Acute Kidney Injury in Trauma. David Lee Skinner MBChB FCS(SA) Trauma Unit Inkosi Albert Luthuli Central Hospital KwaZulu Natal South Africa

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1 Acute Kidney Injury in Trauma David Lee Skinner MBChB FCS(SA) Trauma Unit Inkosi Albert Luthuli Central Hospital KwaZulu Natal South Africa

2 Acute Kidney Injury Acute Renal Failure RIFLE & AKIN

3 RIFLE criteria R I F Creatinine >1.5x baseline or GFR decrease >25% >2x baseline or GFR decrease >50% >3x baseline or GFR decrease >75% or absolute of 4mg/dl (354 µmol/l) Urine Output <0.5ml/kg/hr x 6 hours <0.5ml/kg/hr x 12 hours <0.3ml/kh/r x 24 or Anuria x 12hrs L E Persistent ARF = loss of renal function >4 weeks End stage renal disease

4 Why redefine renal injury? AKI is an independent risk factor for mortality in critical illness Early identification of renal injury prior to tubular damage Allows for interventions based at prevention of renal injury to be implemented early on

5 Pre-renal azotemia New concept Renal dysfunction with the absence of physical change in kidney Why recognise this? can intervene at this stage to prevent structural kidney damage

6 Trauma Pro-inflammatory state Crush Rhabdomyolysis

7 Sjambok Injury

8 Trauma Pro-inflammatory state Crush Rhabdomyolysis Renal Injury / Nephrectomy Hypovolaemia Hypotension Hypothermia

9 IV Contrast Antibiotics Fluid Therapy Abdominal Compartment Syndrome Sepsis

10 How do we prevent AKI in trauma? Limit structural damage Recognise and aggressively treat pre-renal azotaemia How? Maintenance of MAP in order to maintain renal perfusion pressure Fluids Inotropic / vasopressor support Limit use of ionic contrast (low osmolar) Limit nephrotoxic antimicrobials

11 How do we prevent AKI in trauma? Recognition & treatment of sepsis Early recognition & treatment of ACS Renal salvage surgery the two types of kidney Renal biomarkers

12 Once AKI is established? Continued resuscitation to limit damage to remaining nephrons Renal replacement therapy Must be early especially in crush / rhabdomyolysis injuries that don t initially meet the traditional indications for dialysis What is on the horizon for therapy?

13 Anti-apoptotic agents Caspase inhibitors Minocycline Anti-sepsis APC Growth factors Recombinant erythropoietin Anti-inflammatory drugs Fibrates Adenosine analogues Cell based therapy M2 macrophages Regulatory T-cells

14 Don t get stabbed Don t get shot Don t get hit by a car Conclusion

15 Conclusion But if you do. Early initiation of renal replacement injury in the crush / rhabdomyolysis patient Early diagnosis and therapy for reversible causes such as early sepsis and ACS Aggressive initial resuscitation with limitation of the administration of nephrotoxins

16 References 1. Hoste, E.A., et al., RIFLE criteria for acute kidney injury are associated with hospital mortality in critically ill patients: a cohort analysis. Crit Care, (3): p. R Ostermann, M. and R.W. Chang, Acute kidney injury in the intensive care unit according to RIFLE. Critical care medicine, (8): p ; quiz Ostermann, M. and R. Chang, Correlation between the AKI classification and outcome. Critical care, (6): p. R Uchino, S., et al., Transient azotaemia is associated with a high risk of death in hospitalized patients. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association, (6): p Uchino, S., The meaning of transient azotemia. Contributions to nephrology, : p McGillicuddy, E.A., et al., Contrast-induced nephropathy in elderly trauma patients. J Trauma, (2): p Matsushima, K., et al., Posttraumatic contrast-induced acute kidney injury: minimal consequences or significant threat? J Trauma, (2): p ; discussion Bihorac, A., et al., Incidence, clinical predictors, genomics, and outcome of acute kidney injury among trauma patients. Ann Surg, (1): p Beitland, S., H. Moen, and I. Os, Acute kidney injury with renal replacement therapy in trauma patients. Acta Anaesthesiol Scand, (7): p Costantini, T.W., et al., Redefining renal dysfunction in trauma: implementation of the Acute Kidney Injury Network staging system. J Trauma, (2): p ; discussion Anupindi, M. and M. Sugrue, "Renal dysfunction in trauma: even a little costs a lot". J Trauma, (5): p

17 12. Muckart, D.J. and A.T. Abdool-Carrim, Pigment-induced nephropathy after sjambok injuries. South African journal of surgery. Suid-Afrikaanse tydskrif vir chirurgie, (1): p Wan, L., et al., Pathophysiology of septic acute kidney injury: what do we really know? Critical care medicine, (4 Suppl): p. S Bellomo, R., et al., Septic acute kidney injury: new concepts. Nephron. Experimental nephrology, (4): p. e 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, (4): p. R Lewington, A.J. and A. Sayed, Acute kidney injury: how do we define it? Ann Clin Biochem, (Pt 1): p Mehta, R.L., et al., Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Critical care, (2): p. R Bagshaw, S.M., C. George, and R. Bellomo, A comparison of the RIFLE and AKIN criteria for acute kidney injury in critically ill patients. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association, (5): p De Abreu, K.L., et al., Acute kidney injury after trauma: Prevalence, clinical characteristics and RIFLE classification. Indian J Crit Care Med, (3): p Gomes, E., et al., Acute kidney injury in severe trauma assessed by RIFLE criteria: a common feature without implications on mortality? Scandinavian journal of trauma, resuscitation and emergency medicine, : p Kinsey GR et al, Pathogenesis of Acute Kidney Injury : Foundation for Clinical Practice. Am. J. Kid. Disease 2011 in press