ACUTE KIDNEY INJURYQuentin Oury (FY1)

Definition Several!! New Nice guidelines due 2014:

a rise in serum creatinine (of 26 μmol/l or greater within 48 hours)

a 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days

a fall in urine output (to less than 0.5 ml/kg/hour for more than 6 hours in adults and more than 8 hours in children and young people)

a 25% or greater fall in eGFR in children and young people.

Put simply : Rise in serum creatinine over hours/days/weeks

Risk factors Age CKD HF Diabetes Surgery Drugs- CANDA Cognitive/neuro impairment

Causes1) Pre-renal:

Hypovolaemia: sepsis, CCF, D+V, NSAID/ACEi, RAS

2) Renal: ATN due to ischaemia/nephrotoxins

(drugs/contrast/myeloma/rhabdo) Gomerulonephritis, vasculitis

3) Post-renal: Obstruction

History

Think of causes: Infection (UTI/sepsis) Hypovolaemia (D+V, acute blood loss) Drugs (any nephrotoxicx/new meds?) Urine: output (&symptoms of UTI/prostate) Weird and wonderful (nosebleeds,

haemoptysis, backpain/weight loss) PMHx: Diabetes, bladder/prostate Ca, FHx

(PKD)

Examination General Fluid status: BP, skin turgor, mucous

membranes, JVP, oedema (peripheral/pulmonary), urine output

Abdominal (in exams) Palpable bladder?

Investigations Bedside:

Urine dipstick, urine input/output, daily weights/fluid monitoring ABG/VBG ECG

Bloods FBC and regular tests inc cultures “U+E’s” : CREATININE Renal screen: myeloma, vasculitis, rhabdo

Imaging CXR USKUB

Special Urine PCR CT KUB Renal biopsy

Management Treat the cause! Conservative:

Oral fluids, STOP CANDA, diet Medical

IV fluids, treat life-threatening complications (next slide), catheter (if bladder/prostate obstruction), steroids for certain types of GN

Dialysis (if needed-see later) Diuretics (if actually CKD crash-lander)

Surgical Obstruction, bleeding

Complications Hyperkalaemia:

Life-threatening ECG signs: Low/flat P-waves, Broad QRS Tall-tented T waves

Mx: 1-Calcium gluconate (10/10) IV 2-Insulin+dex IV 3-Salbutamol 4-Calcium resonium

Complications (cont) Acidosis

Sodium bicarb IV Dialysis

Pulmonary Oedema Sit up O2 Furosemide

Uraemia

Indications for dialysis1. Hyperkalaemia (refractory)2. Severe acidosis (refractory)3. Severe pulmonary oedema4. Uraemic encephalopathy

Key points Causes: pre-, renal and post- CANDA Treatment: the cause Manage: the complications (& be aware)

Questions?