ACUTE KIDNEY INJURY

- Reduction in renal function following insult to kidneys

PRERENAL
- Ischemia or lack of blood flow to kidneys
- Examples
o Hypovolemia secondary to diarrhea/vomiting
o Renal artery stenosis

INTRINSIC
- Intrinsic damage to glomeruli, renal tubules, or interstitium of kidneys d/t toxins (drugs,
contrast, etc.) or immune-mediated glomerulonephritis
- Examples
o Glomerulonephritis
o Acute tubular necrosis
o Acute interstitial nephritis
o Rhabdomyolysis
o Tumour lysis syndrome

POSTRENAL
- Obstruction to urine coming from kidneys resolving in back flow
- Examples
o Unilateral uretic stone
o Bilateral hydronephrosis secondary to acute retention caused by BPH
o Kidney stone in ureter or bladder
o BPH
o External compression of the ureter

RISK FACTORS
- CKD
- Other organ failure/chronic dx
o Heart failure
o Liver disease
o T2DM
- Hx of AKI
- Use of drugs with nephrotoxic potential
o NSAIDs, aminoglycosides, ACE inhibitors, angiotensin II receptor antagonists, diuretics
within past week
- Use of iodinated contrast agents within past week
o Give IV fluids to reduce risk
- Age 65 years or older

PATHOPHYSIOLOGY: DETECTING AKI

- Oliguria: <0.5 ml/kg/hour aka reduced urine output
- Fluid overload
- Rise in molecules that kidney excretes/maintains ex. potassium, urea, creatinine, sodium
o U & Es for detection

SYMPTOMS AND SIGNS

 - Early AKI = no symptoms
- Reduced urine output
- Pulmonary and peripheral edema
- Arrhythmias (secondary to changes in potassium and acid-base balance)
- Features of uremia (pericarditis or encephalopathy)

AKI CRITERIA
- Rise in serum Cr of 26 mm/L or greater within 48 hours
- 50% or greater rise in serum Cr known or presumed to have occurred within past 7 days
- Fall in urine output to less than 0.5 ml/kg/hour for more than 6 hours in adults

URINARLYSIS IN ALL PTS

IMAGING: if pt has no identifiable cause for deterioration or risk of urinary tract obstruction = renal
ultrasound within 24 hours

MANAGEMENT: supportive – fluid balance & meds review

- Drugs to STOP:
o NSAID (except if aspirin at cardiac dose ex. 75 mg OD)
o Aminoglycosides
o ACE inhibitors
o Angiotensin II receptor antagonists
o Diuretics
- Treat hyperkalemia:
o Stabilization of the cardiac membrane
 IV calcium gluconate
o Short-term shift in potassium from extracellular to intracellular fluid compartment
 Combined insulin/dextrose infusion
 Nebulized salbutamol
o Removal of potassium from body
 Calcium resonium (orally or enema)
 Loop diuretics
 Dialysis – AEIOU

ACUTE INTERSTITIAL NEPHRITIS

- Causes
o Drugs the most common cause, particularly antibiotics
 Penicillin
 Rifampicin
 NSAIDs
 Allopurinol
 Furosemide
o Systemic dx: SLE, sarcoidosis, Sjögren’s syndrome
o Infection: Hanta virus, staphylocci
- Pathophysiology
o Marked interstitial edema and interstitial infiltrate in connective tissue b/w renal tubules
- Features
o Fever
o Rash
o Arthralgia
 o Eosinophilia
o Mild renal impairment
o Hypertension
- Investigations: sterile pyuria, white cell casts
DIAGNOSTIC CRITERIA
- Rise in Cr of > 26 in 48 hrs
- 50% rise in Cr over 7 days
- Fall in urine output to less than 0.5 ml/kg/hr for more than 6 hours

STAGE 1
- Increase in Cr to 1.5-1.9 times baseline
- Increase in Cr by > 26.5
- Reduction in urine output to <0.5 for 6 hours

STAGE 2
- Increase in Cr to 2-3 times baseline
- Reduction in urine output <0.5 for 12 hours

STAGE 3
- Increase in Cr to >3 times baseline
- Increase in Cr to 353.6
- Reduction in urine output