Updates on Acute Kidney Injury

Yousif Bahbahani

Nephrologist, Mubarak Al-Kabeer Hospital

How important is AKI?

How important is AKI?

Question

• 36 years old gentleman in ICU on mechanical ventilation. Has slightly elevated AKI (Stage I). Family asking if patient will develop “Kidney Failure” and asking if there is a test you can do to tell?

1. Plasma Ngal

2. TIMP2*IGFBP7

3. Urine KIM-1

4. Urine Ngal

Question

• 36 years old gentleman in ICU on mechanical ventilation. Has slightly elevated AKI (Stage I). Family asking if patient will develop “Kidney Failure” and asking if there is a test you can do to tell?

1. Plasma Ngal

2. TIMP2*IGFBP7

3. Urine KIM-1

4. Urine Ngal

Biomarkers for AKI

Lag between AKI and rise in serum creatinine

Many limitations for the use of serum creatinine

Need for New Biomarkers for:

• Earlier detection of AKI

• Identifies those who will progress to severe AKI

Biomarkers for AKI

Biomarkers for AKI

Kashani et al

Biomarkers for AKI

Kashani et al

Biomarkers for AKI

Biomarkers for AKI

• NGAL

• KIM-1

• L-FABP

• IL-18

TIMP2*IGFBP7

Clinical Utility of TIMP2*IGFBP7

Am J Kidney Dis 68: 19–28, 2016

Future of Biomarkers

Combination with other biomarkers:

• Furosemide stress test (FST)

• Renal Angina Index (RAI)

Nephro imitation of cardiology

Kidney injury biomarker (e.g. TIMP2*IGFBP7) Our Troponin

+

Kidney functional biomarker (e.g. FST) Our Stress test

Novel therapies for AKI?

E-Alert systems

E-Alert systems

E-Alert : Not Helpful

E-Alert Not Helpful

Wilson et al

E-Alert Helpful : NHS

NHS Studies

E-Alert Helpful: NHS

Aki Care bundle

Novel therapies for AKI?

No magic pill yet!

But we can do much better if apply what we already know!

Question

48 years old lady known HTN and DMt2, admitted to ICU with severe sepsis. Blood pressure is 95/60 Her creatinine is rising from 110 to 360 micromol/L and has decreased urine output. K:4.2, HCO3: 20, Na: 143, Phos: 1.7, Ca: 2.1.

What is your next step in management?

1. Start IHD immediately.

2. Start CRRT immediately.

3. Start CRRT within 48 hrs.

4. Start IHD within 48 hrs.

Question

48 years old lady known HTN and DMt2, admitted to ICU with severe sepsis. Blood pressure is 95/60 Her creatinine is rising from 110 to 360 micromol/L and has decreased urine output. K:4.2, HCO3: 20, Na: 143, Phos: 1.7, Ca: 2.1.

What is your next step in management?

1. Start IHD immediately.

2. Start CRRT immediately.

3. Start CRRT within 48 hrs.

4. Start IHD within 48 hrs.

Early Vs Late CRRT (When no Abs Indication)• Retrospective studies: ?Benefit from early initiation of CRRT

ELAIN Vs AKIKI

SD Barbar et al. N Engl J Med 2018;379:1431-1442.

Overall Survival among Patients Assigned to Early Renal-Replacement Therapy and Delayed Renal-Replacement

Therapy.

Awaiting STARRT-AKI Results!

Question

• 65 years old gentleman with DM, HTN CKD and CAD. Admitted with NSTEMI and scheduled for PCI tomorrow. What would you like to do?

1. N-Acetyl cystine 1200mg PO BD for 48 hrs

2. N-Acetyl cystine 1200mg IV BD for 48 hrs

3. Normal saline Drip before & after PCI.

4. NaHCO3 drip Drip before and after PCI

Question

• 65 years old gentleman with DM, HTN CKD and CAD. Admitted with NSTEMI and scheduled for PCI tomorrow. What would you like to do?

1. N-Acetyl cystine 1200mg PO BD for 48 hrs

2. N-Acetyl cystine 1200mg IV BD for 48 hrs

3. Normal saline Drip before & after PCI.

4. NaHCO3 drip Drip before and after PCI

THE PRESERVE STUDY

SD Weisbord et al. N Engl J Med 2018;378:603-614.

Enrollment and Randomization.

SD Weisbord et al. N Engl J Med 2018;378:603-614.

Forest Plot of Treatment Effects in Prespecified Subgroup Analyses.

Question

• 45 years old lady admitted to ICU with septic shock. What is your fluid prescription for this lady?

1. Ringer’s Lactate

2. Normal Saline

3. Human Albumin

4. HES (Starch)

Question

• 45 years old lady admitted to ICU with septic shock. What is your fluid prescription for this lady?

1. Ringer’s Lactate

2. Normal Saline

3. Human Albumin

4. HES (Starch)

KDIGO Guidelines 2012

What type of Crystalloids???

SALT-ED & SMART Trials

• Same center: Comparing Saline Vs Balanced (Ringer’s or Plasmalyte A)

• SALT-ED: Non-Critically ill : Primary end-point: LOS

• SAMRT: Critically ill: Primary end-point: MAKE30

WH Self et al. N Engl J Med 2018;378:819-828.

SALT-ED Results

MW Semler et al. N Engl J Med 2018;378:829-839.

Clinical Outcomes.*SAMRT Trial

Question

• 64 years old gentleman presented to ER with rapidly rising serum creatinine, hemoptysis and arthralgia. ANCA serology is +ve. What is your management?

1. Pulse steroids

2. Oral Prednisone + Cyclophosphamide

3. Pulse steroid + Cyclophosphamide

4. Pulse steroid + Cyclophosphamide + Plasma exchange

Question

• 64 years old gentleman presented to ER with rapidly rising serum creatinine, hemoptysis and arthralgia. ANCA serology is +ve. What is your management?

1. Pulse steroids

2. Oral Prednisone + Cyclophosphamide

3. Pulse steroid + Cyclophosphamide

4. Pulse steroid + Cyclophosphamide + Plasma exchange

PEXIVAS Trial

• Largest ever AAV trial: 702 patients

• 2 X 2 Factorial design

• Compared:• PLEX Vs No PLEX

• High Vs Low dose steroids NO DIFFERENCE in Death or ESRD Composite

TAKE HOME MESSAGE

• Better detection of AKI: (Biomarkers, Prediction scores, E-Alerts)

AND Linking them to:

• AKI care bundles

THANK YOU