1. AKI (formerly ARF) 13–18% of all people admitted to hospital

2. Format for the Session 8.10 Acute Kidney Injury (AKI) Recognise AKI/potential for AKI Distinction from chronic renal failure Establish underlying pathophysiology (causes) Investigations Management Prognosis Prevention

3. Recognise (Potential) Acute Kidney Injury Within the past 7 days: sCr rise of 26 micromol/l + in 48 hrs 50% + rise in sCr known or presumed to have occurred urine output <0.5 ml/kg/hr for 6 hrs+ NB children differ!

4. Causes of AKI 50% of AKI

5. Investigation of AKI Bedside tests Strict urine output monitoring with catheter (if not already) Dip, urine osmolarity, MCS Weight BD ECG Bloods Lactate Serial sCr, Urea, electrolytes, serum osmolarity Cultures Imaging USS within 24hrs IF pyonephrosis (infected and obstructed kidney[s]) is suspected Chest Xray Special

6. Initial Management of AKI Pre Renal Stop nephrotoxics, do not use loop diuretics to force urine output Rehydrate, correct electrolytes, treat sepsis with ?kidney friendly Abx Renal Call nephrology (NICE say so!) Post Renal Acute retention  catheterise Ureteric obstruction  ?Nephrostomy  Urology

7. AAAAAH my treatment is not helping!! When there’s something bad, and it don’t look good Who ya gonna call?

8. Your SHO/reg and suggest a referral to Renal boffins for an opinion on haemodialysis

9. Indications for dialysis (usually haemofiltration in ITU) Known Tx/dialysis patient OR Initial treatment failure AND one of AEIOU

10. What’s AEIOU you say?!! Acidosis (metabolic) Electrolyte changes (hyperkalemia) Ingested Toxins (barbiturates, salicylates, lithium, methanol) Overload (pulmonary oedema unresponsive to diuretics) Uremia symptoms (pericarditis, encephalopathy)

11. Triggers to call the nephrologist in the 1 st Instance Initial treatment measures fail Specialist diagnosis (vasculitis, glomerulonephritis, tubulointerstitial nephritis or myeloma) AKI cause not clear AKI has caused complications Stage 3 AKI (according to (p)RIFLE, AKIN or KDIGO criteria) Transplant/ CKD stage 4 or 5 patient

12. Prognosis of AKI 20-30% mortality and increasing with each stage of AKI Risk of CKD 15-32% of survivors are dependent on RRT at hospital discharge  Nephrology Follow Up

13. Prevention Older adults, comorbidities, surgery, contrast studies Do NOT perform a contrast investigation without a U&E’s Avoid nephrotoxic meds as far as poss and stop ACE/ARB pre-contrast (pharmacist) Consider preloading with N.Saline Avoid dehydration, particularly before surgery

14. Explain the need for RRT to an elderly man

15. References http://www.fastbleep.com/ NICE clinical guideline 169 guidance.nice.org.uk/cg169

16. kidneys receive 20-25% of the resting cardiac output via the right and left renal arteries 1. Cardiac output which determines the amount of blood flow down the renal arteries 2. Autoregulation which sets the pressure gradient between the afferent and efferent arterioles; and 3. Size and charge of molecules that are going to be filtered through the nephrons

17. 3.26 Abnormalities of sodium and potassium By the end of Phase II students should be able to: initiate investigation of hypo and hyper natraemia and hypo and hyper kalaemia initiate management of these conditions