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