Renal Failure Detecting, Averting & Managing

Damian Fogarty BSc MD FRCP @DamianFog

damian.fogarty@belfasttrust.hscni.net

Real, Real, Gone. What Happens when it Fails

Disclosures & disclaimers Funded research 2000-2014 from Kidney Research

UK, Juvenile Diabetes Foundation, NI HSC Research & Development; NIHR; UK Renal Registry

NICE Anaemia of CKD 2013-2015 GDG Event adjudication for Carmelina Trial (Novartis) Lecture honoraria ~2/year from Boehringer; Baxter-

PD; Pharmacosmos; Novo Nordisk. No private practice

I also struggle with renal tubular acidoses!

Sources

3

Barn door kidney failure Pressure or volume loss

Trauma Sepsis GI loss Urinary losses Poor oral intake Pressure-Volume toxic medications

ACEi ARBs Diuretics

Pre-renal AKI leading to ATN

Prerenal disease

Acute tubular necrosis

intact kidney function

renal injury

timeSpectrum accounts for 2/3rd of all AKI

Biggest risk for AKI is CKD

Perfectly managed AKI

7

Who sees AKI?645 cases in NCEPOD report case review

8

Importance of AKI-ARF Acute Kidney Injury/Renal Failure

Incidence over last 20 years: 2% 5% of hosp admissions 15-30% preventable 50% had room for improvement Figure fell to ~30% if AKI developed during a hospital admission

rather than being diagnosed at admission 24% did not receive adequate senior review

Quality of care in this group was judged to be less good 85% did not have documented evidence of

critical care outreach involvement

http://www.england.nhs.uk/wp-content/uploads/2013/06/a06-acu-kidney-inj-ad.pdfhttp://www.ncepod.org.uk/2009aki.html

Hsu R et al Temporal Changes in Incidence of dialysis-requiring Acute Kidney Injury. JASN. 2013;24:37–42.

Post MI

Post surgery

CCF

Sepsis

The growth of acute kidney injury. Siew ED, Davenport A, Kidney International Jan 2015

Precarious renal circulation in elderly patients

Too wet-CCF risks

Too dry-At risk of AoCKD/AKI

Mortality risk cc no AKIx2 fold

x6 fold

x9 fold

KDIGO Position Statement on Acute kidney injury. Kidney International 2012

Kidney disease not as complicated as most think !

Water and ‘solute’ Coffee

15

Approach to renal failure

Medications & OTCs Contrast agents Light chains Glomerular Dx

Assess volumes Pump & Pressure <110mmHg Vasodilation & Sepsis 3rd spacing-Liver Dx, albumin

PRE-RENAL RENAL POST-RENAL

Catheterise Scan kidneys Monitor volumes out

80% 10% 10%

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NCEPOD Top 10 risk factors-usually multiple

Tools of the trade - very high tech!

Observations Vital ! Fluid balance

+

+Urine

Fancy & forgotten tests

More of these1. Free light chains (wt loss-back pain)2. CK esp with low GCS; alcohol; drugs3. LDH & blood film (platelets ) 4. Cultures if any hypo-tensive/thermic5. Calcium 6. Anti-cardiolipin/phospholipid7. Bicarbonate & lactate8. Urine for ACR (Alb:Creatinine Ratio)9. UNa<20 mmol/L = volume sensitive

Less of these1. “Renal Screen”2. ANCA for vasculitis

with normal CRP & ESR

3. ANA for lupus in 80 year old men

4. ASO titres5. Urine osmolality6. Serum osmolality

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Top tips More of this

1. Involve critical care earlier2. Review the history from home/relatives3. Postural BP & Pulse changes4. Dry or wet? -CXR and SaO2 help5. Measure output properly- not ”PUT”6. Incontinent-catheterise7. Hold most or all drugs8. Review drug doses on Renal Drug

Handbook https://renaldrugdatabase.com9. In frail elderly-RAAS agents @6pm10. Stage 3 AKI involve renal earlier

Less of this1. Diuretics & fluids together2. Treating K+ <5.5 every 6

hours. 3. 3 x CT scan & contrast in 4

days4. Urgent USS when cause

obvious

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Relieving urological obstruction• Refer all patients with upper tract urological obstruction

to a urologist.

• Immediate referral if one or more of following present:• Pyonephrosis i.e. sepsis & obstruction• Obstructed single kidney• Bilateral upper urinary tract obstruction

• When nephrostomy or stenting required – undertake as soon as possible and within 12 hours of diagnosis

NICE CG169

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Drug issues Drugs interfering with renal perfusion/volume

ACE inhibitors and angiotensin receptor blockers NSAIDs All antihypertensives/Nitrates /Nicorandil Diuretics (loop and thiazide)

Drugs requiring dose reduction or cessation Low molecular weight heparins Opiates Metformin (associated lactic acidosis) Sulphonylurea-based hypoglycaemic agents Aciclovir

Interstitial nephritis (± rash, eosinophilia) Omeprazole and other PPIs Penicillin based antibiotics HAART

Drugs requiring close monitoring Warfarin Aminoglycosides-longer courses more injurious

Drugs aggravating hyperkalaemia Digoxin Beta blockers Trimethoprim Potassium sparing diuretics e.g. spironolactone, amiloride

Indications for AKI Referral to a Nephrology or ICU Team

If AKI is part of multi organ failure more appropriate to refer to ICU. Patients likely to need dialysis or specialist renal treatment:

1. Hyperkalaemia (> 6.5 mmol/L) refractory to medical management2. Pulmonary oedema refractory to medical management3. Severe metabolic acidaemia pH ≤ 7.2 due to kidney failure; HCO3 <124. Uraemic complications (pericarditis or uraemic encephalopathy)A. Renal transplantB. Chronic kidney disease (stage 4 or 5)C. Patients suspected of intrinsic renal disease (vasculitis, primary GN, interstitial

nephritis)  Nephrology – Conservative Care Interface

AKI may be part of a terminal illness in a hospitalized patient. Severity of the clinical event/progression of advanced untreatable co-morbidity

critical. Senior medical & nursing staff should identify early in the course of their deterioration Decide on ceilings of care & appropriateness of referral to ICU/renal team. If in doubt discuss

23

Perfectly managed AKI

My first e-alert (aka phone an old friend) Male age 56, T2DM x 20 years, lifelong asthma IHD-CABG 22nd Feb 2011 Fri 25th Feb ICU to ward.

Text from his brother (friend of mine) that his creatinine was 100 post op and now 188.

Sitting in bed- thought SOB normal; cough Apyrexic, tachycardic ~100/min SR Dull left base.

Metformin and ACEi stopped Started on Taz Euvolaemic

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Creat 70umol/l in the year 2000; Drifted slowly to 100-120 prior to CABG. Does he need follow up?

NICE says yes based on: ~3-5% of pure AKI patients develop CKD in next year

versus 1-2% of any hospitalised patient (~RR 3; absolute risk small)

Much higher if dialysis requiring: follow up these

27Age

Diabetes

Obesity

Age

High Blood

Pressure

Smoking

1990

Per million population205+ (260)125 to <20557 to <12549 to <57below 49 (44)

Chronic dialysis incidence rates due to diabetes

2000

29

1

10 at clinics

100 in primary care

Chronic Kidney DiseasePopulation prevalence

0.5 %

5 %

40 80 120

number

weegranny body-builder

serum creatinine is normally distributed according to muscle bulk

umol/l

Interpreting serum creatinine‘normal range’ 40-110 umol/l

Non linear relationship between real GFR and serum creatinine

Creat = 60 µmol/l

Creat = 120 µmol/l

If creatinine doubles GFR halves

♂

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5 10 15 20years

Elevated BPRising creatinine

Albuminuria can occur many years before other features of CKD

Albumin in urine

100

30

3

EstimatedGFR

(mls/min)

100

50

Years

Dialysis

4321 5

Progression of CKD

Rapid progressionSlow progression

Stable

10

Markers of rapid progression?•High blood pressure •Proteinuria•AKI events

If CKD stage 3 (GFR 30-60)•25% will have a vascular event in next 5 years•1% will be on dialysis

Prevention of progressive kidney and vascular disease

34

Hypertension

BP control slows DN progression

35Parving et al, BMJ 1987

The lower the BP The lower the BP the better the renal outcome….in these the better the renal outcome….in these studies!studies!

36

EstimatedGFRas %

100%

50%

Years

Dialysis4321 5

Progression of proteinuric CKD best controlled by Renin Angiotensin Aldosterone (RAAS) blocking drugs

Rapid progression

Slow progression with ACEi or ARB

10%

ACE or ARB started: Creat 130 before, 150 after BUT slower decline in GFR fall

Don’t be too quick to stop RAAS inhibitors with stable rises in creatinine/potassium & patient under close follow up

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Before stopping RAAS inhibitors check patient not dehydrated; stop diuretics; stop NSAIDs.

Check BP

Post AKI-does the patient need to restart RAAS drug for proteinuria?

CKD management a marathon not a sprint!Take time to lower the BP

Creat 70umol/l in the year 2000; drifted to 100-120 with no ACR rise (2mg/mmol).

? DKD due to interstitial and or arterial aetiology not pure diabetic nephropathy.

Remote follow up from renal ACR now rising so will be seen now 5 years later.

Assess AKI risks & volume (early & often) Pre, intra & post renal causes; Pre, intra & post renal monitoring & management CKD common but higher risks from vascular

outcomes Proteinuric are most progressive/preventable Stop more volume/pressure toxic drugs in AKI Start & restart them in the proteinuric CKD patient41

References1. NICE Acute Kidney Injury clinical guidance (CG169) (2013) http://guidance.nice.org.uk/CG1692. National Confidential Enquiry into Patient Outcome and Death (NCEPOD) “Acute Kidney Injury:

Adding Insult to Injury (2009) http://www.ncepod.org.uk/2009aki.htm 3. Elective and Emergency Surgery in the Elderly: An Age Old Problem (2010)

http://www.ncepod.org.uk/reports2.htm 4. Renal Association Clinical Practice Guidelines: Acute Kidney Injury (2011)

http://www.renal.org/Clinical/GuidelinesSection/AcuteKidneyInjury.aspx5. British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (2011)

http://www.bapen.org.uk/pdfs/bapen_pubs/giftasup.pdf6. NICE Intravenous Fluid Therapy clinical guidance (2013) http://guidance.nice.org.uk/CG/Wave25/5

Perioperative acute kidney injury: risk factors, recognition, management, and outcomes. Clinical Review. Borthwick E, Ferguson A. BMJ 2010 Jul 5;341:c3365. doi: 10.1136/bmj.c3365.

7. GAIN Northern Ireland Guidelines for Management of Chronic Kidney Disease (2010) http://www.gain-ni.org/images/Uploads/Guidelines/Chronic%20Kidney%20Disease.pdf

8. GAIN Guidelines for the Treatment of Hyperkalaemia in Adults (2009)http://www.gain-ni.org/images/Uploads/Guidelines/hyperkalaemia_guidelines.pdf

9. Surviving Sepsis Campaign http://www.survivingsepsis.org/bundles/Pages/default.aspx10. NICE CKD Guidelines 2014. https://www.nice.org.uk/guidance/cg18211. KDIGO guidelines: http://kdigo.org/home/guidelines/

@DamianFogdamian.fogarty@belfasttrus

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