Acute Kidney Injury in The Acute Oncology Patient Dr Andrew Lewington BSc MEd MD FRCP Consultant Renal Physician/Honorary Senior Lecturer Leeds Teaching Hospitals
Definition
Definitions and terminology Acute Kidney Injury = AKI Injury rather than failure Represents entire spectrum of acute renal failure Pre kidney Intrinsic kidney Post kidney
Serum Creatinine Criteria
AKIN Staging AKIN stage Serum Creatinine criteria Urine output criteria 1 SCr 26 µmol/l or SCr 150-200% (1.5-2 fold) from baseline 2 SCr > 200-300 % (>2-3 fold) from baseline 3 SCr > 300 % (>3 fold) from baseline or SCr 354 µmol/l with an acute rise of 44 µmol/l in 24 hr or initiated on RRT (irrespective of stage at time of initiation) < 0.5 ml/kg/hr for 6 hr < 0.5 ml/kg/hr for 12 hr < 0.3 ml/kg/hr for 24 hr or anuria for 12 hr
KDIGO Kidney Disease Improving Global Outcomes International guideline group Harmonising RIFLE/AKIN Publication 2010
June 11, 2009 Royal Society of Medicine London
Primary aim examine the process of care of patients who died in hospital with AKI identify remediable factors in the quality of care received by these patients
Patient sample Inclusion criteria patients aged 16 yrs coded for AKI (ARF-WHO ICD 10 N17) died in hospital 3 month period in 2007 Exclusion criteria patients already on RRT admission for palliative care
Key findings < 50% of AKI care considered good poor assessment of risk factors 43% of post-admission AKI - unacceptable delay in recognition
NCEPOD conclusions systematic failings in providing quality patient care poor recognition and response to acutely ill patient patient at risk of AKI delayed renal referral
Impact of the study Report sent to all hospital chief executives medical directors Clinical governance Local enthusiasts university medical school deans Integrate AKI core competancies into curricula
Impact of the study National initiative Department of Health AKI Delivery board National vascular database Renal Association Core competencies range of healthcare professionals AKI guidelines National Institutes of Health Research funding
Impact of the study National initiatives National Institute of Health and Clinical Excellence (NICE) AKI guideline Recommendations will be mandatory Clinical Quality Indicators (CQUINS) % of hospital income dependent upon achieving standard AKI devised based upon NCEPOD study findings
Epidemiology
Epidemiology dependent upon definition 12-49% critically ill oncology patients develop AKI 9-32% critically ill oncology patients require RRT during ICU stay
Aetiology
Pre-kidney Hypovolaemia vomiting and diarrhoea haemorrhage in effective circulating volume cardiac failure septic shock Drugs ACE inhibitors ARB NSAIDs Intrinsic Glomerular ANCA associated vasculitis HUS/TTP Tubular ischaemia sepsis myeloma tumour lysis syndrome nephrotoxins Cisplatin Methotrexate Amphotericin Contrast Interstitial interstitial nephritis Post-kidney Metastatic deposits retroperitoneal fibrosis prostatic hypertrophy cervical Ca urethral stricture obstructed urinary catheter
Risk factors
Risk factors >75yrs Chronic kidney disease (egfr<60) Cardiac failure Liver disease atherosclerotic peripheral vascular disease Diabetes mellitus Myeloma Sepsis Hypovolaemia Nephrotoxins
Pathophysiology
AKI - Pathophysiology ischaemia hypovolaemia sepsis multifactorial nephrotoxins glomerular disease ANCA associated vasculitis interstitial disease interstitial nephritis drug/infection
Recovery Following Ischaemic AKI recovery is possible ATP dependent process activation of multiple genetic programmes tubule epithelial cell proliferation cell migration and re-epithelialisation of the denuded basement membrane role of bone marrow stem cells secretion of growth factors
AKI Post Recovery AKI long-term effects persistent or progressive loss of function chronic kidney disease renal microvasculature interstitial fibrosis tubule atrophy persistent inflammation
Case Presentation
Case Presentation 63yrs female Metastatic breast Ca PMH Type II DM (metformin) Hypertension (ARB) Chronic kidney disease (CKD) stage 3 egfr 39 mls/min/m 2
Case Presentation Treated with Carboplatin/gemcitibine 5d prior to adm Herceptin 3d prior to adm Gemcitabine 2d prior to adm Admitted Fever-39.5 Shortness of breath BP 173/104
Case Presentation Commenced on antibiotics Next 24hrs - BP 104/70 Oliguric FBC Hb 9.4 WCC 3.8 Pl 67 U&Es Bic 16 SCr 320 µmol/l u/s no obstruction
Case Presentation Renal referral Differential diagnosis AKI sepsis, relative hypotension HUS/TTP (unlikely) Clinical course General improvement BP 130/70 Increase urine output Progressive rise in SCr
Management of Acute Kidney
Prevention Identify patient at risk Monitor kidney function Avoid nephrotoxins NSAIDs Contrast Volume expand Improve methods for detection biomarkers
Management of AKI supportive therapy treat underlying cause sepsis stabilise haemodynamics optimise fluid balance optimise cardiac output and MAP target for MAP is unclear (baseline BP important) renal replacement therapy
Fluid Balance in AKI clinical evaluation peripheral perfusion BP,HR,JVP peripheral oedema urine output weight fliud balance charts global perfusion indices ph base excess lactate oxygen saturation
Fluid Therapy - Resuscitation Crystalloid 0.9% sodium chloride 154mmol/l Na + & Cl - hyperchloraemic metabolic acidosis if administered in large amounts Ringer s lactate 130mmol/l Na + & 109mmol/l Cl - 4 mmol/l K + Hartmann s solution 131mmol/l Na + & 111mmol/l Cl - 5 mmol/l K +
Fluid Therapy - Resuscitation colloids more rapid restoration of circulating volume Gelatin 145 mmol/l Na + & Cl - Hydroxyethylstarch (HES) 145 mmol/l Na + & Cl new solutions - 131 mmol/l Na + & Cl
Fluid Therapy - Maintenance Crystalloid Ringer s lactate Hartmann s solution 0.45% sodium chloride 77mmol/l Na + & Cl - 0.18% sodium chloride 30 mmol/l Na + & Cl -
On behalf of 1 BAPEN Medical, 2 the Association for Clinical Biochemistry, 3 the Association of Surgeons of Great Britain and Ireland and Society of Academic and Research Surgery, 4 the Renal Association and 5 the Intensive Care Society. British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients GIFTASUP Jeremy Powell-Tuck (chair) 1, Peter Gosling 2, Dileep N Lobo 1,3 Simon P Allison 1, Gordon L Carlson 3, Marcus Gore 3, Andrew J Lewington 4, Rupert M Pearse 5, Monty G Mythen 5
Treatment of AKI avoid further renal insults nephrotoxins aminoglycosides/nsaids contrast hypotension drug clearance antibiotics cephalosporins penicillins fluconazole opioids and metabolites digoxin
Pharmacological Treatment dopamine no evidence for renal dose significant side-effects mannitol renal transplantation Rhabdomyolysis loop diuretics converts oliguric AKI to non-oliguric AKI aid management of fluid balance could delay appropriate RRT adverse effects deafness worsen hypovolaemia
Renal Replacement Therapy
Initiation of Renal Replacement Therapy absolute indication for RRT hyperkalaemia severe acidosis hypervolaemia pericarditis severe encephalopathy poisoning ethylene glycol lithium
Prognosis
Mortality AKI represents an increased risk in terms of mortality
AKI receiving RRT on ICU N (all patients with AKI) 821 (89.1%) Mean Age ( sd) 59 (17.6) APACHE II score 29 (24-36) Length of hospital stay (days) 18 (7-38) Length of ICU stay (days) 6 (3-12) ICU mortality 448 (55%) Hospital mortality 544 (66%)
AKI receiving RRT on ICU at (St James s University Hospital 5yr experience) Medical No Median days RRT ICU Mortality % Hospital Mortality % Haematology 33 3 (2-6) 67 85 Respiratory 118 4 (2-8.25) 71 79 Oncology 10 2.5 (2-4.5) 70 70 Post-cardiac arrest 20 3 (1.25-9.25) 65 70 Cardiac 29 3 (2-5.5) 48 66 Systemic sepsis 59 4 (2-6) 39 59 Primary renal 12 5 (3-7) 33 58 Other 49 3 (2-7) 45 55