Acute Kidney Injury (AKI) The Clinical Aspects & Medicines Involved Kate Webb Renal Advanced Pharmacist Practitioner University Hospital of North Midlands UK Renal Pharmacy Group

Learning Objectives Understand what is AKI? Understand the clinical issues associated with AKI?

Summary of Presentation Renal Anatomy + Physiology AKI Definition Etiology Outcomes Goals Case Study Conclusion

Renal Anatomy

Renal Physiology Regulation of water & electrolytes Retention of substances i.e. protein / glucose Excretion of waste, H2O soluble & drug products Acid / base balance Endocrine function: - Renin, Aldosterone, ADH Erythropoeitin, Vitamin D

AKI Definition: ‘Abrupt ↓ in kidney function that includes, but is not limited to, Acute Renal failure.’ Various etiologies Kidney diseases (nephritis, vasculitis) Non-specific conditions (ischaemia) Extrarenal pathology (post-renal obstruction)

AKI – Outcomes & Goals Outcomes: - Significant mortality & morbidity Prevent further damage Facilitate recovery of renal function “20-30% AKI is predictable & avoidable”

AKI – Prevent further damage Identify the cause for AKI asap Avoid nephrotoxic meds Aminoglycosides, Amphotericin, NSAIDs Avoid nephrotoxic procedures U/S with contrast Consider ‘drug holidays’ ACEIs, ARBs

AKI – Facilitate recovery of Renal function Identify pts who need dialysis vs. medical management Give fluids (1.5l – 2l /day) Crystalloids vs. Colloids vs. Blood Treat cause e.g. drug toxicity Regular monitoring Avoid hyperglycemia

AKI – Classification & Alerts AKI Stage Creatinine Criteria Urine Output Criteria Predicted Nos / year of AKI in 1000- bedded hospital One ↑ > 26mmol/l above baseline (within 48hrs) OR ↑ > 1.5 fold from baseline < 0.5ml/kg/hr for at least 6 hrs 2727 Two ↑ > 2.0 fold from baseline < 0.5ml/kg/hr for at least 12 hrs 782 Three ↑ > 3.0 fold from baseline AKI with Cr > 354mmol/l Initiation of Renal Replacement Therapy (RRT) < 0.3ml/kg/hr for at least 24 hrs Anuria > 12hrs 636 Total 4145

AKI – Case Study ♂, 34yrs. PC  Collapsed. GCS 12. On admission, Bp 54/30, Tachycardic, Resp Rate > 35, Temp 39.6 PMH  Asthma DHx  Beclomethasone Inh + Salbutamol Inh Implication  Systemic sepsis ? cause

AKI – Case Study Biochemistry: Na+ = 138 K+ = 7.2 Urea = 56.2 Cr = 784 eGFR = 11 CRP = 160 Hb = 126 WBC = 33.6 Plts = 156 Alb = 39 Calcium = 2.2 Phosphate = 1.3

AKI – Case Study Biochemistry: Na+ = 138 K+ = 7.2(High) Urea = 56.2 (High) Cr = 784 (High) eGFR = 11 (Low) CRP = 160 (High) Hb = 126 WBC = 33.6 (High) Plts = 156 Alb = 39 Calcium = 2.2 Phosphate = 1.3

AKI – Classification & Alerts AKI Stage Creatinine Criteria Urine Output Criteria Predicted Nos / year of AKI in 1000- bedded hospital One ↑ > 26mmol/l above baseline (within 48hrs) OR ↑ > 1.5 fold from baseline < 0.5ml/kg/hr for at least 6 hrs 2727 Two ↑ > 2.0 fold from baseline < 0.5ml/kg/hr for at least 12 hrs 782 Three ↑ > 3.0 fold from baseline AKI with Cr > 354mmol/l Initiation of Renal Replacement Therapy (RRT) < 0.3ml/kg/hr for at least 24 hrs Anuria > 12hrs 636 Total 4145

AKI – Case Study CXR  R + L sided consolidation Pneumonia (? Microbiology) Hypoxic + Acidotic Ventilated (Level 3 care) Urine Output  12ml/hr, 5ml/hr, 6ml/hr (Pt wt = 80kg) Filter (Level 3 care)  CVVHDF

AKI – Classification & Alerts AKI Stage Creatinine Criteria Urine Output Criteria Predicted Nos / year of AKI in 1000- bedded hospital One ↑ > 26mmol/l above baseline (within 48hrs) OR ↑ > 1.5 fold from baseline < 0.5ml/kg/hr for at least 6 hrs 2727 Two ↑ > 2.0 fold from baseline < 0.5ml/kg/hr for at least 12 hrs 782 Three ↑ > 3.0 fold from baseline AKI with Cr > 354mmol/l Initiation of Renal Replacement Therapy (RRT) < 0.3ml/kg/hr for at least 24 hrs Anuria > 12hrs 636 Total 4145

AKI – Case Study Pneumonia  Abx broad + empirical Co-Amoxiclav + Clarithromycin Ventilated  Sedated Morphine + Midazolam vs. Alfentanyl + Propofol CVVHDF Effects on drug dosing / Clotting / Dialysis fluids Fluids  ? Give / Type Others  VAP meds / GI protection / TEDs

AKI – Case Study 11 Days later….. U&Es: - Na+ = 138 K+ = 4.3 Urea = 11.2 (High) Cr = 284 (High) eGFR = 32 (Low) CRP = 32 (High) Hb = 126 WBC = 13.6 (High) Urine Output: - 42ml/hr, 54ml/hr, 47ml/hr Pt Discharged Meds: - Co-Amoxiclax 625mg TDS for 4 days Clarithromycin 500mg BD for 4 days Paracetamol 1gram QDS PRN Becotide® 100 ii puffs BD Salbutamol 100 PRN

Conclusion Renal Anatomy + Physiology Understanding of AKI AKI  Prevent further damage  Facilitate recovery AKI application in Practice

Questions