【持续性肾脏替代治疗crrt英文精品课件】acute kidney injury （aki）

Acute Kidney Injury,Bamgbola, OF Childrens Hospital/ LSUHSC New Orleans,Definition of AKI,an abrupt but sustained decline in renal function occurs over few hrs or days; retention of nitrogenous toxins loss of fluid, electrolytes + acid-base homeostasis Impaired GF = oliguria; tubular injury = polyuria Epidemiol data often inaccurate b/c of variation in definition 30 in literatures,AKI definition: pRIFLE,AKI Network consensus definition: modified RIFLE To standardize clinical evaluation + research studies The pediatric version of RIFLE criteria Table 1 AKI is graded into 3 by impaired CrCl + reduction in UOP Acute renal loss and ESKD are outcome variables,Pediatric RIFLE criteria,Early Phase,Acute Kidney Failure,Late Phase,ESKD,Kidney Loss,Acute Kidney Injury,Acute Kidney Risk,Pediatric RIFLE Classification of Acute Kidney Injury,25% loss GFR and/ or Oliguria x 8 hr,50% loss GFR and/ or 12 h Oliguria,75% loss GFR and/ or 24 h Oliguria/ Anuria,AKF X 1 mo,AKF X 3 mo,Ultrasound Illustration of Normal LEFT and Echogenic RIGHT Kidneys,Acute kidney Injury,What size? 10.4 cm 10.9 cm 08.9 cm 12.1 cm,Pre-renal azotemia: pathophysiology,Adaptive response to low renal perfusion Corresponds to stage I-II early AKI pRIFLE BP maintained by CNS sympathetic-outflow; stimulates RAAS VP and aldosterone cause salt + water retention,Hypovolemia CHF Nephrotic syndrome Hepatorenal syndrome Mal-distributive shock,Pre-renal Azotemia: pathophysiology,PG E2R,Ang II (R),Filtration fraction,HYPOVOLEMIA AND RENAL AUTOREGULATION,Acute Kidney Risk: Pre-renal Azotemia,Reversible by prompt restoration of renal perfusion Prolonged hypoperfusion causes renal decompensation Excessive SNS & RAS results in ischemic injury. Dys-autoregulation: Tacrolimus, NSAID and ACEi,Intrinsic AKI: pathogenesis,Corresponds to stage II-III early AKI pRIFLE. Etiologies: HUS, GMN, ATN, TN, IN + UTO. ATN + MOFS (as in sepsis) ses MR by 7 folds ATN: Ischemic depletion of ATP, release of ROS and apoptosis cell desquamation, obstructive cast, and backleak of t/ fluid often reversible; with regeneration of tubular EC,Case illustration,35-yr-old F was on treatment for HBP. Preg on coil recognized at 4 mo. The BP medication was discontinued. She had oligohydraminos at 33 wks GA. Due to pre-eclampsia CS was performed at 34 wks. BW was 2.2 kg; Apgar score was normal; No UOP by 40 hrs,What additional HISTORY do you need to determine the reason for poor UOP?,Additional information to determine reason for OLIGURIA,Accurate IP and OP; record accurate Most NB make urine at delivery; 90% UOP in 24 hrs and 100% by 48 hrs Inadequate fluid intake; 75 cc/kg infant formula 80-120 kcal/kg/d = 15-20 mOsm/kg/d requires 60-80 cc/kg/d of fluid to maintain solute excretion Insensible water loss; not significant TBW 75-90% of Wt vs 60% for AD; thin skin prematurity; ambient temp; respiratory distress assisted ventilation.,Additional history.,Extra-renal losses: None Emesis, Diarrhea assess DHN: capillary refill 2s, AF nl, BP nl Ineffective blood circulation or low cardiac OP: None Sepsis + endotoxemia; CHF TGA, PDA; critical AS Gender of the patient: male Obstructive uropathy from PUV Manual bladder palpation Bladder US examination,Etiology of obstructive uropathy? a) UPJO b) Urethral diverticulum c) Bladder neck obstruction d) Post Urethral Stenosis,Diagnostic studies,Lab studies: s/Cr 1.5 at 24 h Moms Cr 1.7; s/Cr 1.7 at 48 h. Any concern? Peak s/Cr was 5.8 mg/dl at day 4. Renal US and Doppler Flow were normal. NS + Furosemide challenge: no UOP Fluid restricted to IWL Spontaneous UOP on day #3 Plasma telmisartan on day # 10 = 20 ng/l. s/Cr 0.8 mg/dl at D/C on day 18 + 0.5 mg/dl at 1.5 mo.,Doppler ultrasonography in AKI,Reversal of diastolic flow 4 hr after KTX,Normalization of diastolic flow 7 d later,DIAGNOSIS: MATERNAL EXPOSURE TO ANGIOTENSIN II RECEPTOR BLOCKER,Telmisartan is an ARB; 99.5% bound to protein + hepatic conjugation + 97% biliary excretion If no spontaneous renal recovery; may treat with Peritoneal dialysis Hemodialysis CRRT Plasmapheresis None of the above,Case Illustration,11 yr old AAF presented at a local ER anorexia, sleepiness and 5 kg wt loss over 5 mo Frequent emesis, diarrhea and body weakness for 3 d Use of apple cider vinegar + enzyme supplement Question: What in history suggest a dx of kidney injury?,Anorexia: brain anorectic serotonin + reduces NPY appetite stimulant CKD: Wt loss from low calorie + inflam cytokines (IL-1), anemia + MA OTC drug therapy: herbal medications, NSAID Fluid deficit + body weakness Question: If this is acute on CKD, what are the expected physical and lab findings?,Answers: History suggestive of kidney disease,Answers: Acute on CKD; the expected Px / lab findings,Dehydration: extra-renal or renal fluid loss Oliguria: fluid retention, PE or HTN CHF, NS, AIN Anemia (EPO def in CKD and/ or dilutional in AKI) 1, 25-vit D deficiency + 20 HPTH in CKD = hypocalcemia Elevated Cr, HyperPP, hyperK, and metabolic acidosis metabolic acidosis causes lethargy + hyperventilation Acidosis causes EC shift of K,Physical findings in the patient,Normal mental status, pallor + mild DHN T 990F, PR 75, RR 20 anemia, PE, MA, BP 162-177/100-115 mmHg Ht was 153 cm + wt 59 kg baseline = 64 kg. Other Px findings NS. Hb 8.1 g/dl; Na 137, K 2.6, Cl 97, HCO3 19, BUN 73, Cr 8.7, Ca 4.3, P 9.6, alb 2.8 Corrected Ca = 4 2.8 x 0.8 = 0.96 + 4.3 = 5.2 Urine: SG = 1010; Pr 300 mg/dl UPr/ Cr = 300/18 = 16 EKG: prolonged QTc; Echoc = reduced vent. contractility,Determine the stage of kidney INJURY using pRIFLE criteria,Calculate GFR (cGFR) by Schwartz formula is: Calculated GFR = k x Ht (cm)/ SCr (mg/dl) = 0.44 x 153 / 8.7 = 7.7 ml/min/1.73 m2 Calculate the % loss in GFR % loss in GFR = Expected GFR Calculated GFR / Expected GFR x 100 = 127 7.7 / 127 x 100 = 94% Expected GFR = normal GFR for age,Pediatric RIFLE criteria,Thus she has Acute kidney failure + and duration likely 5 mo Therefore ESKD; chronic dialysis is most probably required.,Immediate + long term therapeutic concerns?,Normal mental status, pallor + mild DHN T 990F, PR 75, RR 20, BP 162-177/100-115. Ht was 153 cm + wt 59 kg baseline = 64 kg. Other Px findings NS. Hb 8.1 g/dl; Na 131, K 2.6, Cl 97, HCO3 19, BUN 73, Cr 8.7, Ca 4.3, P 9.6, alb 2.8 EKG: prolonged QTc; ECHO = reduced vent. contractility,Immediate + long term therapeutic concerns?,Fluid deficit Fluid bolus: Yes or No VOTE Caution: Severe HTN = BP 162-177/ 100-115 mmHg Anemia = Hb 8.1 gm/dl Hypoalbuminemia: alb = 2.8 Cardiac insufficiency: prolonged QTc; impaired contractility BUN/ Cr ratio = 73/ 8.7 = 8.4 10:1; non pre-renal Urine indices: UNa = 65 mEq/l; USG 1010; U/Osm = 325; UCr = 19 FENa = UNa/ PNa x PCr/ UCr x 100 = 65/ 131 x 8.7/ 19 = 22,Diagnostic urine indices: pre-renal vs. intrinsic kidney injury,FENa = Urine Na/ Plasma Na x Plasma Cr/ Urine Cr x 100,Immediate + long term therapeutic concerns?,Correct anemia: Yes or No vote symptomatic? tachypnea/ hypoxic cardiac toxicity fluid overload? Give PRBC slowly + ?Lasix or dialysis,Depletes Ca, K,Immediate + long term therapeutic concerns?,Correct metabolic acidosis: Yes or No? HC03 may ppt hypoCa tetany + worsen fluid retention Severe HTN: reduce by 50% over 24 hrs with oral agents. If HBP emergency, give IV nicard, labetalol or nitropusside. Cardiac toxicity (long QT): correct hypoCa After clinical stability, insert HDC for acute dialysis. Chr dialysis: anemia, Vit D def, hyper-P, HBP + PEM,Cell degeneration,Tamm-Horsfall Protein+EC = Cellular casts,Granular casts,Hyaline casts = ATN, NS,CKD,Waxy cast,Fine granular,AKF,Clinical MX: Early (or pre-renal) AKI,To prevent late stage AKI prompt fluid tx mandatory forced diuresis + ionotropic supports in CHF Correct fluid deficit + pressor agents in sepsis syndrome repair fluid deficit + hyperglycemia in DKA Restore oncotic pressure (25% alb/ lasix) in severe NS Avoid nephrotoxic agents: NSAID, contrast agents + AG Abx Higher risk of injury in pre-existing KD/ solitary kidney,Fluid Mx in early (or pre-renal) AKI,Fluid bolus to correct peripheral CF Fluid choice: Crystalloids NS/ LR; colloids alb + dextran Rehydrate: mild, mod and severe DHN Assess adequacy: MS, PR, BP, CVP + UOP Absent UOP in 2 hrs: examine for bladder distension urethral catheterization if urinary retention If no UOP or bladder distension, and CVP is 5-10 cm forced diuresis with 2-4 mg/kg furosemide. Failure suggests intrinsic AKI,Clinical MX: Oliguric late (or intrinsic) AKI,Tx modality depends on severity of GFR loss Fluid restriction: replace ongoing + IW losses. Larger fluid requirement during polyuric recovery phase Correct MA if pH is 7.1 or s/HCO3 12 mEq/L Avoid rapid correction: hypoCa tetany. If combined hyperK/ MA, correct by infusion of 1 mEq/kg NaHCO3 Forc