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

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

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

4. Renal Anatomy

5. 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

6. 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)

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

8. 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

9. 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

10. AKI – Classification & Alerts
AKI Stage
Creatinine Criteria
Urine Output Criteria
Predicted Nos / year of AKI in 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

11. 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

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

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

14. AKI – Classification & Alerts
AKI Stage
Creatinine Criteria
Urine Output Criteria
Predicted Nos / year of AKI in 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

15. 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

16. AKI – Classification & Alerts
AKI Stage
Creatinine Criteria
Urine Output Criteria
Predicted Nos / year of AKI in 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

17. 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

18. 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

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

20. Questions