Acute kidney injury: Perioperative implications

Acute Kidney Injury
Dr. Abhijit S. Nair
Consultant Anesthesiologist,
Department of Anesthesiology & Critical Care,
Citizens Hospital, Hyderabad

Topics covered:
Definitions
Pathophysiology in brief
Special investigations
Preventive strategies
Approach

Definition
“ Abrupt loss of kidney function, resulting in
the retention of urea and other nitrogenous
waste products and in the dysregulation of
extracellular volume and electrolytes”
> 30 definitions available in
literature

NCEPOD Findings & Recommendations :
FINDINGS:
50% of cases with AKI documented as cause of
death received satisfactory or good care
30% of cases inadequately investigated and
managed
20% of post-admission AKI is predictable and
avoidable (or hospital acquired AKI = HAAKI)

Recommendations:
All emergency admissions should have
electrolytes checked on admission and
appropriately thereafter
All acute admissions should receive adequate
senior reviews, with consultant review within 12
hours of admission
Implementation of NICE guidance CG50

Why ?
Associated with increased hospital stay,
morbidity/ mortality , cost
Preventable if detected & preventive measures
taken
Protocols should be implemented from ER level
Reversible if identified & treated on time

Epidemiology:
≈ 10 % in hospitalized patients
≈70% in critically ill patients
5-6% ICU patients require RRT

Beginning of definitions:
ADQI ( 2002): To create consensus & evidence based
guidelines for prevention & treatment of AKI
BIRTH OF RIFLE CRITERIA
3 grades: R,I,F 2 outcomes: L,E

RIFLE criteria for diagnosis of AKI based on The “Acute
Dialysis Quality Initiative” ( 2002):
Increase in SCr Urine output
Risk of renal injury
Injury to the kidney
Failure of kidney
function
0.3 mg/dl increase
2 X baseline
3 X baseline OR
> 0.5 mg/dl increase if
SCr >=4 mg/dl
< 0.5 ml/kg/hr for > 6 h
< 0.5 ml/kg/hr for >12h
Anuria for >12 h
Loss of kidney
function
End-stage disease
Persistent renal failure
for > 4 weeks
Persistent renal failure
for > 3 months
Am J Kidney Dis. 2005 Dec;46(6):1038-48

Definition of Acute Kidney Injury (AKI) based
on “Acute Kidney Injury Network” ( 2004 ):
Stage Increase in Serum
Creatinine
Urine Output
1 1.5-2 times baseline
OR
0.3 mg/dl increase from
baseline
<0.5 ml/kg/h for >6 h
2 2-3 times baseline <0.5 ml/kg/h for >12 h
3 3 times baseline
OR
0.5 mg/dl increase if
baseline>4mg/dl
OR
Any RRT given
<0.3 ml/kg/h for >24 h
OR
Anuria for >12 h

RIFLE vs AKIN:
RIFLE: 7 days, AKIN: 48 hours
AKIN doesn’t entertain GFR
In AKIN: patient investigated after volume
resuscitation and ruling out post renal obstruction
Can determine outcome in RIFLE

KDIGO definition ( 2012
)
AKI is defined as any of the following :
Increase in Creat by > 0.3 mg/dl (X26.5 mol/l)
within 48 hours; or
Increase in Creat to > 1.5 times baseline, which
is known or presumed to have occurred within
the prior 7 days; or
Urine volume < 0.5 ml/kg/h for 6 hours

KDIGO staging:
Stage Serum creatinine Urine output
1 1.5-1.9× baseline
OR
>0.3 mg% 
<0.5 ml/kg/hr for 6-12 hrs
2 2-2.9× baseline <0.5 ml/kg/hr > 12 hrs
3 3 times baseline
OR
RRT
OR
< 18 yrs, GFR < 35
ml/min for 1.73 m2
<0.3 ml/kg/hr > 24 hrs
OR
Anuria > 12 hrs

Pathophysiology:
Endothelial injury
Nephrotoxins
Deranged autoregulation
Inflammatory mediators

Prerenal Azotemia :
 Intravascular volume depletion
bleeding, GI loss, Renal loss, Skin loss, Third space loss
 Decreased cardiac output
CHF
 Renal vasoconstriction
Liver Disease, Sepsis, Hypercalcemia
 Pharmacologic impairment of autoregulation and
GFR in specific settings
ACE inhibitors, ARBs, NSAIDS, Aminoglycosides

Renal causes:
Tubule: ATN ( ischemic, toxins)
Interstitium: AIN ( Drug, infection, neoplasm)
Glomerulus: AGN( primary, infection,
rheumatologic, vasculitis)
Vasculature: Embolic, livedo reticularis,
eosinophiluria, hypocomplementemia

Mechanisms of acute kidney injury: a molecular viewpoint.
Lattanzio M R , and Kopyt N P J Am Osteopath Assoc
2009;109:13-19
Published by American Osteopathic Association

General guidelines for differentiating the etiology of acute kidney injury (ie, prerenal vs renal)
using laboratory studies.
Lattanzio M R , and Kopyt N P J Am Osteopath Assoc
2009;109:13-19
Published by American Osteopathic Association

Urine analysis :
 Unremarkable in pre and post renal causes
 Differentiates ATN vs. AIN. vs. AGN
Muddy brown casts in ATN
WBC casts in AIN
RBC casts in AGN

Can creatinine increase in
absence of AKI?
Inhibition of tubular secretion of creatinine:
Trimethoprim, Cimetidine, Probenecid
False elevation due to interference in lab:
Fluocytosine, Ascorbic acid

NGAL:
◦ Expressed in proximal and distal nephron
◦ Binds and transports iron-carrying molecules
◦ Role in injury and repair
◦ Rises very early (hours) after injury in animals,
confirmed in children having CPB
Range:
<20 ng/ml: considered normal
>1200 ng/ml: HIGH

Cystatin C
Better marker in early detection
Not affected by age, gender, muscle mass, ethnicity
Normal level: 0.5-1 mg/L
Almost 100 times costly, compared to creatinine

IL-18:
◦ Role in inflammation, activating macrophages and mediates
ischemic renal injury
◦ IL-18 antiserum to animals protects against ischemic AKI
◦ Studied in several human models

KIM-1:
◦ Epithelial transmembrane protein, ?cell-cell interaction.
◦ Appears to have strong relationship with severity of renal
injury

Initial assessment:
History
Medications including contrast
RFT, CUE
Volume status
Color of urine
ABG
Imaging

Role of ANP analogues in AKI?
61 patients in 2 cardiothoracic ICU with post-op AKI
assigned to receive recombinent ANP (50ng/kg/min) or
placebo
The need for RRT before day 21 after development of
AKI was significantly lower in ANP group (21% vs 47%)
The need for RRT or death after day 21 was
significantly lower in ANP group (28% vs 57%)
Crit Care Med. 2004 Jun;32(6):1310-5

Diuretic in AKI!
Converts oliguric AKI into non-oliguric
Psychological relief
Better in volume resuscitated patients
Not associated with improved survival or early
recovery

Is there a role for Fenoldopam in prevention or
treatment of AKI in ICU setting?
 Dopamine-1 receptor agonist, lack of Dopamine-2, and
alpha-1 receptor effect, make it a potentially safer drug
than Dopamine!
 Reduces in hospital mortality and the need for RRT in
AKI
 Reverses renal hypoperfusion more effectively than
renal dose Dopamine
 Studied in cardiothoracic ICU patients, awaiting more
powered trials in other groups!
J Cardiothorac Vasc Anesth. 2008 Feb;22(1):23-6.
J Cardiothorac Vasc Anesth. 2007 Dec;21(6):847-50
Am J Kidney Dis. 2007 Jan;40(1):56-68
Crit Care Med. 2006 Mar;34(3):707-14

http://londonaki.net/
1.5 × creatinine or oliguria > 6 hrs: Medical emergency
Fluids
Monitoring
Investigate
“ STOP AKI”: Sepsis & hypoperfusion,
Toxicity, Obstruction, Parenchymal kidney
disease

NAC:
Efficacy proven in CIN
Not an alternative to IV hydration
Protocols to be circulated to ER & Radiology
department
Should be given pre-exposure and to be
continued
Oral NAC had less bioavailability than IV

MEDLINE, OVID,EMBASE
Web of Science, Cochrane Central Register of
Controlled Trials
Conference proceedings from major cardiology
and nephrology meetings
Primary outcome: CIN
Secondary outcomes : renal failure requiring
dialysis, mortality, length of hospitalization

Results:
Too inconsistent at present to warrant a
conclusion on efficacy
Large, well designed trials required

NAC & SEPSIS!
Ineffective in reducing mortality & complications
Can be harmful, even if started early

EPO- TBI trial :NCT00987454
EPO-AKI is a sub study of the above trial
AKI defined as per RIFLE
HOW??! INDUCES HSP70 & prevents
APOPTOSIS
At present studied in cardiac surgery patients &
heterogenous MICU patients
Results awaited

Liver dysfunction & AKI:
Volume responsive AKI
Volume unresponsive AKI ( ATN )
HRS
IV Albumin 40-60 GM/ day × 3-4 days: CIRRHOSIS

Management:
Identify the cause
Fluid optimization
Vasopressor/ Vasodilators
Management of hyperkalemia
Management of acidosis, RRT
CCB( in animals), Antidotes

Perioperative management:
EUVOLEMIA!!
IV volume replacement ( WHICH, HOW MUCH ? )
Acid base balance
Avoid nephrotoxic drugs
Foley’s
MAP, CVP, Cardiac output
Vasopressors
Anticipation

PLoS Med. Feb 2014; 11(2):
e1001601.
Survivors of RENAL study followed upto 4 years/ death
Survivors had heavy burden of proteinuria
Increased frequency of RRT
Costly affair, poor quality of life

Acute kidney injury: Perioperative implications

Acute kidney injury: Perioperative implications

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