Renal Medicine

An Update

Dr. Matthew Welberry Smith Consultant Nephrologist

St. James’ University Hospital, Leeds

Renal

Hannah (age 6)

Terminology

• ARF

• CRF

• ESRF

• ….Transplants

AKI

Acute Kidney Injury

CKD

Chronic Kidney Disease

ESKD

End Stage Kidney Disease

Transplants!

Outline

• Acute Kidney Injury

• Chronic Kidney Disease

• End Stage Kidney Disease (CKD V)

• Renal Transplantation

Acute Kidney Injury (AKI)

• 13-18% of hospital admissions

• £434-£620 million / year

• Inpatient mortality 10-80% (!)

• Independent risk factor

• NCEPOD report “Adding Insult to Injury” 2009 – All emergency admissions to have U+E

– 24h Renal U/S (and nephrostomy) cover

– RRT facilities

AKI – definitions and recognition (UK Renal Association, KDIGO based)

• Serum creatinine – rises by ≥ 26µmol/L within 48 hours – rises ≥ 1.5 fold from a reference value – (reference value = lowest creatinine within 3 months)

– Urine output < 0.5ml/kg/hr for >6h (<35ml/hr for 70kg)

• If a reference serum creatinine value is not available within 3 months and AKI is suspected: repeat serum creatinine within 24 hours

AKI – NICE guidance • August 2013

• Identifying AKI in at risk groups

• Identifying at risk patients having

– Surgical procedures – Contrast based interventions

• Ongoing in hospital assessment

• Identifying the cause of AKI

• Referral to nephrology

Medics / Nephrologists

Medics / Nephrologists

Surgeons / Radiologists / Medics / Nephrologists

• Age >65 • Comorbidities

– Chronic Kidney Disease – Heart failure – Liver failure – Diabetes – Neurological / cognitive impairments (dependence re: fluids) – Sepsis – Previous AKI – Urological disorders / obstructive symptoms – Nephrotoxins (ACEI/ARB/NSAID/Gentamicin/Contrast)

At risk of AKI - NICE

Older patients, other systems suboptimal

Unable to drink adequately

Are infected

Have had this before

Structurally abnormal

Nasty drugs in the mix

Referral to Nephrology

• Discuss within 24h where any of:

– Possible specialist acute diagnosis e.g. vasculitis

– AKI with no clear cause

– Inadequate response to treatment

– Complications associated with acute kidney injury

– Renal transplant patient

– CKD stage IV or V

You don’t know why they have AKI

It’s not getting better / it’s getting complicated

They’re ours anyway – significant CKD / transplants

AKI – how to respond immediately

• Check potassium result – if high, urgent ECG! – High means >6.0

– If you have to send them to A+E – so be it!

• Assuming potassium is not an immediate problem: – Stop nephrotoxins (go through the drug chart….)

– Check fluid status

– Get a urine dipstix

• Ask for help (Medics / Renal)

Vasculitic rash

http://immuneweb.xxmu.edu.cn/

AKI – things you might be asked

• Renal SpR is usual contact point (hospital switchboard)

• Creatinine results (with dates) • Urea result, evidence of uraemia (flap?!) • K+ (and maybe Bicarb) results • BP and P • Respiratory distress (O2 sats, RR) • Urine output, urine dipstix result • Drug history