ACUTE KIDNEY INJURY

-is a rapid loss of renal function due to damage to the kidneys. Depending on the duration and severity of
AKI, a wide range of potentially life-threatening metabolic complications can occur, including metabolic
acidosis as well as fluid and electrolyte imbalances.
-Possible changes include nonoliguria (greater than 800 mL/day), oliguria (less than 0.5 mL/kg/hr), or
anuria (less than 50 mL/day)
So yung Acute kidney injury (AKI), also known as acute renal failure (ARF), eto yung sudden episode of
kidney failure or kidney damage na nangyayari within a few hours or a few days. Eto nagccause siya ng
build-up of waste products in the blood and makes it hard for the kidneys to keep the right balance of
fluid in the body. Pwede rin maapektuhan yun other organs such as the brain, heart, and lungs. Acute
kidney injury is common in patients who are in the hospital, in intensive care units, and especially in
older adults.

PATHOPHYSIOLOGY

So this is the pathophysiology of acute kidney injury starting with the three categories of Pre renal, renal
amd post renal
With pre renal nagddcrease yung effective circulating blood volume as a
result nagkakroon ng pagbaba ng BP and then with renal meron renal
tubular necrosis or yung damage sa kidney tubule cells yung yung kidney cells na
reabsorb fluid and minerals from urine as it forms. As a result nag iincrease yung
sympathico-adrenergic system (SAS) and renin-angiotensin-system (RAS) kung saan
nag kakaroon ng vasoconstriction and nag reresult din sa decreases renal perfusion.
Yung renal tubular necrosis pwede rin siya mag cause sa renal tubular obstruction kung
saan nagkakaroon ng increase in renal tubular pressure at decrease in renal fluid
volume.
Sa renal pwede rin siyang magcause ng glomerular injury which can lead to glomerular basement
permeability changes and then next is pwede rin magkaroon ng renal instertitial

 Glomerular Filtration Rate: rate of blood flow through the kidneys

(ml/min). This shows how well the glomerulus is filtering the blood….great
for determining kidney function.

CLASSIFICATION
Classification criteria for AKI include assessment of three grades of severity and two outcome-level
classifications. This 5-point system is known as the RIFLE classification system.
the RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease)
classification, was proposed in order to define and stratify the severity of acute kidney injury
(AKI). This system relies on changes in the serum creatinine (SCr) or glomerular filtration rates
and/or urine output,

The RIFLE classification (Table 1) is based on SCr and UO determinants, and considers three
severity classes of AKI (Risk, Injury and Failure),nag bbased according to the variations in SCr
and/or UO, pati sa two outcome classes (loss of kidney function and end-stage kidney disease).
The patient should be classified using the criteria (SCr and/or UO) which leads to the worst
classification (maximum RIFLE), for exampl , if a patient was in the Risk class according to the
UO but in the Injury class according to SCr variation, then worst criteria which is yung nasa
injury classs (SCr) ang gagamiti for classifying the severity of AKI in this patient.

CATEGORIES

Prerenal

 Prerenal failure is caused by interference with renal perfusion (e.g., blood volume
depletion, volume shifts [“third-space” sequestration of fluid], or excessive/too-rapid
volume expansion), manifested by decreased glomerular filtration rate (GFR).

-For pre renal ito yung issue with perfusion to the kidneys (any injury BEFORE the
kidneys)

-This leads the kidney function to decrease. Yung kidneys are being deprived of
nutrients to function properly pati na rin yung amount of blood it can filter. So pwede
siyang mag lead sa intrarenal damage kung saan yung nephrons becomes damaged.

 Disorders that lead to prerenal failure include cardiogenic shock, heart failure (HF),
myocardial infarction (MI), burns, trauma, hemorrhage, septic or anaphylactic shock, and
renal artery obstruction.
These conditions can lead to decreased perfusion to the kidney.
For example yung Issues with the heart in conditions that decrease cardiac output such as
acute myocardial infarction. So in this condition, the heart muscle is damaged and can’t
pump sufficient amounts of blood to the kidney.

Renal (or intrarenal)

 Intrarenal causes for renal failure are associated with parenchymal changes caused by
ischemia or nephrotoxic substances.
  Acute tubular necrosis (ATN) accounts for 90% of cases of acute oliguria.
 Destruction of tubular epithelial cells results from (1) ischemia/hypoperfusion (similar
to prerenal hypoperfusion except that correction of the causative factor may be
followed by continued oliguria for up to 30 days) and/or (2) direct damage from
nephrotoxins.

Sa sa renal or intrarenal category nagkakakaroon damage to the nephrons of the

kidney (injury in WITHIN the kidneys)

Kapah yung nephrons are damaged the kidneys can’t filter the blood, maintain
electrolyte levels, and remove excessive waste and fluid from the body.

Postrenal

 Postrenal failure occurs as the result of an obstruction in the urinary tract anywhere
from the tubules to the urethral meatus.
 Obstruction most commonly occurs with stones in the ureters, bladder, or urethra;
however, trauma, edema associated with infection, prostate enlargement, and
strictures also cause postrenal failure.
Dito namwn meron blockage in the urinary tract after the kidneys to the urethra (injury
found AFTER the kidneys)

Eto Pineprevent niya yung urine from draining out of the kidneys, which leads to build
up pressure and waste in the kidney and decreases their function.

CAUSES
Causes of Acute Kidney Injury
1. Prerenal Failure
Volume depletion resulting from:

 Gastrointestinal losses (vomiting, diarrhea, nasogastric suction)

 Hemorrhage
 Renal losses (diuretic agents, osmotic diuresis)
 Impaired cardiac efficiency resulting from:
 Cardiogenic shock
 Dysrhythmias
 Heart failure
  Myocardial infarction
Vasodilation resulting from:

 Anaphylaxis
 Antihypertensive medications or other medications that cause
 vasodilation
 Sepsis

 A sudden, serious drop in blood flow to the kidneys such as  Heavy blood loss, an
injury, or a bad infection called sepsis can reduce blood flow to the kidneys. Not enough fluid
in the body (dehydration) also can harm the kidneys.

2. Intrarenal Failure
Prolonged renal ischemia resulting from:

 Hemoglobinuria (transfusion reaction, hemolytic anemia)

 Rhabdomyolysis/myoglobinuria (trauma, crush injuries, burns)
 Pigment nephropathy (associated with the breakdown of blood cells
 containing pigments that in turn occlude kidney structures)
Nephrotoxic agents such as:

 Aminoglycoside antibiotics (gentamicin, tobramycin)

 Angiotensin-converting enzyme inhibitors
 Heavy metals (lead, mercury)
 Nonsteroidal anti-inflammatory drugs
 Radiopaque contrast agents
 Solvents and chemicals (ethylene glycol, carbon tetrachloride,
arsenic)
Infectious processes such as:

 Acute glomerulonephritis
 Acute pyelonephritis

3. Postrenal Failure
Urinary tract obstruction, including:

 Benign prostatic hyperplasia

 Blood clots
 Calculi (stones)
 Strictures
 Tumors

PHASES
There are four phases of AKI: initiation, oliguria, diuresis, and recovery.

Initiation. The initiation period begins with the initial insult, and ends when oliguria develops.
Yung initiation phase creates injury to the kidney and then signs and symptoms start to
appear which leads to the next stage. Nagl lasts a few hours to several days.

Oliguria. The oliguria period is accompanied by an increase in the serum concentration of

substances usually excreted by kidneys
.yung Urine output dito will be less than 400 ml/day
Diuresis. The diuresis period is marked by a gradual increase in urine output, which signals that
glomerular filtration has started to recover.

In this phase yung Nephrons can’t concentrate urine meaning it can’t regulate water and
electrolyte levels yet) pero they can  filter out waste. So, what will be found highly
concentrated in the urine will be yung WASTE…specifically urea.

Ang tendency nito is magccause OSMOTIC DIURESIS.

So yung patient will be voiding out an excessive amount of urine (3-6 Liters/day)due
to osmotic diuresis. Nagooccur ito from the high amounts of urea in the newly
filtered filtrate.

Nursing intervention dito is strict I and O’s, daily weights, monitor for signs and
symptoms of dehydration, HYPOVOLEMIA, hypotension.

This usually Lasts a week to 3 weeks

Recovery. The recovery period signals the improvement of renal function and may take 3 to 12
months.

Eto naman nagStart siya when GFRreturns to normal and the kidneys start to function
normally.

Yung Urine output bumabalik na sa normal along with BUN and creatinine, and
electrolytes level. Therefore, yung body is now able to maintain these values.

This stage pwede siyang last a year or more, and naka depende sa amount of damage
done to the kidney and the patient’s age.

In some cases,some patients are unable to progress to the recovery phase and instead
nagdedevelop sila ng Chronic Kidney Disease.