1. Renal disease: AKI vs CKD
Chris Dobson

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

3. 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 mmol, creatinine , oliguria <400ml in a day, fluid balance 30ml/kg/ day

4. Say what you see.... A

5. RIFLE CRITERIA

6. 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

7. 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

8. 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

9. 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...

10. 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

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

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

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

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

18. 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?

19. 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

20. 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

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

22. 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

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

24. 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

26. End