ACUTE KIDNEY INJUERY BY AHMED SOLIMAN MD

CURRENT KIDNEY INJURIES
BASIC INFORMATIONS
APPROCHES

1. BY Ahmed S.A. Soliman , MD ACUTE KIDNEY INJURY P r a c t I c a l p o I n t s MISSION TO TOUCH THE SUN AUGEST 12, 2018

2. INTRODUCTION TO AKI A C U T E K I D N E Y I N J U R Y BASIC CONCEPTS Desanti De Oliveira B, Xu K, Shen TH, Callahan M, Kiryluk K, D'Agati VD, Tatonetti NP, Barasch J, Devarajan P Nat Rev Nephrol. 2019;15(10):599. Epub 2019 Aug 22. Acute kidney injury (AKI) is defined as the abrupt loss of kidney function that results in a decline in glomerular filtration rate (GFR), retention of urea and other nitrogenous waste products, and dysregulation of extracellular volume and electrolytes. The term AKI has largely replaced acute kidney failure (AKF), Pediatric AKI presents with a wide range of clinical manifestations from a minimal elevation in serum creatinine to anuric kidney failure, arises from multiple causes, and occurs in a variety of clinical settings

3. AKI KDIGO DEFINITION A C U T E K I D N E Y I N J U R Y BASIC CONCEPTS Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2012; 2:8. Copyright © 2012.  www.nature.com/kisup .

4. A C U T E K I D N E Y I N J U R Y CLINICAL APPROACH

5. RIFLE AND OR KDIGO CRITERIA CONFIRM A C U T E K I D N E Y I N J U R Y APPROACH 1 EVALUATION ACUTE MANAGEMENT DIALYSIS DIAGNOSTIC (4QS) & EMERGENCY INTERVENSION 2 FLUIDS , ACID-BASE , ELCTROLYTES , CAUSE 3 WHEN AND WHAT ? 4 INTIAL LABS WORK UP CBC , Blood Film , CRP , Serum Urea , Creatinine , Sodium , Potassium , Calcium , Phosphorous , Magnesium , Bicarbonate . LFT , PT , PTT , BLOOD CULTURE , URINE FOR BLOOD , PROTEIN , CAST , Electrolytes , Creatinine , Chest X RAY , US KUB

6. CONFIRM AKI A C U T E K I D N E Y I N J U R Y APPROACH 1 REVIEW RIFLE AND OR KDIGO CRITERIA 1

7. EVALUATION DIAGNOSTIC APPROCH A C U T E K I D N E Y I N J U R Y APPROACH 1 Focus Your History , Examinations And Laboratory Imaging Workup To Answer 4 Questions 2

8. EVALUAION A C U T E K I D N E Y I N J U R Y APPROACH Focus Your History , Examinations And Laboratory Imaging Workup To Answer 4 Questions Are There Life Threatening Events Indicated For Immediate Intervention ( Dialysis ) ? Uremic Encephalopathy And Coma (Apply GCS) Refractory Pulmonary Edema /Over Load Refractory Sever Hypertensive Emergency Refractory Sever Acid Base And Electrolytes Disturbance 1 Consider Emergency Dialysis Kellumand JA, Lameire N, KDIGO AKI Guideline Work Group. Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1). Crit Care 2013;17:204–219 2

9. EVALUAION A C U T E K I D N E Y I N J U R Y APPROACH Focus Your History , Examinations And Laboratory Imaging Workup To Answer 4 Questions ACUTE OR ACUTE ON TOP OF CHRONIC? 2 Failure To Thrive Skeletal Deformities Chronic Anemia High Serum PTH RECUREENT UTI Urinary And Kidney Anomalies Small Atrophied Kidneys In Us Chronic NSAIDS Chronic hypokalemia Kellumand JA, Lameire N, KDIGO AKI Guideline Work Group. Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1). Crit Care 2013;17:204–219 2

10. EVALUAION A C U T E K I D N E Y I N J U R Y APPROACH Focus Your History , Examinations And Laboratory Imaging Workup To Answer 4 Questions Dark urine (gross hematuria ) , evidence of nephritic syndrome , nephrotic or both ,hx of bloody diarrhea skin rashes , arthritis , un treated pre-renal event , nephrotoxic medications , Malignancy (TLS) Vomiting , Diarrhea , Sepsis , Cardiac , Hypoxic Events ,Burn , Shock , Dehydration , Poor Perfusion Suggests Pre-renal Causes . 3 Vomiting , Diarrhea , Sepsis , Cardiac , Hypoxic Events ,Burn , Shock , Dehydration , Poor Perfusion POSSIBLE CAUSES? PRE RENAL POST So Labs Should Directed According To The Cause ( Eg Blood Film ,STOOL CULTURE , Type And Hold , STEC Serology , Retic Count HUS , C3 &C4 , ASO ,Serum IG A , ANA , Ds DNA , ANTI-GBM ,ANCA, Hepatitis Serology In Case Of Nephritis , Serum Ck , Urine Myoglobin In Case Of Rhabdomyolysis Kellumand JA, Lameire N, KDIGO AKI Guideline Work Group. Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1). Crit Care 2013;17:204–219 Kidney Biopsy Is Indicated If Nephritic , Nephrotic Or Both Or Unclear Etiology 2

11. EVALUAION A C U T E K I D N E Y I N J U R Y APPROACH Focus Your History , Examinations And Laboratory Imaging Workup To Answer 4 Questions IS THERE ARE ASSOCIATED COMPLICATIONS ? 4 Metabolic Acidosis (High Or Mixed AGMA) Hyperkalemia Hypokalemia Hyponatremia Hypernatremia Hypocalcemia Hyperphosphatemia Non Emergency Hypertension Non Emergency Fluid Volume Overload Kellumand JA, Lameire N, KDIGO AKI Guideline Work Group. Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1). Crit Care 2013;17:204–219 2

12. ACUTE MANAGEMENT A C U T E K I D N E Y I N J U R Y APPROACH 1 FLUID , ACID-BASE ,ELCTROLYTES & CAUSE 3

13. MANAGEMENT A C U T E K I D N E Y I N J U R Y APPROACH GENERAL CONCEPTS What Is Hydration State ? Is There Is Urine Out Put ? Urinary Catheter Is Essential To Confirm Oliguria Or Monitoring UOP. Intake Should Be Calculated Carefully . Frequent Vitals And Neurological Monitoring . Electrolytes , Creatinine And Glucose Montring Is Essential During Fluid Management . K. Phadke et al. (eds.), Manual of Pediatric Nephrology, 349DOI 10.1007/978-3-642-12483-9_8, © Springer-Verlag Berlin Heidelberg 2014 3 F L U I D M A N A G E M E N T

14. MANAGEMENT A C U T E K I D N E Y I N J U R Y APPROACH K. Phadke et al. (eds.), Manual of Pediatric Nephrology, 349DOI 10.1007/978-3-642-12483-9_8, © Springer-Verlag Berlin Heidelberg 2014 3 F L U I D M A N A G E M E N T HYPOVOLEMIA 20 ML/KG Normal Saline OR Ringer Lactate Over 20 -30 Minutes + oxygen supplement (if shocked ) RESPONSE Good UOP Good peripheral perfusions Normal heart rate Improved mottled skin Improved mental status Continue As Euvolemic No Response Still Oliguria Weak Peripheral Perfusions Tachycardia Or Bradycardia Mottled Skin Altered Mental Status Normal saline boluses can repeated twice , if no response more boluses should be guided by central venous pressure monitoring Albumin combined with diuretics can be given in case of nephrotic syndrome or sever hypoalbuminemia (symptomatic )

15. MANAGEMENT A C U T E K I D N E Y I N J U R Y APPROACH K. Phadke et al. (eds.), Manual of Pediatric Nephrology, 349DOI 10.1007/978-3-642-12483-9_8, © Springer-Verlag Berlin Heidelberg 2014 3 F L U I D M A N A G E M E N T Euvolemic Replace maintenance water and electrolytes Insensible water loss (400ml/m2) Daily urine out put Ongoing loss Ongoing Loss Urine: replace same volume with ½ isotonic saline (0.45 % NaCl). GIT: Nasogastric (NG) tube, emesis, or stool losses: replace same volume with isotonic or ½ isotonic saline Potassium Replacement Replacement of potassium (e.g., from GI losses) will depend on patient’s serum potassium level, acid-base status (acidemia leads to relative hyperkalemia), overall potassium depletion, and kidney function. Use D5% ½ NS To Keep The Patient Normoglycemic

16. MANAGEMENT A C U T E K I D N E Y I N J U R Y APPROACH K. Phadke et al. (eds.), Manual of Pediatric Nephrology, 349DOI 10.1007/978-3-642-12483-9_8, © Springer-Verlag Berlin Heidelberg 2014 3 F L U I D M A N A G E M E N T OVERLOD Furosemide 2-5mg/kg/dose (Single dose ) Fluid restriction No response Replace insensible , 50%-70% of urine Out put , oral feeding oral or iv medications should be included furosemide infusion 0.1-0.3 mg/kg/h for short period 4 hours No response Response Adequate urine out put with in 1-2 hours Trial of furosemide infusion 0.1-0.3 mg/kg/h for short period 4 hours No adequate urine out put in 2 hours Consider Dialysis If Still No Improvement

17. MANAGEMENT A C U T E K I D N E Y I N J U R Y APPROACH GENERAL CONCEPTS Do Not Give Potassium And Phosphorous In Oliguric Patient Unless Significant Hypokalemia Or Hypophostemia Sodium Restricted To 2-3 Meq /Kg/Day To Avoid Fluids Overload And Hypertension Polyureic Aki Has Loss Of Electrolytes In Urine And Shuold Be Replaced Based On Serum And Urinary Elctrolytes K. Phadke et al. (eds.), Manual of Pediatric Nephrology, 349DOI 10.1007/978-3-642-12483-9_8, © Springer-Verlag Berlin Heidelberg 2014 3 ELCTROLYTES & ACID BASE

18. MANAGEMENT A C U T E K I D N E Y I N J U R Y APPROACH INDICATION OF BICARB THERAPY Not affect AKI prognosis If Ph Is Less Than 7.2 Or Bicarbonate Level Is Below 15 Mmol/L Or Hyperkalemia . mmol NaHCO3 3 = ( 18 − measured HCO ×0 .6 × weight in kg). Max sodium bicarb dose is 50 meq Bicarb Therapy May Precipitate Hypocalcemia And Seizure So In Case Of Hypocalcemia Correct Calcium Level First (do not start iv bicarb therapy unless corrected total blood calcium level is not less than 2 mmol/l and ionized calcium not less than 1 mmol/l K. Phadke et al. (eds.), Manual of Pediatric Nephrology, 349DOI 10.1007/978-3-642-12483-9_8, © Springer-Verlag Berlin Heidelberg 2014 3 METABOLIC ACIDOSIS

19. MANAGEMENT A C U T E K I D N E Y I N J U R Y APPROACH K. Phadke et al. (eds.), Manual of Pediatric Nephrology, 349DOI 10.1007/978-3-642-12483-9_8, © Springer-Verlag Berlin Heidelberg 2014 3 HYPERKALEMIA Inhaled B2 agonists If No Response And Consider RRT

20. MANAGEMENT A C U T E K I D N E Y I N J U R Y APPROACH K. Phadke et al. (eds.), Manual of Pediatric Nephrology, 349DOI 10.1007/978-3-642-12483-9_8, © Springer-Verlag Berlin Heidelberg 2014 3 HYPERKALEMIA Anti-hyperkalemic Measures

21. MANAGEMENT A C U T E K I D N E Y I N J U R Y APPROACH K. Phadke et al. (eds.), Manual of Pediatric Nephrology, 349DOI 10.1007/978-3-642-12483-9_8, © Springer-Verlag Berlin Heidelberg 2014 3 HYPONATERMIA Often Due To Extracellular Fluid Dilution ( Fluid Overload) And Not To Sodium Deficit . • If severe and symptomatic or serum sodium <120 mmol/l, consider administration of hypertonic saline (3 % = 0.5 mmol/ml) to correct to 125 mmol/l: [Sodium deficit (mmol) = (125 – [Na+]) × 0.6 × body weight (in kg)]. • Hypertonic (3 %) saline is infused IV over 2–4 h. (max single dose 100 ml) • In the presence of anuria or if hyponatremia is persistent, may require dialysis

22. MANAGEMENT A C U T E K I D N E Y I N J U R Y APPROACH 3 HYPERNATERMIA Much less common than hyponatremia. Most commonly due to severe dehydration, very occasionally due to diabetes insipidus. Salt poisoning (deliberate or iatrogenic) rarely occurs Careful assessment of fluid status is therefore mandatory. Give furosemide 3–4 mg/kg IV (maximum 12 mg/kg/day) if salt retention is the cause and patient has urine output. Fluid replacement will depend on cause and hydration. Severe hypernatremia with oliguria is an indication for dialysis

23. MANAGEMENT A C U T E K I D N E Y I N J U R Y APPROACH K. Phadke et al. (eds.), Manual of Pediatric Nephrology, 349DOI 10.1007/978-3-642-12483-9_8, © Springer-Verlag Berlin Heidelberg 2014 3 HYPOCALCEMIA Hypocalcemia In Patients With AKI Is Often Secondary To Hyperphosphatemia And Will Correct Once Serum Phosphate Levels Normalize. Consider IV calcium gluconate for symptomatic hypocalcemia (neuromuscular irritability, numbness, muscle cramps, laryngospasm, seizures) and if bicarbonate therapy is needed to treat severe acidosis and/or hyperkalemia. If AKI on preceding CKD, commence activated vitamin D ( alfacalcidol or calcitriol) at a dose of 0.01 micrograms/kg/day.

24. MANAGEMENT A C U T E K I D N E Y I N J U R Y APPROACH Kellumand JA, Lameire N, KDIGO AKI Guideline Work Group. Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1). Crit Care 2013;17:204–219 3 HYPERTENSION • Usually Due To Fluid Overload , Although It Is Important To Be Sure That It Is Not Due To Intense Vasoconstriction Because Of Hypovolemia (Very Rare). • First Treatment Is Furosemide, And Failure To Respond Is An Indication For Dialysis Although It Is Usual To Consider Other First-line Agents (E.G. Calcium Channel Blockers, Labetalol If Severe Hypertension With Signs Of Encephalopathy) In Addition, Particularly Since It Usually Takes Several Hours To Establish Emergency Dialysis. • If dialysis is adequate but hypertension persists, CALCIUM CHANNEL BLOCKERS OR ACEI is the first line .

25. MANAGEMENT A C U T E K I D N E Y I N J U R Y APPROACH Kellumand JA, Lameire N, KDIGO AKI Guideline Work Group. Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1). Crit Care 2013;17:204–219 3 DRUG THERAPY Correct drug doses according to GFR. Change of GFR will necessitate regular revision of drug dosages. It is preferable to avoid known nephrotoxic drugs in AKI when an alternative is available

26. MANAGEMENT A C U T E K I D N E Y I N J U R Y APPROACH Kellumand JA, Lameire N, KDIGO AKI Guideline Work Group. Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1). Crit Care 2013;17:204–219 3 TREATMENT OF THE CAUSE

27. DIALYSIS A C U T E K I D N E Y I N J U R Y APPROACH When We Can Take Dialysis Decision? https://www.uptodate.com/contents/pediatric-acute-kidney-injury-aki-indications-timing-and-choice-of-modality-for-kidney-replacement-therapy-krt?search=acute%20kidney%20injury&topicRef=6090&source=see_link#H1406959811 4 Fluid overload >10%-15% with multiple organ failure & oliguria or a hindrance administration of medications and blood products. Serious and potentially life-threatening complications due to fluid overload such as pulmonary edema, heart failure, and hypertension that is refractory to pharmacologic therapy. Life-threatening metabolic derangements that are refractory to medical management ( hyperkalemia >6.5 mmol/l , PH >7.1 , Hyponatremia is rare indication of RRT) Progressive Life threatening uremia ( risk of uremic encephalopathy , pericarditis , bleeding ) Urgent Indications

28. DIALYSIS A C U T E K I D N E Y I N J U R Y APPROACH When We Can Take Dialysis Decision? https://www.uptodate.com/contents/pediatric-acute-kidney-injury-aki-indications-timing-and-choice-of-modality-for-kidney-replacement-therapy-krt?search=acute%20kidney%20injury&topicRef=6090&source=see_link#H1406959811 4 Reduced or fixed urine output ( ie , oligoanuria ), with high-volume requirement for administration of nutrition, medications, and/or blood products with evidence of continued deterioration of renal functions . Refractory electrolytes and acid-base disturbances – Deteriorating electrolyte and acid-base anomalies not responding to supportive management ( eg , refractory severe hyperkalemia) but not yet meeting life-threatening values. BUN between 30-50 mmol/l but without uremic life threatening events (not reliable indication ) Non-Urgent Indications