AKI: un dramma diffuso nei paesi poveri Maurizio Gallieni

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1 AKI: un dramma diffuso nei paesi poveri Maurizio Gallieni U.O. Nefrologia e Dialisi - Ospedale S. Carlo Borromeo, ASST Santi Paolo e Carlo DIBIC L. Sacco - Università degli Studi di Milano

2 Thousands of people are still dying in vain of AKI, especially in less developed or emerging countries. AKI should no longer be a death sentence for these people. Nobody should die of preventable and treatable Acute Kidney Injury (AKI) by 2025! G. Remuzzi, ISN Past President ( )

3 Background Acute kidney injury (AKI, previously known as acute renal failure) covers a wide spectrum of injury to the kidneys, not just kidney failure AKI is a preventable and treatable disorder encountered yearly by over 13.3 million people worldwide. Over 2.3 million of them die from it annually. The disease afflicts all ages. It is seen across multiple out-of-hospital and in-patient settings

4 Background AKI results from a myriad of causes including infections, drug toxicity, surgery and iatrogenic insults Up to 18% of all hospital admissions have AKI Inpatient AKI-related mortality is between 25 and 30% The costs of care increase three-fold in AKI patients. The development of chronic kidney disease (CKD) in over 30% of survivors often results in end-stage kidney disease (ESKD) that requires dialysis or transplantation Over 85% (11.3 million) of people who suffer an episode of AKI live in low and middle-income countries. Between 20 and 30% of cases of AKI are preventable.

5 Background: prevention and early identification AKI can be readily identified by close monitoring of routine serum creatinine and urine output results AKI can be prevented by early recognition and treatment of the underlying cause, for example: Early treatment of infections/sepsis Early treatment/prevention of dehydration Correcting hypovolaemia AKI can also be prevented by: Monitoring use of drugs such as NSAIDs and ACE inhibitors, especially if a patient is acutely unwell Taking care with at-risk patients who need iodinated contrast agents with scans

6 AKI 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

7 AKI Risk factors in children 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

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11 Lancet 2016; 387: Background. Epidemiological data for acute kidney injury are scarce, especially in low-income countries (LICs) and lowermiddle-income countries (LMICs). We aimed to assess regional differences in acute kidney injury recognition, management, and outcomes.

12 Methods In this multinational cross-sectional study, 322 physicians from 289 centres in 72 countries collected prospective data for 4018 pediatric and adult patients with confirmed AKI in hospital and non-hospital settings who met criteria for AKI Metha et al. Lancet 2016; 387:

13 Results Hypotension (40% of patients) and dehydration (38%) were the most common causes of AKI. Dehydration was the most frequent cause of AKI in lower income countries (46% vs 39% in high income countries. Hypotension was more frequent in HICs (45% vs 38% in LLMICs. Mortality at 7 days was 11%, and was higher in LLMICs (12%) than in HICs (10%). Metha et al. Lancet 2016; 387:

14 PD for AKI: Saving Young Lives Project

15 PD for AKI: Saving Young Lives Project Developing sustainable programs for treating acute kidney injury (AKI) in sub-saharan Africa and South East Asia. SYL is a partnership between four international nephrology organizations: ISN IPNA (Int. Pediatric Nephrology Association) ISPD (Int. Society for Peritoneal Dialysis) Euro PD SKCF (Sustainable Kidney Care Foundation), a nonprofit organization whose goal is to make dialysis supplies available in very low resource settings.

16 WHAT IS THE SAVING YOUNG LIVES PROGRAM? We established the Saving Young Lives (SYL) program in 2012 with the goal of establishing proof-of-principle sustainable acute PD programs in very low-resource settings, measuring their success, and providing a template for the extension of such programs across the many parts of the world where they will save lives.

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18 The 5R (Risk assessment, early Recognition, appropriate Response, Renal support, and Rehabilitation) approach for management of acute kidney injury (AKI) in the developing world. Metha et al KI reports 2017

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21 2014

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23 Grazie per l attenzione maurizio.gallieni@unimi.it