Acute Kidney Injury in ICU

Slides:



Advertisements
Similar presentations
Acute Renal Replacement Therapy for the Infant Dr.Fahad Gadi, MD Pediatrics Demonstrator King Abdulaziz University Rabigh Medical School.
Advertisements

Journal Club: AKI and timing of RRT in Post-op ITU Patients
A Comparison of Early Versus Late Initiation of Renal Replacement Therapy in Critically III Patients with Acute Kidney Injury: A Systematic Review and.
Introduction to Nephrology Sandeep K. Shori, D.O. Dialysis Associates Fort Worth, TX.
EVIDENCE IN THE ED AMOS SHEMESH, MD, PGY-III MARCH 2014 LMNOP in ADHF: Should Lasix Stay in the Acronym?
Horng H Chen MD on behalf of the NHLBI Heart Failure Clinical Research Network Renal Optimization Strategies Evaluation in Acute Heart Failure (ROSE AHF):
Mechanisms and Management in Acute Kidney Injury Paul Stevens Kent Kidney Care Centre.
Renal Megan McClintock, RN, MS 10/27/11 “TO PEE IS TO LIVE”
ACUTE KIDNEY INJURY Martin Havrda. Acute kidney injury - RIFLE Risk –50% rise of s-creatinine –25% drop of GFR –Urine output < 0,5 ml/kg.h during 6 hours.
Intensive care conference: management of acid-base disorders with CRRT International Society of Nephrology 主講人 : R2 顏介立.
Severe Sepsis Initial recognition and resuscitation
Sepsis.
Acute kidney injury R3 李岳庭 / F1 王奕淳 / VS 林景坤 Brenner and Rector's The Kidney, 8th ed P 高雄長庚腎臟科 Journal reading.
Care of Patients with Shock
Adult Medical-Surgical Nursing Renal Module: Acute Renal Failure.
Pediatric Acute Renal Failure: CRRT/Dialysis Outcome Studies Stuart L. Goldstein, MD Assistant Professor of Pediatrics Baylor College of Medicine.
The long-term outcome after acute renal failure Presented by Ri 顏玎安.
Dose Adjustment in Renal and Hepatic Disease
Chapter 26 Acute Renal Failure and Chronic Kidney Disease
Stuart L. Goldstein, MD Professor of Pediatrics
Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris-South France Optimal blood pressure target in septic shock.
Copyright 2008 Society of Critical Care Medicine
Diagnosis and Management of Shock Dr. Anas Khan Consultant, EM MBBS, MHA, ArBEM.
Excessive fluid is not needed: So why is Dr. Durward so wasteful? Timothy E Bunchman MD Professor & Director Pediatric Nephrology
Bicarbonate-Based Solutions in the Management of Acute Kidney Injury Vania Cecilia Prudencio-Ribera, MD 1 ; Universidad Mayor de San Simón, School of Medicine,
Acute Kidney Injury SUSAN BUDNICK, MD. What is an Acute Kidney Injury?  AKI is a heterogeneous group of conditions that are all characterized by an acute.
Dr. Aya M. Serry Renal Failure Renal failure is defined as a significant loss of renal function in both kidneys to the point where less than 10.
Haemofiltration for sepsis: burial or resurrection?
Acute Renal Failure Doç. Dr. Mehmet Cansev. Acute Renal Failure Acute renal failure (ARF) is the rapid breakdown of renal (kidney) function that occurs.
Acute Kidney Injury Guidelines
Proposal of a flow-chart to avoid circuit clotting in prolonged intermittent renal replacement therapy (PIRRT): a monocentric experience 1 Vincenzo Cantaluppi,
Results Methods Abstract Number 69 Objectives 1.Nephrol Dial Transplant (2011) 26: 537–543 2.J Support Oncol 2011;9:149–155 3.N Engl J Med. 2009; 361:1627–1638.
Exercise Management Chronic Heart Failure Chapter 12.
Key facts about AKI 5 Facts about acute kidney injury (AKI), formerly known as "acute renal failure“ Up to 20% of hospital admissions have AKI Up to 25%
Retrospective Monocentric 10-Year Analysis Of Sepsis-Associated Acute Kidney Injury: Impact On Outcome, Dialysis Dose And Residual Renal Function 1 Vincenzo.
Rajeev Annigeri. Apollo Hospitals, Chennai.
The ‘SEPSIS 6’ <insert date> Faculty: <insert faculty>
Presentation by JoAnn Czech RN/CDS St. Cloud Hospital.
Acute Kidney Injury. 100,000 deaths are year are associated with acute kidney injury. (NCEPOD 2009)
신장내과 R4 강혜란 Cardiorenal syndrome (CRS).  Patients with heart failure (HF) who have a reduced GFR -> Mortality ↑  Patients with chronic kidney disease.
An AKI project for critically ill cancer patients
CRRT Fundamentals Pre- and Post- Test
University of Alabama at Birmingham
CRRT (Continuous Renal Replacement Therapy)
When fluids go wrong: CRRT in fluid overload
ACUTE KIDNEY INJURY Lecture by : Dr. Zaidan Jayed Zaidan
Presented By Dr / Said Said Elshama
12th Global Nephrologists Annual Meeting
Cardiovascular System: The Integrated System for Blood Pressure Regulation Prepared by iqra ayub.
Quantification and Dosing of Renal Replacement Therapy in Acute Kidney Injury: A Reappraisal Blood Purif 2017;44: DOI: / Fig.
Developed by 91 Civil Affairs Presented/modified by 1BCT, 82D ABN DIV
Shiraz Medical University
Acute kidney injury 2010년 1월 8일 내과 3년차 서정우.
6/18/2018 Intensive Care; Acute Renal Failure 1 Continuous Renal Replacement Therapy (CRRT) Maureen Walter,Raquel Lomeli Anika Stevenson,Nellie Preble.
Acute and Chronic Renal Failure
Acute Kidney Injury (AKI)
M. H. Rosner, M. Ostermann, R. Murugan, J. R. Prowle, C. Ronco, J. A
Diuretics, Kidney Diseases Urine R&M
Sheldon Chen  Advances in Chronic Kidney Disease 
Objectives Early initiation of continuous renal replacement therapy
Andrew Durward St Thomas NHS Foundation Trust Orlando 2017 CRRT IN AKI.
Lan Nguyen, MSN, CNN, CNP January 17, 2018
Infections in Surgical Patients: Intensive Care Unit
Volume 80, Issue 7, Pages (October 2011)
Figure 1 Principal pathogenic mechanisms of
New Advice for AKI Detection and Prevention in Primary Care
Volume 77, Issue 8, Pages (April 2010)
Dr Donal O’Donoghue National Clinical Director for Kidney Care
Clinical Background. A clinically applicable approach to continuous prediction of future acute kidney injury.
Presentation transcript:

Acute Kidney Injury in ICU Dr. Firouzeh Moeinzadeh Nephrologist 2/30/1395

Purposes Definition of AKI Etiology of AKI in ICU setting Renal replace therapy in ICU Fluid or diuretics? 2/30/1395

AKI is not a single disease but rather a syndrome comprising multiple clinical conditions 2/30/1395

Depending on the definition, acute renal failure was said to affect anywhere from 1 to 25% of intensive care unit (ICU) patients and to carry a mortality rate from 15 to 60%. 2/30/1395

Patients, especially patients in the ICU, are dying of AKI and not just simply with AKI. 2/30/1395

2/30/1395

RIFLE classification was useful for predicting Recovery of renal function: P≤0.001 Requirement for renal replacement therapy: P≤0.001 Length of hospital stay for survivors: P≤0.001 In-hospital mortality: P=0.035 2/30/1395

Survival appears to be affected for at least 1 year and maybe longer. It is the interaction between susceptibility (i.e., features intrinsic to the patient) and exposure (i.e., the causative factor or factors). 2/30/1395

Urinary tract obstruction Exposures: Myonecrosis Heart failure Sepsis Nephrotoxins Ischemia Urinary tract obstruction Major surgery Liver disease 2/30/1395

SEPSIS induced AKI Several studies have reported that sepsis induced AKI is associated with short- and long-term risk of death. The development of sepsis appears to be common in patients with AKI and is associated with high mortality and increased hospital duration. 2/30/1395

Multiple common settings: sepsis, cardiac surgery, radio contrast…… is common!! 2/30/1395

Recovery of renal function is also a problem, with many patients failing to recover renal function: patients with AKI who required renal replacement therapy that 33% of the survivors were still on renal replacement therapy after 12 months. 2/30/1395

less severe AKI may be associated with important long-term outcomes including progression of CKD and cardiovascular disease 2/30/1395

2/30/1395

AKI and the (innate) immune system Increased myocardial transcription of tumor necrosis factor-a and interleukin (IL)-1. Blockade of tumor necrosis factor-a inhibited apoptosis. Patients with septic AKI have impaired leukocyte rolling when compared with septic patients without AKI. 2/30/1395

Treatment of AKI Intermittent hemodialysis (IHD), Treatment of acute kidney injury (AKI) is principally supportive -- renal replacement therapy (RRT) indicated in patients with severe kidney injury. Goal: optimization of fluid & electrolyte balance Multiple modalities of RRT : Intermittent hemodialysis (IHD), continuous renal replacement therapies (CRRTs) hybrid therapies, ie sustained low-efficiency dialysis (SLED) 2/30/1395

Timing of initiation of RRT Earlier initiation of RRT in critically ill patients with AKI may have a beneficial impact on survival and outcomes but data is insufficient Many recommend initiation of RRT prior to the development of advanced uremic symptoms, or when the BUN reaches 80 - 100 mg/dL No known threshold of fluid overload for initiating RRT 2/30/1395

Discontinuation of RRT Until “evidence of recovery of kidney function” Improved urine output in oliguria Decreasing creatinine Creatinine clearance minimum 12 mL/min, some say 20 mL/min 2/30/1395

RRT in sepsis/MODS RRT has been proposed as a “Extracorporeal blood purification therapy (EBPT)” as adjuvant therapy for sepsis/MODS for removal of harmful inflammatory mediators or endotoxemia Some support from animal models and small clinical studies Eg cytokines can be demonstrated in dialysis effluent Miller's Anesthesia, 7th ed. 2009 2/30/1395 Foot. Current Anaesthesia and Critical Care 2005; 16:321-329

RRT in sepsis/MODS Overall, no good data showing improved outcomes Insufficient evidence to support a role for RRT as adjuvant therapy for septic shock unless severe acute renal failure is present. 2/30/1395

Conclusions AKI in the ICU is common and associated with high mortality The best time to initiate and stop RRT is controversial No good data that CRRT is better than IRRT in the ICU, except for a few specific situations Consider CRRT if severely unstable pts, severe volume overload, combined renal/hepatic failure IRRT best if bleeding risk or acute hyperkalemia/poisoning SLED is the most flexible 2/30/1395

Conclusions More intense RRT dosing in the ICU does not improve outcome Insufficient evidence to support a role for RRT as adjuvant therapy for septic shock unless severe acute renal failure is present Ultrafiltration is effective for fluid removal in CHF 2/30/1395

Specific considerations in ICU patients with AKI 2/30/1395

Oliguria and AKI in ICU Very common. Oliguria is short-lived, the typical response is observation (but not always). Is sustained, two responses are typically applied Fill (fluid administration) hoping that urine will “spill” Squeeze (increase BP with vasoactive drugs) and diurese (start and sustain diuresis with loop diuretic) 2/30/1395

Fill and Spill is dangerous and futile In the vast majority of ICU patients there is no “fluid depletion” More fluid= No difference to renal blood flow 2/30/1395

More fluid =Minor short-lived changes in urine output More fluid =Increased risk of dangerous fluid overload Yet “fill & spill” is very common 2/30/1395

After fill and spill (into the lungs!) 2/30/1395

Why we need to squeeze Almost all ICU patients are fluid replete Almost all are relatively hypotensive The typical MAP in a 60 year old man is >100 mmHg !! 2/30/1395

Renal blood flow is pressure dependent at low MAP Restoring blood pressure closer to normal may improve renal blood flow and diuresis 2/30/1395

2/30/1395

Why we also need to diurese Sustained oliguria leads to fluid overload due to obligatory fluid intake in ICU Fluid, acid-base, potassium management is much easier if urine output is maintained Loop diuretics have useful effects on renal hemodynamics 2/30/1395

Possible beneficial effects of loop diuretics Renal Vasodilatation (Direct vasodilatation, Inhibition of renal prostaglandin dehydrogenase; Blockade of TGF-induced vasoconstriction; Blockade of obstruction effect. Increased tubular flow (Decreased tubular obstruction by casts; Less back-leak; Decreased back pressure with effect on GFR) 2/30/1395

Oliguria/AKI: A Real ICU doctor’s approach Restore MAP with noradrenaline (norepinephrine) Make sure CO is adequate All simultaneous and rapid (minutes) 2/30/1395

Approach….. Administer furosemide infusion Maintain diuresis at between 1-2 ml/kg/hr Administer potassium and magnesium as needed 2/30/1395

The Physiological Folly of (excessive) Fluid Filling Fluids are bad after surgery Fluids are bad in ARDS They are physiologically futile in oliguria After the first couple of hours, they are physiologically irrational in most ICU patients 2/30/1395

In critically ill patients and in patients with AKI, fluid accumulation has been shown to worsen prognosis. A 10% fluid accumulation was associated with adverse outcomes in clinical settings. 2/30/1395

Mortality was lower when fluid overload was corrected by dialysis. The duration of fluid overload while remaining on dialysis was similarly associated with increased mortality, suggesting a cumulative effect of fluid overload on mortality. Mortality was lower when fluid overload was corrected by dialysis. 2/30/1395

Cumulative fluid overload may also be associated with a decreased likelihood of renal recovery. 2/30/1395

Conclusions Fluids can have a high physiological price Fluids do not correct vasodilatation Fluids do not increase renal O2 delivery They do not increase perfusion pressure You can get rid of vasopressor effects in minutes but getting fluid out is not that easy 2/30/1395

Are you agree: fluids kill !! Squeeze and diurese !! 2/30/1395

Thanks for your attention 2/30/1395