Acute Kidney Injury in Trauma David Lee Skinner MBChB FCS(SA) Trauma Unit Inkosi Albert Luthuli Central Hospital KwaZulu Natal South Africa
Acute Kidney Injury Acute Renal Failure RIFLE & AKIN
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
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
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
Trauma Pro-inflammatory state Crush Rhabdomyolysis
Sjambok Injury
Trauma Pro-inflammatory state Crush Rhabdomyolysis Renal Injury / Nephrectomy Hypovolaemia Hypotension Hypothermia
IV Contrast Antibiotics Fluid Therapy Abdominal Compartment Syndrome Sepsis
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
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
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?
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
Don t get stabbed Don t get shot Don t get hit by a car Conclusion
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
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