1. Developed by 91 Civil Affairs Presented/modified by 1BCT, 82D ABN DIV
Acute Kidney Injury
Developed by 91 Civil Affairs
Presented/modified by
1BCT, 82D ABN DIV

2. Renal function
Kidney has many roles: 1. Excretory function 2. Osmolality regulation 3. pH balance 4. BP regulation through salt and water balance 5. Hormone secretion (Erythropoietin, Vit D3)

3. Definition of Acute Kidney Injury
Acute decline in renal function • Rapid ( < 48 hrs) • Seen as: A- Rise in serum creatinine, defined by either: 1- absolute increase in serum creatinine of >0.3mg/dl( >26μmol/l) 2- % increase in serum creatinine of > 50% B - Reduction in urine output, defined as < 0.5ml/kg/hr for more than 6 hrs or 30-50cc/hr

4. Mortality
• 5-10% in uncomplicated AKI • 50-70% in AKI secondary to other organ failure( intensive care) • > 50% in dialysis

6. Diagnosing pre-renal AKI
Signs of Hypovolemia:
a. Low BP( and reduced pulse pressure)
b. Postural BP drop ( a fall in systolic BP > 10mmHg)
c. Sinus tachycardia and postural increase in heart rate ( increase in HR > 10 beat/min)
e. Cool peripheries and vasoconstriction ( septic patients may be vasodilated)
f. Poor urine output.

7. Resuscitate - Hypotensive and tachycardic 0.9% Normal saline
be aware of fluid overload
high BP, RR, basal lung crackles and low satO2)
fluid challenge
trial ml N saline IV in 10min, then re-assess, repeat if necessary

8. Replacement (after rescucitation is complete, then give the following)
first liter over 2 hours, THEN REASSESS
second liter over 4 hours, THEN REASSESS
- third liter over 6 hours, THEN REASSESS

9. Maintenance
Once euvolemic, and assume no other losses, match urine out put plus 30mls/hour
(insensible loss may be higher if febrile)

10. Correcting Hypovolemia (from Up To Date)
Overly aggressive volume repletion should be avoided as excessive volume expansion may lead to pulmonary congestion, especially in septic patients.
We suggest judicious administration, beginning with 1 to 3 liters of fluid, with careful and REPEATED CLINICAL ASSESSMENT to assess the patient's response to this therapy.
In some cases, additional fluid therapy may be necessary (eg, severe burns, acute pancreatitis).

11. Correcting Volume Depletion (From Up To Date)
Overly aggressive volume repletion should be avoided as excessive volume expansion may lead to pulmonary congestion, especially in septic patients.
We suggest judicious administration, beginning with 1 to 3 liters of fluid, with careful and REPEATED CLINICAL ASSESSMENT to assess the patient's response to this therapy.
In some cases, additional fluid therapy may be necessary (eg, severe burns, acute pancreatitis).

12. RENAL (INTRINSIC) AKI (beyond the scope of this training, should not be down range)

13. POST-RENAL AKI Nature of Obstruction--Foley
Outside - Tumors, prostate, retroperitoneal fibrosis, cervical Ca
Within wall - Tumors, strictures
Within lumen - Stones, tumors

14. Diagnosing post renal AKI
1. History: pain, anuria, hematuria, prostatism 2. Examination: palpable bladder, central abdominal mass, Post Void Residual 3. Observation 4. Laboratory investigations - Urine - Blood - Imaging – US, CT

15. Treatment of Post renal AKI
Obtain drainage of Urine
- Bladder catheter – per urethra, suprapubic
- Retrograde drainage
- Antegrade drainage

16. Post recovery diuresis
Occurs post resolution of AKI - Post relief of obstruction - Post ATN Important to check fluid status - Clinical exam - BP and pulse - Daily weight - Input and output chart Treatment – IV fluids, replace electrolyte

17. Complications of AKI Pulmonary edema Acidosis Uremia
Other electrolyte disturbance such as hyerphosphatemia and hypocalcemia

18. Who is a risk?
1- Elderly 2- Pre-existing renal disease 3- Surgery, trauma, sepsis or rhabdo 4- Diabetes 5- Volume depletion 6- LV dysfunction 7- Nephrotoxic drugs 8- Cirrhosis (reduce arterial volume)

19. Common nephrotoxins NSAID Antibiotics, Aminoglycosides, Vancomycin
IV contrast