Acute Kidney Inj ury Focus on Perioperative S etting Oct ober 10, 2018 Banff, Albert a
Disclosures Part icipat e in a research group wit h funding from several sources including indust ry – funding is at arms lengt h, no overlap wit h AKI
Disclosures A lot of t he dat a discussed t oday is populat ion dat abase derived- met hodology varies , definit ions vary, and analysis varies. I am aware of t he issues but am not an expert in t hese met hodologies.
Obj ectives Increase awareness of t he import ance of AKI event s and survivors Review some aspect s of diagnosis and management Review some emerging processes in diagnosis and management
Meht a RL, et al. Lancet 2015; 385: 2616-2643 S usant it aphong P et al. Clin J Am S oc Nephrol 2013; 8: 1482-1493
RIFLE (2004), AKIN (2007), KD:IGO (2012) Consensus Definitions for AKI criteria Stage Serum Creatinine or eGFR Urine Output RIFLE KD:IGO RIFLE KD:IGO AKIN AKIN Increased sCr ≥ 1.5 x baseline or GFR > < 0.5 ml/kg/h ≥ 6 h Risk 1 Increased sCr 1.5 – 1.9 x baseline 25% within prior 7 days or Increased sCr x 26.4 µmol/ L [0.3 mg/ dl] within 48 hours Increased sCr ≥ 2 x baseline or GFR > 50% < 0.5 ml/kg/h ≥ 12 h Inj ury 2 Increased sCr 2– 2.9 x from baseline Increased sCr ≥ 3 x baseline or GFR > < 0.3 ml/kg/h ≥ 24 h Failure 3 Increased sCr 3 x from baseline, 75% , or or ≥ 354 µmol/L, with an acute ≥ 44 anuria ≥ 12 h or ≥ 354 µmol/L], with an acute ≥ 44 µmol/ L µmol/ L or receiving RRT Bellomo R, et al. RIFLE. Crit Care 2004; 8(4): R204-12 Meht a RL, et al. AKIN. Crit Care 2007; 11: R31-38 KDOGI. KD:IGO. Kidney Int 2012; 2(suppl 1):19-36
Minj ae K et al Anest hesia & Analgesia 2014; 119(5): 1121-1132
S usant it aphong P et al. Clin J Am S oc Nephrol 2013; 8: 1482-1493
Acute Kidney Inj ury – a continuum Definition: “ abrupt and sustained decrease in glomerular filtration, urine output, or both.” S ubclinical AKI does not meet AKI criteria and Biomarker concentration increased AKI Meets AKI criteria and rapid reversal within 48 hrs up to 7 days (renal recovery) AKD S ustained reduced renal function > 7 days CKD S ustained reduced renal function > 90 days
KDIGO. Kid Int S upplement s 2012; 2(S uppl 1): 19-36
Forni LG et al Int ensive Care Med (2017) 43:855– 866
AKI Outcomes Deat h? Deat h Deat h Dedhia P and Thakar CV . Core Concept s in Acut e Kidney Inj ury. S . S . Waikar et al. (eds.) S pringer S cience+Business Media, LLC 2018
KDIGO. Kid Int 2012; 2(S uppl 1): 19-36 Ferenbach DA and Bonvent re JV . Nephrologie & Therapeut ique 2016; 12S : S 41– S 48 Y ang Y et al. Pharmacology and Therapeut ics 2016;163: 58-73
AKI, Renal Recovery, CKD risk No AKI AKI - R AKI- NR Pannu N et al Clin J Am S oc Nephrol 2013; 8: 194– 202 Bucaloui ID et al Kidney Int 2012; 81: 477-485 Heung M et al Am J of Kidney Dis 2015; 67(5):742-
Bihorac A et al Annals of S urgery 2009; 249 (5):851-858
Kork F et al Anest hesiology 2015; 123(6): 1301-1311
S ummary Normal kidneys wit h minimal risk can develop AKI The more risk fact ors for AKI, t he great er t he risk for an AKI event Wit h AKI t here is an increased risk of S hort erm and longt erm mort alit y, repeat AKI, hospit al readmission, Incident CKD progression t o CKD and ES RD CKD is a significant AKI risk fact or
AKI Management – Moving to the 5Rs? Hx: Co-morbidit ies, prior AKI event s/ CKD, FHx, acut e clinical set t ing, Medicat ion exposure Px: Hemodynamic st at us, infect ion, sepsis, anemia, hypovolemia, chronic organ dysfunct ion (Heart , Lung, Liver), presence of 3 rd spacing Invest igat ions: urine dipst ick/ micro , +/ - renal U/ S , and as indicat ed Management S t op Nephrot oxins, renal dose remaining medicat ions Volume resuscit at e, do not volume overload Serial follow-up ; volume st at us, Cr/ eGFR, manage associat ed complicat ions Treat hyperglycemia Consult colleagues as required (Nephro, Cardio, hepat ol, ICU)
Ult rasonography should be performed: when t here is no ident ified cause of acut e kidney inj ury when pt s present wit h risk fact ors/ sympt oms of urinary t ract obst ruct ion when an infect ed and obst ruct ed kidney is suspect ed, or when t hey are at medium or high risk of obst ruct ion based on t he risk scoring syst em Rout ine ult rasonography of t he urinary t ract is not required: when a non-obst ruct ive cause of t he acut e kidney inj ury has been ident ified for pat ient s wit hout sympt oms of obst ruct ion, wit hout risk fact ors when at low risk of urinary t ract obst ruct ion based on t he risk scoring syst em
Provincial Clinical Knowledge Topic Acut e Kidney Inj ury, Adult – Inpat ient V 2.0 December 2017, page 7
Hospital AKI Incidence overall 2-23% (more recent ly 2-9% ) (Albert a 20-30% ) Varies wit h set t ing – ICU, ward, surgery ICU 22- 57% Medical ward (18% ) Incidence of in-hospit al (non-ICU/ S urgical) AKI likely plat eauing (4% ) mort alit y rat es have generally fallen by 50% wit h and wit hout dialysis Bellomo R et al. Lancet 2012; 380: 756-766 Host e EA et al. Int ensive Care Med 2015; 41: 1411- 1423 Finlay S et al. Clin Med 2013; 13(3): 233-238 Bihorac A, et al. Crit Care Med 2013; 41(11): 2570- 2583 O’ Neal JB et al. Crit Care 2016; 20: 187-195 G ME t l A J Kid Di 2016 67(6) 872 880
Perioperative AKI For general surgery 1-2% (7% )? Higher risk surgeries: Cardiac 15% Trauma 26% Transplant 71% Neuro 13% AKI is associat ed wit h higher rat es of all post op complicat ions, including CV Bellomo R et al. Lancet 2012; 380: 756-766 Host e EA et al. Int ensive Care Med 2015; 41: 1411-1423 Finlay S et al. Clin Med 2013; 13(3): 233-238 Bihorac A, et al. Crit Care Med 2013; 41(11): 2570-2583 O’ Neal JB et al. Crit Care 2016; 20: 187-195 Grams ME et al. Am J Kid Dis 2016; 67(6): 872-880 Wang HE et al. Am J Nephrol. 2012;35:349– 355
Case #1 - ED 64 yr old male, married, ret ired handyman, present ing wit h sympt oms of bowel obst ruct ion x 24 hours and 6 mont h hx of int ermit t ent BRBPR) wit h progressive const ipat ion. PMHx – HTN, obesit y, ex-smoker (age 57, 40+ pk yrs). Ret ired 7 years ago due t o chronic low back pain. Had gained 10 kg since t hen but loss 5 kg recent ly. No prior S x or hospit alizat ions. FHx - Only child, mot her 84 (T2DM, HTN, Chol, CAD, prior TIA). Fat her died of lung cancer remot ely Meds – perindopril 4/ 12.5, aodipine 2.5 mg (t ook yest erday) NKDA
Case #1-ED ROS - sedent ary, fat igued, denies CV sympt oms or syncope, MRC class 2 dyspnea (t rue? ), no obvious OS A, no oral int ake last 24 hours Non-drinker, Vit als: 115/ 85 P 95 (reg) afebrile O2sat 93% PX: conj unct iva pale, dist ended abdomen(BS ), JVP low, no S 3S 4, no carot id bruit , prolonged exp phase, no edema, no rash, no nodes, no hepat osplenomegaly Lab: Cr 98, K 3.9, Na 132, CO2 21, Cl 96 ; Hgb 120, Plt 276, WBC 14, cholest at ic liver profile, albumin 38, INR/ PTT normal
Case #1 What do you t hink his risk is high, low, somet hing else? What are his risk fact ors for AKI? What t o do preop? Investigations interventions
AKI Risk Factors Hypovolemia COPD Cirrhosis Hypoalbuminemia Advanced age >60, >75 Hypotension Female MM Black CTD Prior AKI Cancer CKD (wit h or wit hout prot einuria) Sepsis DM CIN CHFrEF (35% cardiac S x) (50% CIN) Drugs
Communit y AKI General S x Cont rast Cardiac S x
Wilson T et al. Nephrol Dial Transplant (2016) 31: 231– 240
Comparison of 3 perioperative AKI evaluations Biteker M et al 2014 Bell S et al 2015 Keterpal S et al 2009 N = 1200 prospect ive single N = 10,615 (6220 development N = 15,102 from 65,043 cs acut e care facilit y cohort , 4395 validat ion cohort ) ret rospect ive single acut e care 2010-2012 facilit y 2003-2006 AKI 6.7% N = 80 AKI 10.8 and 6.7 % AKI 0.8% N = 121 Age Age Age RCRI Male S ex Male DM DM DM AS A AS A CHF NS AID/ Cox-2 Renal insufficiency Tot al #of drugs Int raperit oneal S x ACEI/ ARB Ascit es Emergency S x Bit eker M et al Am J of S urgery 2014; 207(1): 53-59 Ket erpal S et al Anest hesiology 2007; 107: 892-902 Bell S et al BMJ 2015;351:h5639
Our patient Age Male ACE-I Hypovolemic Intraperitoneal S x Emergency S x? What we added: HgbA1C 6.3% Urine dispstick +1; ACR 22 Urinalysis
Dipstic ACR k Neg <10 Trace 10-29 +1 30-299 +2 300-999 James MT et al Am J of Kidney Dis 2015 66(4): 602-612 ≥ +3 ≥ 1000
Part ridge JS et al Age and Ageing 2012; 41: 142– 147
TJA S ilva Clinics(S ao Paulo)2009 Jul; 64(7): 613– 618
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