Acute Kidney Injury Sheldon Chaffer, MD Assistant Professor Program Director, Nephrology Fellowship Division of Nephrology and Hypertension Scott and White Clinic Texas A&M University Health Science Center
Objec&ves Discuss differen&al diagnosis of Acute Kidney Injury (AKI). Discuss signs and symptoms of AKI, including pre renal, intrinsic and post renal lesions. Outline diagnos&c approach in the evalua&on of AKI. Iden&fy common electrolyte abnormali&es seen in AKI, including treatment considera&ons Outline common pharmacologic issues in the secng of AKI. Discuss preven&on of AKI in the hospitalized popula&on, including Contrast Induced Nephropathy. Discuss indica&ons for dialysis in the secng of AKI.
When you hear hoo,eats.don t expect to see a zebra. Theodore Woodward, MD Nobel laureate 1948 AKI Pre renal Intrinsic Post renal 85% Acute Tubular Necrosis (ATN) 10% Interstitial Nephritis (AIN) 5% Acute Glomerulonephritis 50% Ischemia 35% Nephrotoxic Adapted from: Thadhani, R. et al. N Engl J Med 1996;334:1448-1460
Chronic Kidney Disease vs Acute Kidney Injury
Objective data suggestive of Chronic Kidney Disease Persistent elevation in serum Cr Often without clear etiology Normocytic/Normochromic Anemia Impaired Iron metabolism Evidence of protein calorie malnutrition Acidosis most commonly with normal anion gap Small and/or echogenic renal parenchyma on ultrasound Impaired bone mineral metabolism
Signs and Symptoms of Uremia Sleep reversal Dysgeusia Pruritis Nausea, vomiting, protein aversion Loss of appetite Protein calorie malnutrition Uremic pericarditis/uremic frost
Cross talk Pulmonary renal Cardiorenal Hepatorenal Mineral and bone disease Anemia of CKD Renal acidosis Uremia
Pulmonary Renal Syndrome: Diagnostic Considerations Goodpasture s syndrome Wegener s granulomatosis Microscopic polyangiitis Churg Strauss syndrome Henoch Schönlein purpura Mixed cryoglobulinaemia Behçet s disease IgA nephropathy Idiopathic pulmonary renal syndrome Propylthiouracil D-Penicillamine Hydralazine Allopurinol Sulfasalazine Goodpasture s syndrome Wegener s granulomatosis Scleroderma Polymyositis Rheumatoid arthritis Mixed collagen vascular disease Antiphospholipid syndrome Thrombotic thrombocytopenic purpura Infections Neoplasms
Pulmonary Renal Syndromes Papiris et al. Critical Care 2007, 11:213
Cardiorenal Syndrome Type I Acute HF AKI HTN with preserved LV pulmonary edema Acute decompesation of chronic HF Cardiogenic shock RV failure Type II Chronic HF progressive CKD Type III AKI acute HF e.g. bilateral renal artery stenosis Type IV CKD chronic cardiac systolic and/or diastolic dysfunction
Type I Roncho C, et al. J Am Coll Cardiol 2008;52:1527 39
Type II Roncho C, et al. J Am Coll Cardiol 2008;52:1527 39
AKI in Setting of Cirrhosis Garcia-Tsao G, et al. Hepatology 2008; 48(6):2066.
Baseline Renal Func&on and Markers of AKI Glomerulus Interstitial Disease Renal Blood Flow Urinary Outflow Glomerular Filtration Rate
Crea&nine Muscle: crea&ne and phosphocrea&ne Freely filtered Secreted in proximal tubule: 15 50% of U Cr Diurnal varia&on Adapted from: Hosten AO. Clinical Methods: the History, Physical, and Laboratory Examinations. 3 rd ed.
RIFLE Criteria for Diagnosis of Acute Kidney Injury
Serum Creatinine Trend 3.50 3.00 2.50 2.00 1.50 1.00 0.50 0.00 8/7/2002 11/7/2002 2/7/2003 5/7/2003 8/7/2003 11/7/2003 2/7/2004 5/7/2004 8/7/2004 11/7/2004 2/7/2005 5/7/2005 8/7/2005 11/7/2005 2/7/2006 5/7/2006 8/7/2006 11/7/2006 2/7/2007 5/7/2007 8/7/2007 11/7/2007 2/7/2008 5/7/2008 8/7/2008
25.00 Serum Creatinine Trend 20.00 15.00 10.00 5.00 0.00 8/2/09 8/16/09 8/30/09 9/13/09 9/27/09 10/11/09 10/25/09 11/8/09 11/22/09 12/6/09 12/20/09 1/3/10 1/17/10 1/31/10 2/14/10 2/28/10 3/14/10 3/28/10 4/11/10 4/25/10 5/9/10 5/23/10
Serum Creatinine Trend 9.00 8.00 7.00 6.00 5.00 4.00 3.00 9/23/2002 12/23/2002 3/23/2003 6/23/2003 9/23/2003 12/23/2003 3/23/2004 6/23/2004 9/23/2004 12/23/2004 3/23/2005 6/23/2005 9/23/2005 12/23/2005 3/23/2006 6/23/2006 9/23/2006 12/23/2006 3/23/2007 6/23/2007 9/23/2007 12/23/2007 3/23/2008 6/23/2008 9/23/2008 12/23/2008 3/23/2009 6/23/2009 9/23/2009 12/23/2009 2.00 1.00 0.00
5.00 Serum Creatinine Trend 4.50 4.00 3.50 3.00 2.50 2.00 1.50 1.00 0.50 Urine specific gravity: 1.010 Recurrent sterile pyuria 8/21/2003 10/21/2003 12/21/2003 2/21/2004 4/21/2004 6/21/2004 8/21/2004 10/21/2004 12/21/2004 2/21/2005 4/21/2005 6/21/2005 8/21/2005 10/21/2005 12/21/2005 2/21/2006 4/21/2006 6/21/2006 8/21/2006 10/21/2006 12/21/2006 2/21/2007 4/21/2007 6/21/2007 8/21/2007 10/21/2007 12/21/2007 2/21/2008 4/21/2008 0.00
Urine Color Hemoglobinuria Myoglobinuria Porphyrinuria Alkaptonuria Nitrofurantoin Chloroquin Senna Rhubarb Hematuria Hemoglobinuria Myoglobinuria Crystallinuria Phenytoin Beetroot Prerenal azotemia ATN Bilirubinuria Hypercalciuria Crystallinuria Chyluria Why is American beer served cold? So you can tell it from urine. David Moulton
GFR Decline: microalbuminuria vs. progression to overt proteinuria Methods to Evaluate Proteinuria Random urine Protein/Cr Microalbumin/Cr Index 24 hour urine collec&on Protein UPEP/Immunofixa&on Lemli KV, et al. AJP Renal 2005; 289:863-870
Red Blood Cell Cast
Tubular Epithelial Cell Cast White Blood Cell Cast
Waxy (Broad) Cast
Muddy Brown Granular Cast
Varia<ons in Mean Arterial Pressure and Concept of Autoregula<on Palmer, B. F. N Engl J Med 2002;347:1256-1261
Tubular-Cell Injury and Repair in Ischemic Acute Renal Failure Thadhani, R. et al. N Engl J Med 1996;334:1448-1460
Natural History Acute Tubular Necrosis (ATN)
Electrolyte Abnormalities in AKI
Hyonatremia and Hypernatremia During Maintenance Phase of ATN
Hyperkalemia
Hyperkalemia
Hyperkalemia
44 year old WM with history of chronic alcohol abuse and previous suicide aaempts was found non responsive in his garage by his wife with unclear down &me. Prehospital services found pa&ent with spontaneous respira&ons, though unable to adequately protect his airway. Therefore pa&ent was endotracheally intubated. Ini&al laboratories were drawn in the emergency department and the pa&ent was transferred to the medical intensive care unit for further evalua&on.
134 103 20 4.7 9 1.1 ABG: ph 7.14, P a CO 2 22 Acidemia or Alkalemia? What is the anion gap? What is the primary disorder? Compensation appropriate? In setting of AGMA What is the / gap (ratio)?
Anion Gap Metabolic Acidosis due to ethylene glycol intoxication
Common Pharmacologic Issues in the secng of AKI Diure&c dosing is GFR dependent One excep&on is mineralocor&coid receptor blockers (spironolactone and eplerenone) Avoid medica&ons that may impair GFR Consider holding ACE I/ARB NSAID s Hyperkalemia Loop diure&cs Insulin Β blockers Sodium polystyrene sulfonate (Kayexalate ) Dialysis Avoid use of IV contrast
Decreased egfr Furosemide dose= age+bun -House of God. Samuel Shem Hypoalbuminemia Serum albumin <2.0 g/dl May need to double dose Furosemide Proteinuria Nephrotic range: May require serial doubling of dose to achieve diuresis Hypotension Prerenal azotemia: May result in apparent diuretic resistance
Preven&on of Contrast Nephropathy IVF Bicarbonate Acetylcysteine (Mucomyst ) Sta&n therapy Renal dose dopamine Fenoldopam
Indications for Dialysis Acidosis, refractory Electrolyte abnormalities Hyperkalemia Ingestions Toxic alcohol, drugs Overload, fluid Uremia