Dr Shubham Upadhyay

© Medi - Lectures 2021 Dr Shubham Upadhyay

CONTENTS
• Introduction • Diagnostic Evaluation
• Etiopathogenesis History & Physical Examination
Pre Renal AKI Urine Findings
Intrinsic AKI Blood Reports
 Sepsis Associated Renal Failure Indices
 Ischemic Radiology
 Nephotoxin Associated Renal Biopsy
Post Renal AKI Novel Biomarkers
• Complications
• Prevention & Treatment
• Prognosis
© Medi - Lectures 2021 Dr Shubham Upadhyay
INTRODUCTION
• Impairment of kidney filtration & excretory function
• Over days to weeks --> Retension of nitrogenous & other waste
• Clinical Diagnosis (not a structural one)
• Occurs in 30% of ICU admissions
• ↑ risk for development or worsening of CKD

© Medi - Lectures 2021 Dr Shubham Upadhyay

© Medi - Lectures 2021 Dr Shubham Upadhyay
ETIOPATHOGENESIS - PRERENAL AKI
• MC form of AKI
• Inadequate renal plasma flow -> Inadequate intraglomerular
hydrostatic pressure
• Hypovolemia, ↓ CO, medications
• No parenchymal damage, reversible
• Compensatory response to hypovolemia, ↓ CO
Myogenic Reflex (Afferent arteriolar dilatation)
Renal Efferent Vasoconstriction
Tubuloglomerular Feedback
• AKI in Hepatorenal Syndrome
• Type 1 HRS
• Type 2 HRS
© Medi - Lectures 2021 Dr Shubham Upadhyay
ETIOPATHOGENESIS - INTRINSIC AKI
• MCC - Sepsis, Ischemia, Nephrotoxins

© Medi - Lectures 2021 Dr Shubham Upadhyay

SEPSIS ASSOCIATED AKI
• Complicates >50% cases of severe sepsis
• ↓ in GFR can occur even in the absence of hypotension
• Pathophysiology?
• Mechanism
• Efferent arteriole vasodilatation
• Afferent Vasoconstriction
• Endothelial damage

© Medi - Lectures 2021 Dr Shubham Upadhyay

 ISCHEMIA ASSOCIATED AKI
• Healthy kidneys - 20%of CO, 10%
of O2 consumption
• Renal Medulla - one of the most
hypoxic regions in body
• AKI more commonly develops in
settings of
Limited renal reserve
Co existing Insults

© Medi - Lectures 2021 Dr Shubham Upadhyay

• Post Operative AKI

• Burns & Acute Pancreatitis

• Diseases of Microvasculature leading to Ischemia

© Medi - Lectures 2021 Dr Shubham Upadhyay

NEPHROTOXIN ASSOCIATED AKI
• Exogenous Nephrotoxins
Contrast Agents
Antimicrobials
Chemotherapeutics
Toxic ingestions
• Endogenous Nephrotoxins
Myoglobin
Hemoglobin
Uric Acid
Myeloma Light Chain

© Medi - Lectures 2021 Dr Shubham Upadhyay

NEPHROTOXIN ASSOCIATED AKI
• Exogenous Nephrotoxins
Contrast Agents
Antimicrobials
Chemotherapeutics
Toxic ingestions
• Endogenous Nephrotoxins
Myoglobin
Hemoglobin
Uric Acid
Myeloma Light Chain

© Medi - Lectures 2021 Dr Shubham Upadhyay

ACUTE TUBULOINTERSTITIAL DISEASE
• Inflammatory Infiltrate
• Peripheral & Urinary Eosinophilia
• PPIs & NSAIDs
• Severe Infections
• Malignant & Non Malignant Infiltration

GLOMERULONEPHTITIS

© Medi - Lectures 2021 Dr Shubham Upadhyay

ETIOPATHOGENESIS - POSTRENAL AKI
• Normal Unidirectinal flow of urine -> Acutely blocked
• ↑ Retrograde Hydrostatic pressure -> Interference with GF
• Functional or Structural derangements from pelvis to urethra

© Medi - Lectures 2021 Dr Shubham Upadhyay

DIAGNOSTIC EVALUATION
• AKI is defined as:
Rise of s Creat atleast 50% higher from the baseline within 7 days OR
Rise of s Creat atleast 0.3 mg/dl from baseline within 2 days OR
Reduction in Urine output to <0.5 ml/kg/hr for >6 hrs
• Stages of AKI
• Stage I - s Creat 1.5 to 1.9 times the baseline
• Stage II - s Creat 2.0 to 2.9 times the baseline
• Stage III - s Creat ≥3.0 times the baseline
• AKI vs CKD
Radiology
Lab tests
© Medi - Lectures 2021 Dr Shubham Upadhyay
RIFLE Criteria

© Medi - Lectures 2021 Dr Shubham Upadhyay

HISTORY & PHYSICAL EXAMINATION
SCENARIO PROBABLE CAUSE
Vomiting, Diarrhea, Glycosuria ->Polyuria
Medications- Diuretics, NSAIDS, ACE -/ARBs
P/E- Orthostatic hypotension, ↑ HR, ↓JVP, ↓skin
turgor, dry mucous membrane
CHF, CLD
Extensive Vascular disease
Prostate pathology, Nephrolithiasis
Pelvic or Para aortic Pathology
Cilicky Flank Pain --> Groin
Urinary Frequency, Urgency,Hesitancy
Abdominal Fullness with Suprapubic pain
Palpable purpura, pulmonary hmg, sinusitis
Tense , tender Abdomen
© Medi - Lectures 2021 Dr Shubham Upadhyay
URINARY FINDINGS
• Urine Volume
• Complete Anuria
• Oliguria
• AKI with preserved Urine Output
• Red - brown urine
• Protenuria
• Mild (<1 gm/day)
• Moderate (<3.5 gm/day)
• Heavy (>3.5 gm/d

© Medi - Lectures 2021 Dr Shubham Upadhyay

© Medi - Lectures 2021 Dr Shubham Upadhyay
BLOOD REPORTS
• Characterstic Patterns
Prerenal Azotemia
Contrast Nephropathy
Atheroembolic Disease
Thrombotic Microangiopathy
TTP or HUS
• Anemia
• Peripheral Eosinophilia
• Hyperkalemia, Hyperphosphatemia, Hypocalcemia
• Creatine Kinase & Uric Acid
• Anion Gap
© Medi - Lectures 2021 Dr Shubham Upadhyay
RENAL FAILURE INDICES
• FeNa
• Depends on
• <1%
• >1%
• Urine Osmolality
• >500 mOsm/l
• <350 mOsm/l

© Medi - Lectures 2021 Dr Shubham Upadhyay

RADIOLOGY
• Obstruction
• Renal USG or CT
• Antegrade or Retrograde Pyelography
• Renal Size & Echogenecity
• CKD
• AKI
• Vasular Imaging

© Medi - Lectures 2021 Dr Shubham Upadhyay

RENAL BIOPSY

© Medi - Lectures 2021 Dr Shubham Upadhyay

NOVEL BIOMARKERS
• Kidney Injury Molecule 1 (KIM -1)

• Neutrophil Gelastinase Associated Lipocalin (NGAL)

• Insulin Like Growth Factor Binding Protein 7 (IGFBP7) &

• Tissue Inhibitor of Metalloproteinase-2 (TIMP2)

© Medi - Lectures 2021 Dr Shubham Upadhyay

COMPLICATIONS
1. Uremia
2. Hypervolemia & Hypovolemia
3. Hyponatremia
4. Hyperkalemia
5. Acidosis
6. Hyperphosphatemia & Hypocalcemia
7. Bleeding
8. Infections
9. Cardiac Complications
10. Malnutrition
© Medi - Lectures 2021 Dr Shubham Upadhyay
PREVENTION & TREATMENT
• Prerenal Azotemia
Optimization of renal perfusion

Optimization of Cardiac function

© Medi - Lectures 2021 Dr Shubham Upadhyay

Cirrhosis & Hepatorenal Syndrome

© Medi - Lectures 2021 Dr Shubham Upadhyay

• Intrinsic AKI

© Medi - Lectures 2021 Dr Shubham Upadhyay

• Post Renal AKI

© Medi - Lectures 2021 Dr Shubham Upadhyay

© Medi - Lectures 2021 Dr Shubham Upadhyay
© Medi - Lectures 2021 Dr Shubham Upadhyay
© Medi - Lectures 2021 Dr Shubham Upadhyay
DIALYSIS INDICATIONS & MODALITY

© Medi - Lectures 2021 Dr Shubham Upadhyay

© Medi - Lectures 2021 Dr Shubham Upadhyay
© Medi - Lectures 2021 Dr Shubham Upadhyay
© Medi - Lectures 2021 Dr Shubham Upadhyay
PROGNOSIS

© Medi - Lectures 2021 Dr Shubham Upadhyay