Renal disease: AKI vs CKD Chris Dobson

What is acute kidney injury (AKI) Hyperkalaemia What is chronic kidney disease (CKD) Case/off

So what is an AKI? Significant deterioration in renal function over hours/days How would you define that clinically? Urea↑ creatinine ↑ Oliguria? Fluid balance? Urea 2.5-6.7mmol, creatinine 70-150, oliguria <400ml in a day, fluid balance 30ml/kg/ day

Say what you see.... A

RIFLE CRITERIA

In real life... RIFLE is complicated Urine <0.5ml/kg/hr or creatinine >26umol Symptoms: Pallor, dehydration, N+V, confusion Signs: Pallor, rash, dehydration, hypertension, palpable bladder, ↑JVP

Causes of an AKI Pre renal: Intrinsic: CLANG! Post renal: hypovalaemia, hypotension, sepsis, renal artery stenosis, burns Intrinsic: acute tubular necrosis, drugs, vasculitis, autoimmune CLANG! Post renal: tumours, crystals, obstruction Contrast, loop duiretics, ace inhibitor, nsaids, gentamicin

Investigate Assess the patient: obstruction, comorbidities, nephrostomy Bloods: FBC, K+, U+E’s, ABG’s, clotting, cultures, CK Bedside: urine dip Images: CXR, KUB Other: ECG

The best manager in the world. BOOM Management Depends on the cause.. Stabilise the patient: shock, hypovalemia, hypotension, sepsis Stop nephrotoxic drugs Furosemide for fluid overload Manage hyperkalaemia...

Hyperkalaemia what do you know? K+ >5.5 mmol ECG changes? Weakness, fatigue, muscle paralysis, chest pain, palpitations, Tall tented t waves, wide qrs, widening-disapearing p wave

Managing Hyperkalaemia Calcium gluconate 10ml 10% IV (cardioprotective) Calcium resonium 15g/8h Salbutamol 5mg nebs Insulin+glucose Furosemide

CKD Kidney damage >3months Based on eGFR...

Causes... Hypertension Diabetes Glomerulonephritis Pyleonephritis BPH Myeloma Amyloidosis Alport syndrome

Presentation Usually asymptomatic Severe cases can present with anoreixa, N+V, muscle cramps, fatigue, impotence Signs: skin excoriation, pallor, peripheral oedema, restless legs

investigate Caution for: AKI, cardiovascular disease, SLE, renal calculi, FH CKD5 eGFR is best measure Rule out UTI, anaemia, heart failure (ECG) Any druggy culprits?

Manage Lifestyle advice: salt/fluid restriction Correct hypertension Still the special one? Manage Lifestyle advice: salt/fluid restriction Correct hypertension Exclude anaemia/renal osteodystropy Furosemide for oedema Gabapentin for restless legs Check calcium/phosphate levels for renal osteodystrophy

Case 1 A 50 year old alcoholic male presents with sepsis secondary to klebsiella pneumonia. His background includes IHD, previous pneumonia, hypercholesterolaemia and hypertension. Medications include: furosemide, enalapril, aspirin, clopidogrel, co-amoxiclav (current) and simvastatin He is treated with IV antibiotics and is managed on an ITU setting for 1 week On step down to a medical ward routine bloods reveal: Sodium 132 Potassium 5.0 Urea 24 (from 8) Creatinine 390 (from 60) Clinically he is mildly dry, with a BP 135/83, HR 90, he is catheterised with a U/O 35ml/hr  

How do we manage Stop furosemide, enalapril Push fluids Monitor urine output Underlying cause

Case 2 George is a 72 year old male found collapsed at home on floor of his bedroom, incontinent of urine and faeces. He complained of significant pain in his right hip with shortening and rotation. George’s family last had contact with George 3 days prior to his collapse. Assessment: On arrival at ED he is confused and combative with a GCS 0f 13 Initial observations reveal BP 78/60; Pulse 74, RR 32, SPO2 91% (NRB 15L) ABG which shows a Potassium of 9.0, pH of 7.23 and a Blood Glucose Level of 32mmol Medical History: CCF, Hypertension, Type 2 DM, Osteoarthritis Medication History: George is taking enlapril for hypertension; spironolactone & metoprolol for his CCF and celebrex for his osteoarthritis His diabetes is diet controlled. Celebrex celecoxib

Hyperkalaemia: Calcium gluconate 10% 10ml IV Inuslin glucose IV Salbutamol nebs Calcium resonium IV Furosemide IV

So... AKI- urine output decreasing; creatinine/urea increasing over hours Stop nephrotoxic drugs Hyperkalaemia- complication of AKI, treat quickly CKD- measured from eGFR, manage underlying cause

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