Acute Kidney Injury

Dr Alexis Missick
FY2
 Presentation
• Case
• Objectives
• Definition & Aetiology
• Investigation
• Management
• Complications
 Clinical Scenario
• History: 55 year old lady presents to A&E with a 5 day
history of diarrhoea and vomiting. She believes this
was caused by a Chinese take away she had a day
before developing symptoms. She has been unable to
keep anything down including water and now feels very
poorly.
• PMHx: HTN managed with ramipril.
• SHx: non-smoker, drinks alcohol occasionally.

• O/E: she appears very dry and has reduced skin turgor.
BP is 100/70 and HR 95. Examination is otherwise
unremarkable
Differentials?
 Clinical Scenario
• History: 55 year old lady presents to A&E with a 5 day history of
diarrhoea and vomiting. She believes this was caused by a Chinese
take away she had a day before developing symptoms. She has
been unable to keep anything down including water and now feels
very poorly.
• PMHx: HTN managed with ramipril.
• SHx: non-smoke, occasional alcohol.
• O/E: she appears very dry and has reduced skin turgor. BP is
100/70 and HR 95. Examination is otherwise unremarkable

• Ix: normal FBC, Na 149, K 6.7, Urea

17.0 and Creatinine 258
 Objectives
• Recognition of AKI
• Learn classification of causes and common
examples
• Identification of appropriate investigations
• Understand principles of management of AKI
• Knowledge of indications for dialysis
• Awareness of complications and management
of hyperkalaemia (common complication)
 Definition
• Rapid impairment in renal function resulting in raised
plasma urea/creatinine, fluid and/or acid-base imbalance
which is reversible.

• AKIN Criteria for diagnosis of AKI

1. Time course – rapid (<48hours)
2. Reduction in Kidney function
1. Rise in serum creatinine (absolute increase of >0.3mg/dl or
percentage increase of > 50%)
2. Reduction in urine output (<0.5ml/kg/hr for >6hours)

• RIFLE criteria (prosposed by ADQI) for staging of AKI:

Risk, Injury, Failure, Loss, End stage kidney disease
 Staging RIFLE Criteria
• Proposed by ADQI
• Severity (Stage 1-3)
– Risk: GFR decrease >25%, serum creatinine increased 1.5
times OR urine production of <0.5 ml/kg/hr for >6 hours
– Injury: GFR decrease >50%, doubling of creatinine OR
urine production <0.5 ml/kg/hr for 12 hours
– Failure: GFR decrease >75%, >tripling of creatinine or
creatinine >355 μmol/l (>4 mg/dl) OR urine output below
0.3 ml/kg/hr for 24 hours
• Outcome
– Loss: persistent AKI or complete loss of kidney function for
more than 4 weeks
– End-stage renal disease: need for renal replacement
therapy (RRT) for more than 3 months
 Aeitology

http://www.medicalassessmentonline.net/terms.php?R=3
 Presentation
• Symptoms
– Malaise
– Anorexia, Nausea and Vomiting
– Pruritis
– Dehydration
– Confusion, convulsions
• Signs
– Hypertension
– Fluid overload: peripheral oedema, SOB/ bibasal
crackles/raised JVP
– Dehydration: postural hypotension, poor urine output
(palpable bladder)
 Investigations
• Bedside: BP (lying and standing), urine dip
(?haematuria ?proteinuria), ECG
• Biochemistry: ABG, FBCs, U+Es, LFTs, CRP/ESR,
Ca2+, blood culture
• Imaging: CXR, USS KUB or CT KUB

• Special tests:
– CK, blood film, Myeloma screen (Bence-Jones protein), Renal Screen
(ANA, ANCA, anti-BM)
– Urine osmolality and cast cells
– Renal biopsy
– Doppler Renal USS and/or Angiography
 Management
• Assess fluid status
• Fluid resuscitation
• Stop nephrotoxic drugs

• Treat the cause

– Infection – give antibiotics, renal doses
– Intrinsic renal disease – R/v medication
– Obstruction- ?catheters ?calculus removal
?nephrostomies ?surgery
 Complications – Indication for
Immediate Dialysis!!
• Hyperkalaemia
(persistent >7mmol/L)
• Metabolic Acidosis
(if pH<7.2, bicarbonate
<12)
• Pulmonary Oedema
(refractory)
• Pericarditis
• Symptomatic ureamia -
Encephalopathy
http://homeopathyexpert.blogspot.co.uk/2011/05/chronic-renal-failure.html
 Hyperkalaemia
• Potassium range is 3.5 – 5mmol/L
• Rise in serum K+ >5mmol/l
• Signs/symptoms: muscle weakness

• ECG changes:
– Flattened P waves
– Broad QRS complex
– Slurring of ST segment
– Tall tented T waves

http://www.aafp.org/afp/2006/0115/p283.html
 Hyperkalaemia
• Potassium >6.0 mmol/L
– Calcium resonium 15g QDS PO
– If septic or rising quickly treat as though K+ 6.5

• Potassium >6.5 mmol/L

– Dextrose-insulin (50ml 50% Dextrose with 10units
Actrapid insulin, IV over 5mins) Monitor BM
– Calcium resonium 15g QDS PO
 Hyperkalaemia
• Potassium >7 mmol/L
– Calcium gluconate (10ml of 10% solution into
central vein or diluted into 40ml 0.9% saline into
peripheral vein over 10mins, with cardiac monitor)
– Dextrose insulin
– Nebulised salbutamol 5mg
– IV sodium bicarbonate (50ml 8.4% over 5mins
centrally or 500mls 1.26% over 30mins
peripherally
– Calcium resonium