ischaemia Reperfusion (40 min) Gardner and Devonald, in preparation

13 AKI is common RIFLE stage Incidence (%) Risk 9.1 Injury 5.2 Failure 3.7 All 18.0 KDIGO stage Incidence (%) D 0.6 All 16.6 Uchino et al, Crit Care Med 2006 n=20,126 Porter et al, Nottingham University Hospitals (unpublished) n=140,190

14 Detection of AKI

15 KDIGO 2012 First identify AKI (rise in SCr x baseline within 7d or rise 26 µmol/l <48 h). Thenstage: Stage SCr criteria U/O criteria x baseline OR 26 µmol/l increase <0.5mL/kg/h for 6 12 h x baseline <0.5mL/kg/h for 12 h x baseline OR Increase in SCr to 354 µmol/l OR Initiation of RRT OR In patients <18 years, decrease in egfr to <35 ml/min per 1.73 m 2 <0.3mL/kg/h for 24 h OR anuria for 12 h

16 2009 The advisors judged there to be an unacceptable delay in recognising post-admission AKI in 43% of patients. June 2009

17 AKI e-alerts Tell you that SCr has risen (if you haven t worked that out for yourself) Stage the AKI (KDIGO or similar) passive, active, interruptive

18 What is AKI e-alerting? Algorithm-based DETECTION Clinical ALERT SCr based standard criteria RIFLE, AKIN, KDIGO Passive alert Message with SCr result SCr based non-standard criteria >75% increase, SCr Active alert Phone call, text Non-SCr based Urine output Interruptive alert Compulsory action

19 Continuous assessment and staging of AKI 1st SCr during admission Subsequent SCr measured Pt admitted Time 1 year 7 days Identify and stage AKI KDIGO Baseline If no actual baseline SCr, use imputed SCr assuming egfr 75 ml/min

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21 Why do we need AKI e-alerting? Request SCr Look up RESULT ACTION KDIGO RIFLE AKIN Frequent failure to notice small (or large) ΔSCr Delayed detection of AKI e.g. NCEPOD 2009 Failure to document AKI Increased mortality Wilson FP et al Clin Nephrol 2013

22 Apologies for stating the obvious but You will not get an AKI e-alert if you haven t checked the SCr

23 Does e-alerting improve outcomes? Lancet 2015

24 Wilson FP et al, Lancet 2015

25 Wilson FP et al, Lancet 2015

26 Summary so far: AKI is common, serious and expensive AKI (even stage 1?) leads to CKD e-alerts useful but effects uncertain

27 DetecKon Diagnosis AKI is a syndrome not a diagnosis

28 AKI is easy, isn t it? Case 2A: 52F 1/52 malaise, mild fever, R loin pain ABs for UTI from GP Admitted SCr 420uM (BL 80) Urinalysis Bld++ Prot++ Nit+ IV Abs, IVI Stage 3 AKI Case 2B: 78M 1/52 post-op TKR Peri-op hypotension, N+V Post-op SCr rises to 650uM (BL 140) Urinalysis Bld- Prot+ Nit- Oliguric, K 6.8 Stage 3 AKI Temporary HD then IVI Good U/O, feels well SCr Good U/O, feels well SCr

29 1 week later Case 2A: 52F Completed Abs Oral fluids SCr Case 2B: 78M Well Oral fluids SCr What would you do? ANCA + PR3>100 R renal vein thrombosis IgG paraprotein 28g/L Myeloma (cast nephropathy)

30 DetecKon Diagnosis Be prepared to reconsider your diagnosis (especially if AKI does not resolve as expected) IV fluid will often cause a transient fall in SCr (dilution not improvement in renal function)

31 Diuretics and the dark art of dialysis

32 Case 3: 58M Known IHD, CCF, CKD 3A Rx Ramipril 10 mg od, spironolactone 25mg od, furosemide 80mg bd etc Admitted grossly overloaded SCr 180uM (BL 130), urea 26mM, K 5.6mM Started on IV furosemide 160mg bd Minor improvement in overload after a week; furosemide 250mg bd IV SCr: Urea: You, yes YOU. Dialyse my patient would you? diuretic resistance bla bla

33 Cardiorenal Syndrome (CRS) CRS Type 1 Acute cardiorenalsyndrome CRS Type 2 Chronic cardiorenalsyndrome CRS Type 3 Acute renocardiacsyndrome CRS Type 4 Chronic renocardiacsyndrome Acute cardiac problem leads to AKI Chronic heart problem leads to CKD AKI leads to acute cardiac problem CKD leads to chronic cardiac problem CRS Type 5 Secondary cardiorenalsyndrome Systemic condition leads to cardiac and renal problems

34 What do you do? 2 comments Bad heart + bad kidneys = bad prognosis Cardiac status usually determines outcome A few suggestions Agree on realistic plan and goals Aim for volume offload by Remove spiro + ACEI temporarily to allow diuretic increase Thiazide + loop = synergistic Salt and water restriction MDT discussion about renal replacement therapy (would they tolerate long term RRT?)

35 AKI update: cardiorenal

36 AKI update: diuretic resistance Rao et al, JASN 2017

37 AKI update: diuretic resistance Rao et al, JASN 2017 Justifies addition of thiazide to loop diuretic in diuretic resistance

38 Contrasting cases

39 Case 4A: 80M 3/52 diarrhoea, jaundice, wt loss AKI SCr 320 (BL 100) U/S: ascites, possibility of metastases IVI SCr: Case 4B: 56F Acute abdomen, unwell, hypotensive, guarding. Surgical hx. AKI: SCr 280 (BL 80), low Hb, high lactate. Poor U/O Physicians want CT with contrast Surgeons want CT with contrast What do you advise?

40 RISK? Risk factors CKD egfr<40 DM + CKD Heart failure Age >75 Hypovolaemia Large volume of contrast Intra-arterial route NICE CG169, 2013

41 Case 4A: 80M 3/52 diarrhoea, jaundice, wt loss AKI SCr 320 (BL 100) U/S: ascites, possibility of metastases IVI SCr: Case 4B: 56F Acute abdomen, unwell, hypotensive, guarding. Surgical hx. AKI: SCr 280 (BL 80), low Hb, high lactate. Poor U/O Physicians want CT with contrast Surgeons want CT with contrast Could wait but risk is low Can t wait Ensure that risk assessment does not delay emergency imaging NICE CG169, 2013

42 Update: AKI biomarkers

43 Traditional AKI biomarkers are poor KDIGO SCr UO Marker of glomerular filtration NOT injury Can take 24-48h to rise after injury Need to know baseline Can be a normal physiological response Has to be measured continuously Has to be measured for >6 hours

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45 AKI outreach: aims How does early detection change management? Early detection Fluid balance Medicines review Intensity of monitoring Specialist review Avoid dehydration or overload Avoid nephrotoxins; Adjust doses Frequency, extent, cost Transfer, escalation, discharge

46 Cystatin C NGAL KIM-1 Ideal Biomarker Accessible sample Sensitive Specific Stable Cheap IGFBP-7/ TIMP-2 NephroCheck

47 Fig 1. Mean corrected urinary Cd at different stages of AKI Fig 2. Mean corrected urinary Cu at different stages of AKI

48 Summary (1) AKI is common, serious and expensive AKI increases risk of CKD E-alerts help to detect AKI but benefits uncertain

49 DetecLon Diagnosis Summary (2) Cardiorenal syndrome needs realistic MDT approach If a contrast scan is important, do it SCr is a poor AKI biomarker but it s not been eclipsed yet

50 Thank You