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Acute Kidney Injury 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 Objecves • Discuss differenal diagnosis of Acute Kidney Injury (AKI). • Discuss signs and symptoms of AKI, including pre‐renal, intrinsic and post‐renal lesions. • Outline diagnosc approach in the evaluaon of AKI. • Idenfy common electrolyte abnormalies seen in AKI, including treatment consideraons • Outline common pharmacologic issues in the seng of AKI. • Discuss prevenon of AKI in the hospitalized populaon, including Contrast Induced Nephropathy. • Discuss indicaons for dialysis in the seng of AKI. “When you hear hooeats….don’t expect to see a zebra.” Theodore Woodward, MD Nobel laureate 1948 AKI Pre‐renal Intrinsic Post‐renal 85% 10% 5% Acute Tubular Interstitial Acute Necrosis (ATN) Nephritis (AIN) Glomerulonephritis 50% 35% Ischemia 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 • Goodpasture’s syndrome • Wegener’s granulomatosis • Wegener’s granulomatosis • Microscopic polyangiitis • Scleroderma • Churg–Strauss syndrome • Polymyositis • Henoch–Schönlein purpura • Rheumatoid arthritis • Mixed cryoglobulinaemia • Mixed collagen vascular disease • Behçet’s disease • Antiphospholipid syndrome • IgA nephropathy • Thrombotic thrombocytopenic • Idiopathic pulmonary–renal syndrome purpura • Propylthiouracil • Infections • D-Penicillamine • Neoplasms • Hydralazine • Allopurinol • Sulfasalazine Pulmonary Renal Syndromes Papiris et al. Critical Care 2007, 11:213 Cardiorenal Syndrome Type I – Acute HFAKI HTN with preserved LVpulmonary edema Acute decompesation of chronic HF Cardiogenic shock RV failure Type II – Chronic HFprogressive CKD Type III – AKIacute HF e.g. bilateral renal artery stenosis Type IV – CKDchronic 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 Funcon and Markers of AKI Interstitial Glomerulus Disease Renal Urinary Blood Outflow Flow Glomerular Filtration Rate Creanine • Muscle: creane and phosphocreane • Freely filtered • Secreted in proximal tubule: 15‐50% of UCr • Diurnal variaon Adapted from: Hosten AO. Clinical Methods: the History, Physical, and Laboratory Examinations. 3rd ed. RIFLE Criteria for Diagnosis of Acute Kidney Injury 3.50 3.00 2.50 2.00 1.50 1.00 0.50 Serum Creatinine Trend 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 20.00 15.00 10.00 5.00 Serum Creatinine Trend 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 9.00 8.00 7.00 6.00 5.00 4.00 3.00 2.00 1.00 0.00 9/23/2002 12/23/2002 3/23/2003 6/23/2003 Serum Creatinine Trend 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 5.00 4.50 4.00 3.50 3.00 2.50 2.00 1.50 1.00 0.50 0.00 8/21/2003 10/21/2003 12/21/2003 2/21/2004 Serum Creatinine Trend 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 Urine specific gravity: 1.010 2/21/2006 Recurrent sterile pyuria 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 Urine Color Hypercalciuria Crystallinuria Chyluria Prerenal azotemia Hematuria Hemoglobinuria ATN Hemoglobinuria Myoglobinuria Bilirubinuria Myoglobinuria Porphyrinuria Crystallinuria Alkaptonuria Phenytoin Nitrofurantoin Beetroot Chloroquin Senna Rhubarb “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 collecon • Protein • UPEP/Immunofixaon 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 Variaons in Mean Arterial Pressure and Concept of Autoregulaon 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 aempts was found non‐responsive in his garage by his wife with unclear down me. Prehospital services found paent with spontaneous respiraons, though unable to adequately protect his airway. Therefore paent was endotracheally intubated. Inial laboratories were drawn in the emergency department and the paent was transferred to the medical intensive care unit for further evaluaon. 134 103 20 4.7 9 1.1 ABG: pH 7.14, PaCO2 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 seng of AKI • Diurec dosing is GFR dependent – One excepon is mineralocorcoid receptor blockers (spironolactone and eplerenone) • Avoid medicaons that may impair GFR – Consider holding ACE‐I/ARB – NSAID’s • Hyperkalemia – Loop diurecs – Insulin – Β blockers – Sodium polystyrene sulfonate (Kayexalate®) – Dialysis • Avoid use of IV contrast Decreased eGFR Hypoalbuminemia Furosemide dose= age+BUN Serum albumin <2.0 g/dL -House of God. Samuel Shem May need to double dose Furosemide Proteinuria Hypotension Nephrotic range: Prerenal azotemia: May require serial doubling May result in “apparent” of dose to achieve diuresis diuretic resistance Prevenon of Contrast Nephropathy • IVF • Bicarbonate • Acetylcysteine (Mucomyst®) • Stan therapy • “Renal dose” dopamine • Fenoldopam Indications for Dialysis • Acidosis, refractory • Electrolyte abnormalities – Hyperkalemia • Ingestions – Toxic alcohol, drugs • Overload, fluid • Uremia .
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