Acute Kidney Injury
Andrew Lunn Consultant Paediatric Nephrologist
Sep 2019
Overview
• Definitions
• Case illustration
• AKI
– Who needs follow-up?
AKI
AKI
AKI – Nottingham Data
• What does this mean practically:
– 3 months of alert data in Nottingham wards
– 786 alerts in 295 patients
– Per 100 beds per week approximately
• Stage 1; 11 patients
• Stage 2; 3 patients
• Stage 3; 5 patients
Mortality and hospital length of stay (LOS) by AKI severity stage in ICU and non-ICU
hospitalizations.
Scott M. Sutherland et al. CJASN 2015;10:554-561
©2015 by American Society of Nephrology
AKI
Response – early detection
Response – early intervention
Case
• 10 year old girl
– Abdo pain, vomiting and fever
• Background
– Crohn’s disease
– Treated with infliximab and methotrexate
• Investigations
– Raised lipase
– Increased VZV PCR
Case
• 10 year old girl
– Abdo pain, vomiting and fever
• Diagnosis
– Varicella related pancreatitis
– Commenced aciclovir
• Clinically
– Negative fluid balance
– Wt 35.45 kg – decrease of 1.8 kg from clinic
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Case
Risk factors
• Abdo pain, vomiting and fever
• Crohn’s Disease
• Varicella related pancreatitis
• Aciclovir
• Negative fluid balance
• Wt 35.45 kg – decrease of 1.8 kg from clinic
Learning Points
• Early increase in fluids
• Daily weights
• More aggressive fluid management
• Earlier review
• Earlier alteration of medication
• eAlert with guideline would aid management
Why would AKI lead to CKD?
What would contribute to maladaptive repair?
• Severity of AKI
• Pre-existing CKD
• Previous AKI
AKI – Who needs follow-up?
• Reason for follow-up
– Prevent the preventable
• Further AKI / admissions
– Treat the treatable
• Future CKD
AKI prevention
AKI and progression to CKD
• PICU follow-up data EMEESY
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Yr 1 (27) Yr 2 (16) Yr 3 (14) Yr 4 (6) Yr 5 (6)
CKD4
CKD3
CKD 2
>90
AKI and progression to CKD
42 42 29
AKI 1(n=44)
AKI 2(n=47)
AKI 3(n=35)
no CKD CKD
54
59
13
CKD No CKD
Risk of CKD
CKD
- GFR 60-90 ml/min/1.73m2
- HTN - Hyperfiltration
- GFR < 60 ml/min/1.73m2
- albuminuria
Am J Kidney Dis. 2012 Apr;59(4):523-30.
AKI and progression to CKD
AKI and progression to CKD
• Early detection of CKD
– Lifestyle changes
– Phosphate
AKI and progression to CKD
• Early detection of CKD
– Lifestyle changes
– Phosphate
– Protein control
AKI and progression to CKD
• Early detection of CKD
– Lifestyle changes
– Phosphate
– Protein control
– BP control
Suggested follow-up
• Review at
– 1 month
– 3 months
– 12 months
– Annually
• Refer if HTN, proteinuria or eGFR < 90
• GP review if old enough and no problems after ? years
• Review by SPIN / Paeds nephrologist if AKI 2-3
• Purpose of review
– Assess for CKD
– Educate patient / parents / carers
Conclusions
• Constant vigilance
– Earlier detection of AKI
• Stop kidney attack
– Earlier intervention to reduce severity of AKI
• Follow-up
– Further AKI
– Future CKD