RCP : Regional Update in Medicine Acute Kidney Injury : A Renal Problem? Lui G Forni : Consultant Intensivist & Nephrologist Faculty of Health Sciences : University of Surrey
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
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
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
Alternative Definitions?
Don t Believe Me?
Alternative Definitions?
Alternative (Favourite) Definitions?
AKI.The Beginning Where Did It All Begin?
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.
ARF : Was A Bit like Pornography. Easy to Recognise.. Hard to Define!
Now over a decade ago
We Now Have Definitions Stage Serum Creatinine Urine Output 1 1.5-1.9 times baseline or 0.3 mg/dl (>26.4 µmol/l) increase < 0.5 ml/kg.h for 6-12 hrs 2 2.0-2.9 times baseline < 0.5 ml/kg.h for 12 hrs 3 3.0 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
Why I Dislike AKI?
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 971 979
The Pinocchio Effect. In Intensive Care we Invent Diseases ARDS, ARF, SIRS, PRES etc etc And Then Spend our Time Looking for a Cure.
and as intensivists we don t have a fairy godmother
Population Heterogeneity
Other Examples? Syndrome Homogeneity
Meningococcal infection in an 18 year old Urosepsis Peritonitis in an 80 year old Necrotising Fasciitis
Sepsis
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)
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..
Whether I Like it or Not We Have Evolved From ARF KDIGO And Guidelines Have RIFLE ARF AKIN Evolved
141 Pages Long 132 Page Appendix 64 Pages of Tables
But Not All Embraced KDIGO.
Criticisms
So, the Construct of AKI is based on.
But AKI Is Clearly an Issue..
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 AKI : Must be very Important 3000 2000 1000 0
AKI : What s The Problem? Common High Mortality Heavy Burden of Illness Acute Chronic Expensive!!!
Epidemiology : Recent Studies?
Multi-Centre, Retrospective
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%
? Possible Interventions?
Risk of death increases with AKI Stage and co-morbidities
Risk of Death
Surprising
Not Surprising HT, Heart Failure, Cirrhosis, Diabetes
Alexa Wonnacott et al. CJASN 2014;9:1007-1014 2014 by American Society of Nephrology
In-hospital outcomes: community- versus hospital-acquired AKI Alexa Wonnacott et al. CJASN 2014;9:1007-1014 2014 by American Society of Nephrology
Long-term mortality outcomes according to AKI stage. AKI Stage 1 : 60%!!! Alexa Wonnacott et al. CJASN 2014;9:1007-1014 2014 by American Society of Nephrology
Conclusions AKI in > 50% ICU Patients 30% Stage 3 13.5% receive RRT Increasing AKI Stage = Increasing Mortality
Nothing.
So Who Is At Risk of AKI?
271 Pages Long 126 References
Kidney Disease: Improving Global Outcomes WWW.KDIGO.ORG
Proteinuria Kidney Disease: Improving Global Outcomes WWW.KDIGO.ORG
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 2009 WWW.KDIGO.ORG
Prevention, Risk Assessment & Treatment of AKI Can We Predict AKI??
Do Prediction Scores For AKI Exist? They do : But Mostly Single Centre AKI Mortality 36-75% Where Externally validated : performance poor Common Risk Factors?
Common Risk Factors In AKI Scores Age, Gender Hypotension, Oliguria Liver Failure, Hypoalbuminaemia Sepsis Mechanical Ventilation
Author/Study Year Number AKI (?) Rasmussen 1985 148 SCr > 160 Lohr 1988 126 50% Elevation Poorly Performing Variable Definitions Schaefer 1991 134 RRT Liano 1993 328 RRT Paganini 1996 506 SCr > 160 Chertow 1998 256 RRT Lins 2000 197 Rise SCr > 80 Mehta 2002 605 SCR > 160 Lins 2004 293 SCr > 160 Dharan 2005 265 50% rise in SCr Chertow 2006 618 SCr > 40 Demirjian 2011 1122 SCr > 2 / RRT
Risk prediction for acute kidney Injury in acute medical admissions in the uk : The RISK study
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
Can We Even Identify AKI?
But.
Interventions? 67% Volume Deplete 21% On Nephrotoxins 17.6% Obstructive Symptoms 36.3% Sepsis
Completion CB within 24 Hrs
Limitations? Not Randomised Low % age completion rates Treatment in non-completed with no care bundle?
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
I used to think this