RCP : Regional Update in Medicine Acute Kidney Injury : A Renal Problem?

Transcription

1 RCP : Regional Update in Medicine Acute Kidney Injury : A Renal Problem? Lui G Forni : Consultant Intensivist & Nephrologist Faculty of Health Sciences : University of Surrey

2 Disclosures Research Funding Commercial Trials: Honorarium/Travel Expenses: Astute Medical, OCD SBRI/D4D s Renal Technologies BRS/BKPA Roche Fresenius; Astute Medical; Ortho Clinical Diagnostics; Baxter/Gambro/Renal

3 What Shall We Talk About? Introduction AKI : The Beginning Why I Dislike AKI What s The Problem? We can t do anything about it anyway

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5 Intro : What Is A Nephrologist? A Doctor specialising in diseases of the kidney A physician board specialised in non-surgical kidney disease Meat & Potatoes diseases Salary 275 K + 10% bonus

6 Alternative Definitions?

7 Don t Believe Me?

8 Alternative Definitions?

9 Alternative (Favourite) Definitions?

10 AKI.The Beginning Where Did It All Begin?

11 In the Beginning. There was Acute Renal Failure : Remember that? Defining it could be relatively straightforward... The patient has Acute Renal Failure when I say they have.

12 ARF : Was A Bit like Pornography. Easy to Recognise.. Hard to Define!

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14 Now over a decade ago

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16 We Now Have Definitions Stage Serum Creatinine Urine Output times baseline or 0.3 mg/dl (>26.4 µmol/l) increase < 0.5 ml/kg.h for 6-12 hrs times baseline < 0.5 ml/kg.h for 12 hrs times baseline OR increase in creatinine 4 mg/dl (352 µmol/l) < 0.3 ml/kg.h for 24 hrs OR Anuria 12 hrs In patients < 18 yrs decrease of egfr to 35 ml/kg/1.73 m²

17 Why I Dislike AKI?

18 Does AKI suffer from the Pinocchio effect? Geppetto created a toy to be his little boy The toy was so lifelike it behaved like a boy But no matter how much he wished it be otherwise, in reality it was always a toy Neil Soni Anaesthesia, 2010, 65, pages

19 The Pinocchio Effect. In Intensive Care we Invent Diseases ARDS, ARF, SIRS, PRES etc etc And Then Spend our Time Looking for a Cure.

20 and as intensivists we don t have a fairy godmother

21 Population Heterogeneity

22 Other Examples? Syndrome Homogeneity

23 Meningococcal infection in an 18 year old Urosepsis Peritonitis in an 80 year old Necrotising Fasciitis

24 Sepsis

25 We Can Define AKI AKI : A Broad Clinical Syndrome But Not The Cause Specific Kidney Diseases (e.g., acute interstitial nephritis, acute glomerular and vasculitic renal diseases) Non-specific Conditions (e.g, ischemia, toxic injury) Extrarenal Pathology (e.g., prerenal azotemia, and acute postrenal obstructive nephropathy)

26 So Why I Dislike AKI? It was invented. Only describes a change in creatinine and/ or urine output It is not a diagnosis.. Often precious little to do with the kidneys or nephrologists..

27 Whether I Like it or Not We Have Evolved From ARF KDIGO And Guidelines Have RIFLE ARF AKIN Evolved

28 141 Pages Long 132 Page Appendix 64 Pages of Tables

29 But Not All Embraced KDIGO.

30 Criticisms

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32 So, the Construct of AKI is based on.

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34 But AKI Is Clearly an Issue..

35 AKI : Must be very Important

36 AKI : What s The Problem? Common High Mortality Heavy Burden of Illness Acute Chronic Expensive!!!

37 Epidemiology : Recent Studies?

38 Multi-Centre, Retrospective

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40 Risk Factors CA-AKI (3.3%) HA-AKI (7.4%) Sepsis 15.2% UTI 12.3% CKD 11.8% Cardiac Surgery 43.7% Sepsis 32.0% ICU 30.3%

41 ? Possible Interventions?

42 Risk of death increases with AKI Stage and co-morbidities

43 Risk of Death

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45 Surprising

46 Not Surprising HT, Heart Failure, Cirrhosis, Diabetes

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48 Alexa Wonnacott et al. CJASN 2014;9: by American Society of Nephrology

49 In-hospital outcomes: community- versus hospital-acquired AKI Alexa Wonnacott et al. CJASN 2014;9: by American Society of Nephrology

50 Long-term mortality outcomes according to AKI stage. AKI Stage 1 : 60%!!! Alexa Wonnacott et al. CJASN 2014;9: by American Society of Nephrology

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53 Conclusions AKI in > 50% ICU Patients 30% Stage % receive RRT Increasing AKI Stage = Increasing Mortality

54 Nothing.

55 So Who Is At Risk of AKI?

56 271 Pages Long 126 References

57 Kidney Disease: Improving Global Outcomes

58 Proteinuria Kidney Disease: Improving Global Outcomes

59 Incidence and outcomes of acute kidney injury in intensive care units: A Veterans Administration study Risk Dependent on Clinical Situation Kidney Disease: Improving Global Outcomes CV Thakar et al, Crit Care Med

60 Prevention, Risk Assessment & Treatment of AKI Can We Predict AKI??

61 Do Prediction Scores For AKI Exist? They do : But Mostly Single Centre AKI Mortality 36-75% Where Externally validated : performance poor Common Risk Factors?

62 Common Risk Factors In AKI Scores Age, Gender Hypotension, Oliguria Liver Failure, Hypoalbuminaemia Sepsis Mechanical Ventilation

63 Author/Study Year Number AKI (?) Rasmussen SCr > 160 Lohr % Elevation Poorly Performing Variable Definitions Schaefer RRT Liano RRT Paganini SCr > 160 Chertow RRT Lins Rise SCr > 80 Mehta SCR > 160 Lins SCr > 160 Dharan % rise in SCr Chertow SCr > 40 Demirjian SCr > 2 / RRT

64 Risk prediction for acute kidney Injury in acute medical admissions in the uk : The RISK study

65 Invitation to participate Risk prediction for acute kidney Injury in acute medical admissions in the uk : The RISK study Week Of March 7 th 2016 Aims: Assessment of the prevalence of AKI in acute medical assessment units Assessment of physiological and laboratory risk factors for AKI Assessment of pharmacological risk factors for AKI Assessment of patient and renal outcomes within 7 days of admission luiforni@nhs.net Nicholas.Selby@nottingham.ac.uk andrew.lewington@nhs.net

66 Can We Even Identify AKI?

67 But.

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76 Interventions? 67% Volume Deplete 21% On Nephrotoxins 17.6% Obstructive Symptoms 36.3% Sepsis

77 Completion CB within 24 Hrs

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79 Limitations? Not Randomised Low % age completion rates Treatment in non-completed with no care bundle?

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81 Conclusions AKI is a clinical syndrome NOT a disease Think about the cause rather than the label Predicting those at risk may be beneficial Good general medical care may be the magic bullet

82 I used to think this

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