+ Acute Kidney Injury Finals Teaching 2014 Alison Portes FY1

+ Objectives Be able to recognise and define acute kidney injury Understand risk factors for developing AKI Describe causes of AKI Identify relevant features of history, examination and investigations Know key features of management of both AKI and hyperkalaemia

+ Which of these patients has AKI? 89 year old lady found on the floor by her carer, Ur 7, Creat year old presenting at A&E following 2 days of severe vomiting and diarrhoea, Ur 20 Creat year old on the ward being treated for CAP, nurses are concerned he is not passing urine

+ Definition A rise in serum creatinine (of 26 μ mol/l or greater) within 48 hours) A 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days A fall in urine output (to less than 0.5 ml/kg/hour for more than 6 hours in adults and more than 8 hours in children and young people) “ Rise in serum creatinine from normal baseline over hours or days”

+ Causes Pre-renal (hypoperfusion) Hypovolaemia Sepsis Drugs e.g., NSAIDs Renal artery stenosis Renal Glomerulonephritis Drugs e.g., gentamicin Rhabdomyolysis Myeloma Haemolytic-uraemic syndrome Post-renal (obstruction) Tumours BPH Retroperitoneal fibrosis

+ History Think of causes: Infection (UTI/sepsis) Hypovolaemia (D+V, acute blood loss) Drugs (any nephrotoxic/new meds?) Urine: output (&symptoms of UTI/prostate) Weird and wonderful (nosebleeds, haemoptysis, backpain/weight loss) PMHx: Diabetes, bladder/prostate Ca, FHx (PKD)

+ Examination General Fluid status: BP, skin turgor, mucous membranes, JVP, oedema (peripheral/pulmonary), urine output Abdominal (in exams) Palpable bladder? Ballotable kidneys?

+ Investigations Observations Bedside Urine Dip, ECG, ABG, BM Bloods FBC, U&Es, renal screen – complement, autoantibodies, myeloma screen Imaging USS renal tract CXR Special tests Biopsy

+ Management of AKI Treat the cause! Conservative: Oral fluids, STOP CANDA, diet Medical IV fluids, treat life-threatening complications, catheter (if bladder/prostate obstruction), steroids for certain types of GN Dialysis Surgical Obstruction, bleeding

+ Complications of AKI Hyperkalaemia Metabolic Acidosis Pulmonary Oedema Uraemia

+ ECG changes in hyperkalaemia Tall tented T waves Low flat P waves Broad, bizarre QRS

+ Treatment of hyperkalaemia Protect the heart Monitor Calcium Gluconate Shift the potassium Insulin/dextrose Salbutamol nebs Treat the cause Reassess

+ Indications for Dialysis AEIOU Acidosis – refractory metabolic acidosis Electrolyte imbalance (refractory hyperkalaemia) Intoxication – poisoning with dialysable substances Overload – refratory pulmonary oedema Uraemic symptoms – pericarditis, encephalopathy

+ Key points History and Examination – concentrate on doing the basics well Investigations – what differential will it rule out? Learn the essentials now and keep repeating them… Pre-renal, renal, post-renal CANDA ECG changes in hyperkalaemia Treatment of hyperkalaemia Indications for dialysis Practice communication task Questions?