ACUTE KIDNEY INJURY FOLLOW UP. David Broodbank EMEESY Network Meeting 10/10/14

Transcription

1 ACUTE KIDNEY INJURY FOLLOW UP David Brdbank EMEESY Netwrk Meeting 10/10/14

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3 Definitin Creatinine rise >26mml/L within 48 hurs >50% rise in creatinine ver prceeding 7 days Urine utput <0.5ml/Kg/hr ver 8 hurs >25% fall in egfr ver prceeding 7 days

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5 Sme NICE Guidance Mnitr [7] serum creatinine after an episde f acute kidney injury. Cnsider referral t a nephrlgist r paediatric nephrlgist when egfr is 30 ml/min/1.73 m 2 r less in adults, children and yung peple wh have recvered frm an acute kidney injury Cnsider referral t a paediatric nephrlgist fr children and yung peple wh have recvered frm an episde f acute kidney injury but have hypertensin, impaired renal functin r 1+ r greater prteinuria n dipstick testing f an early mrning urine sample [7] The frequency f mnitring shuld be based n the stability and degree f renal functin at the time f discharge.

6 S Why Fllw Up? AKI des prgress t CKD Special cases, HUS. JAMA Sep 10;290(10): Lng-term renal prgnsis f diarrhea-assciated hemlytic uremic syndrme: a systematic review, meta-analysis, and meta-regressin. Garg AX 1, Suri RS, Barrwman N, Rehman F, Matsell D, Rsas-Arellan MP, Salvadri M, Haynes RB, Clark WF. 25% f survivrs demnstrate lng-term renal sequelae (>3400 pts in study)

7 S Why Fllw Up And the rest? Less clear Epidemilgy may give a clue (mre secndary causes f AKI and thus CKD) New Bimarkers may help tracking AKI t CKD e.g.neutrphil gelatinase-assciated lipcalin (NGAL), Kidney Injury Mlecule 1 (KIM 1), Liver Type Fatty acid binding prtein (L-FABP) Viaud et al:- 2/3 f thse with severe AKI had evidence f renal injury (all cause) at 12 years (received RRT) (13 pts) Mammen et al:- 10% f all AKI admitted t PICU had CKD at 3 years (126 pts) Preterm infants may be even mre significantly affected

8 Why t fllw (2) CKD is a prgressive but mdifiable disease 50% reductin in GFR, GFR <10 ml/min/1.73 r RRT

9 Wh t fllw? All patients with significant AKI Can prbably exclude thse with rapidly reslving pre-renal causes Certainly all wh received RRT Stage 1 Serum Creatinine egfr < 75 ml/min/1.73m 2 Or decrease in egfr by 25% Or increase creatinine x baseline Urine Output <0.5 ml/kg/hr fr 6 hurs Stage 2 egfr < 50 ml/min/1.73m 2 Or decrease in egfr by 50% Or increase creatinine 2 3 x baseline <0.5 ml/kg/hr fr 12 hurs Stage 3 egfr <35 ml/min/1.73m 2 Or decrease in egfr by 75% Or increase in creatinine > 3 x baseline Or requirement fr renal replacement therapy <0.3 ml/kg/hr fr 24 hurs Or anuria fr 12 hurs

10 Hw t fllw?

11 Fr the less visual learners Creatinine check year 1and year 5 Annual BP check Annual urine dip r prtein : creatinine rati Frmal GFR (fr thse wh received RRT and thse with HUS) at 1 yr, 5 yrs and pst puberty.

12 Special Cases -Onclgy Ifsphamide and platinum chemtherapy Bth effect glmerular functin (AKI and CKD) Bth effect tubular functin Sme effects may reslve E.g. tubular effects f ifsphamide Others persist E.g. tubular effects f cisplatin r glmerular dysfunctin Fllw up therefre invlves Urine dip / PCR Assessment f tubular functin, phsphate, bicarbnate etc Creatinine Bld pressure Risk factrs alne (high cumulative dse, single kidney) will nt predict all cases f nging kidney disease

13 Mulder et al. Cancer Epidemil Bimarkers Prev 2013; 22:

14 Special cases -Nenates 20 Nenates <1000g with AKI (rise in creat >48 hrs r U/O <0.5ml/kg/hr) 18 year review Mean age 7.5 yrs 9 GFR <75ml/min/1.73m 2. Predictrs fr CKD P:CR at 1 year Serum creatinine at 1 year Hw t fllw? Urine dip Creatinine Bld pressure

15 References A Akcan-Arikan 1, M Zappitelli 1, L L Lftis 2, K K Washburn 1, L S Jeffersn 2 and S L Gldstein. Mdified RIFLE criteria in critically ill children with acute kidney injury. Kidney Internatinal (2007) 71, di: /sj.ki ; published nline 28 March 2007 Stuart L. Gldstein & Prasad Devarajan. Acute kidney injury in childhd: shuld we be wrried abut prgressin t CKD? Pediatr Nephrl (2011) 26: Marianne Viaud & Brigitte Llanas & Jérôme Harambat. Renal utcme in lng-term survivrs frm severe acute kidney injury in childhd. Pediatr Nephrl (2012) 27: Sharn Phillips Andreli. Acute kidney injury in children. Pediatr Nephrl (2009) 24: Wesley Hayes, Martin Christian. Acute kidney injury. PAEDIATRICS AND CHILD HEALTH 22:8 Carlyn L. Abitbl Charles R. Bauer, Brenda Mntané,Jayanthi Chandar, Shahnaz Duara, Gastón Zilleruel. Lng-term fllw-up f extremely lw birth weight infants with nenatal renal failure. Pediatr Nephrl (2003) 18: Mulder et al. Cancer Epidemil Bimarkers Prev 2013; 22: C. Mammen, A. Al Abbas, P. Skippen, H Nadel, D Levine, J P Cllet and D G Matsell. Lng-term risk f CKD in children surviving episdes f acute kidney injury in the intensive care unit: a prspective chrt study. American Jurnal f Kidney Diseases. (2012) 59 (4) NICE (2013) Acute kidney injury: preventin, detectin and management f acute kidney injury up t the pint f renal replcaement therapy. KDIGO (2012) Clinical Practice Guidelines fr Acute Kidney Injury.

16 EMEESY Netwrk Fllw up Mlly McLaughlin Paediatric Renal Critical Care Nurse

17 Backgrund Histrically: n defined pathway fr fllw up January 2014: AKI fllw up intrduced fr all patients having CRRT within PICU Initially 5 year fllw up, nw extended t lifelng Plan t widen this t all AKI(level 3, persistent, all receiving RRT)

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19 Referrals t date 16 patients identified since January fr fllw up within EMEESY PICUs Sheffield 4 2 SCH 1 Dncaster 1 Rtherham (currently being seen at SCH) Nttingham 5 3 NUH 1 Kettering 1 Cambridge Leicester (LRI/GH) 7 3 NUH 2 UHL 1 Kettering 1 Bstn

20 Ptential challenges Identifying patients & ensuring initial referral prving prblematic Referral pathway D all patients cme under a Nephrlgist at NUH? Blds nly appintment in ther centre Fllw up f all AKI