Professional Documents
Culture Documents
Acute Kidney Injury
Acute Kidney Injury
Waleed Khairy, MD
Ain Shams University
There are more than 35 definitions of AKI
(formerly acute renal failure) in literature!
Stage Increase in Serum Urine Output
Creatinine
1 1.5-2 times baseline <0.5 ml/kg/h for >6 h
OR
0.3 mg/dl increase
from baseline
2 2-3 times baseline <0.5 ml/kg/h for >12
h
3 3 times baseline <0.3 ml/kg/h for >24
OR h
0.5 mg/dl increase if OR
baseline>4mg/dl Anuria for >12 h
OR
Any RRT given
Increase in SCr Urine output
Risk of renal injury 0.3 mg/dl increase < 0.5 ml/kg/hr for > 6 h
.
Inhibition of tubular creatinine secretion
Trimethoprim, Cimetidine, Probenecid
IL-18:
◦ Role in inflammation, activating macrophages and mediates ischemic renal
injury
◦ IL-18 antiserum to animals protects against ischemic AKI
◦ Studied in several human models
KIM-1:
◦ Epithelial transmembrane protein, ?cell-cell interaction.
◦ Appears to have strong relationship with severity of renal injury
Unremarkable in pre and post renal causes
Differentiates ATN vs. AIN. vs. AGN
Muddy brown casts in ATN
WBC casts in AIN
RBC casts in AGN
Disease Category Incidence
Prerenal azotemia caused by acute renal 55-60%
hypoperfusion
Dennen P, Douglas I, Anderson R,: Acute Kidney Injury in the Intensive Care Unit: An update and primer for the
Intensivist. Critical Care Medicine 2010; 38:261-275.
Intravenous albumin significantly reduces
the incidence of AKI and mortality in
patients with cirrhosis.
Albumin decreases the incidence of AKI
after large volume paracentesis.
Albumin and terlipressin decrease mortality
in HRS.
Sort P, Navasa M, Arroyo V, et al.: Effect of intravenous albumin on renal impairment and mortality
in patients with cirrhosis and spontaneous bacterial peritonitis. New England Journal of Medicine
1999; 341:403-409.
Gines P, Tito L, Arroyo V, et al.: Randomised comparative study of therapeutic paracentesis with
and without intravenous albumin in cirrhosis. Gastroenterology 1988; 94:1493-1502.
Bourgoin A, Leone M, Delmas A, et al.: Increasing mean arterial pressure in patients with septic shock: Effects on
oxygen variables and renal function. Critical Care Medicine 2005; 33:780-786
no statistical difference between volume
resuscitation with saline or albumin in
survival rates or need for RRT.
Finfer S, Bellomo R, Boyce N, et al.: A comparison of albumin and saline for fluid resuscitation in the intensive
care unit. New England Journal of Medicine 2004; 350: 2247-2256.
Fluid conservative therapy decreased
ventilator days and didn’t increase the need
for RRT in ARDS patients.
Association between positive fluid balance
and increased mortality in AKI patients.
Wiedeman H, Wheeler A, Bernard G, et al.: Comparison of two fluid management strategies in acute
lung injury. New England Journal of Medicine 2006; 354:2564-2575.
Payen D, de Pont A, Sakr Y, et al.; A positive fluid balance is associated with worse outcome in patients
with acute renal failure. Critical Care 2008; 12: R74
There is no evidence that from a renal
protection standpoint, there is a vasopressor
agent of choice to improve kidney outcome.
Dennen P, Douglas I, Anderson R,: Acute Kidney Injury in the Intensive Care Unit: An update and primer for the
Intensivist. Critical Care Medicine 2010; 38:261-275.
renal dose dopamine (<5 μg/kg of body weight/min)
increases RBF and, to a lesser extent, GFR.
Dopamine is unable to prevent or alter the course of
ischaemic or nephrotoxic AKI]. Furthermore,
dopamine, even at low doses, can induce tachy-
arrhythmia’s, myocardial ischaemia, and
extravasation out of the vein can cause severe
necrosis .Thus, the routine administration of
dopamine to patients for the prevention of AKI or
incipient AKI is no longer justified.
Lauschke A, Teichgraber U, Frei U, et al.: “Low-dose” dopamine worsens renal perfusion in patients with acute renal failure. Kidney 2006;
69:1669-1674.
Argalious M, Motta P, Khandwala F, et al.: “Renal dose” dopamine is associated with the risk of new onset atrial fibrillation after cardiac
surgery. Critical Care Medicine 2005; 33:1327-1332.
61 patients in 2 cardiothoracic ICU with post-op
AKI assigned to receive recombinent ANP
(50ng/kg/min) or placebo