Acute Kidney Injury (Mhs Smt IV FK Unud)

8/2/2019 Acute Kidney Injury (Mhs Smt IV FK Unud)

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ACUTE KIDNEY INJURY (AKI)

(Cedera Ginjal Akut)

Another term : Acute Renal Failure

Many references / literatures still use this term

DEFINITION :AKI is an abrupt (less then 7 days) and sustained decrease in

kidney function.

changes in blood biochemistry : increased of serum

creatinine, blood urea nitrogen decreased of urine out put in 80-90% cases (10-20%

normal or increase) or both

kidney function used to be normal

When the patient has a previous episode of kidney disease,

the term is : Acute on Chronic Kidney Disease (ACKD)


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1. Risk of Renal Dysfunction (R) serum creatinine increased 1.5 fold, or

GFR decreased by more than 25%

Less than 0.5 ml/kg/h of urine production for 6 hours

2. Injury of the Kidney (I)

doubling of serum creatinine or

GFR decreased by more by 50% or

urine production less than 0.5 ml/kg/h in 12 hours

CLASIFICATION

AKI classified according to degree and outcome of renal

function by RIFLE criteriaR = Risk I = Injury F = Failure

L = Loss E = End Stage


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3. Failure of Kidney Function

serum creatinine increased 3 fold, or GFR decreased by more than 75%

less than 0.3 ml/kg/h of urine for 24 hours

4. Loss of Kidney Function

Complete loss of kidney function for longer

than 4 weeks

5. End Stage Renal Disease

The need for dialysis for longer than 3 month


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Established renal failure (loss of

function > 3 months)

Loss of kidney function > 4 weeks but

< 3 months

Three-fold increase in creatinineor > 75% decrease in GFR or

creatinine > 350 (acute rise)

Urine output < 0.3 ml/kg/hrfor 24 hours (or anuria for

12 hours)

Two-fold increase in

creatinine or > 50%

decrease in GFR

Urine output < 0.5 ml/kg/hr for

at least 12 hours

50% decrease in creatinine or

> 25% decrease in GFR

Urine output < 0.5 ml/kg/hr for

at least 6 hours

GFR Criteria Urine output CriteriaAND/OR

Failure of

kidney function

Loss of kidneyfunction

ERF

Risk of renal

dysfunction

Injury to the

kidney

Acute renal failure (ARF) classified according to degree and outcome by RIFLE criteria


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CAUSES OF AKI

Causes of AKI divided into three matter :

1. Prerenal :

Decreased of renal perfusion (hypoperfusion)

2. Renal (Intrinsic)

Damage of parenchyma of the kidney (glomeruli,

tubules, intra-renal vasculature, interstitial nephritis)

3. Post-renal

Obstruction of urinary tract


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PRERENAL CAUSES OF AKI

1. Shock :

cardiogenic ahock

distributive shock (e.g.sepsis, anaphylactic)

2. Hypovolemia hypovolemic shock

haemorhage

gastrointestinal loss (vomiting, diarrhea)

cutaneous losses (e.g.burns)

3. Renal hypoperfusion

renal artery stenosis

hepatorenal syndrome

4. Changes of water distribution (oedema)

congestive heart failiure

hepatic failure

nephrotic syndrome


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RENAL / INTRINSIC CAUSES OF AKI

1. Glomerular disease

glomerulonephritis

2. Tubular injury

prolonged renal hypoperfusion

toxin (snake venom), drugs (aminoglycosides),3. Vascular

vasculitis

arterial or venous thrombosis

4. Interstitial nephritis

infiltrative malignancy

toxin (alcohol, metal)

infection (leptospiral)


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POST-RENAL CAUSES OF AKI

Obstruction :

stone

urethral stricture

prostate hypertrophy

pelvic tumor

retroperitoneal fibrosis


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Prerenal


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Renal


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Postrenal


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DIAGNOSTIC

1. History of disease

gastroenteritis, bleeding ?

heart disease

toxin ? post infection ?

stone disease ?

2. Investigation

A. Physical examination.

blood pressure (hypotension/shock)

anemic, dehydration

renal colic, ballotment, full vesica urinaria


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COMPLICATIONS1. Volume overload

acute pulmonary oedema

acute left heart failure

2. Metabolic acidosis

3. Electrolyte imbalance

hyperkalemia


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MANAGEMENT

A. Manage the initial causes / initial disease properly

B. Patient must be hospitalized and admit in

Intensive Care Unit

water, electrolyte and acid-base balance

antibiotic

C. Supportive Therapy

dialysis ultrafiltration


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PREVENTION Identify and treat patients most at risk

gastroenteritis

bleeding

heart failure

pre- operation

drugs / toxin

infection


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AKI ACKD

History of kidney disease No/unknown Yes

Physical examination

- hypertension rare mostly

- oedema rare mostly

Blood biochemistry :- anaemic rare mostly

- hyperphosphatemia (PO4) rare mostly

Ultrasonographic normal small kidney

Deferential diagnosis between

Acute Kidney Injury (AKI) and

Acute on Chronic Kidney Disease (ACKD) :


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What is the management ?

Acute Kidney Injury (Mhs Smt IV FK Unud)

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