Acute Kidney Injury

Dr Alexis Missick
FY2

Presentation

Case
Objectives
Definition & Aetiology
Investigation
Management
Complications

Clinical Scenario
History: 55 year old lady presents to A&E with a 5
day history of diarrhoea and vomiting. She
believes this was caused by a Chinese take away
she had a day before developing symptoms. She
has been unable to keep anything down including
water and now feels very poorly.
PMHx: HTN managed with ramipril.
SHx: non-smoker, drinks alcohol occasionally.
O/E: she appears very dry and has reduced skin
turgor. BP is 100/70 and HR 95. Examination is
otherwise unremarkable

Differentials?

Clinical Scenario
History: 55 year old lady presents to A&E with a 5 day history
of diarrhoea and vomiting. She believes this was caused by a
Chinese take away she had a day before developing
symptoms. She has been unable to keep anything down
including water and now feels very poorly.
PMHx: HTN managed with ramipril.
SHx: non-smoke, occasional alcohol.
O/E: she appears very dry and has reduced skin turgor. BP is
100/70 and HR 95. Examination is otherwise unremarkable

Ix: normal FBC, Na 149, K 6.7,

Urea 17.0 and Creatinine 258

Objectives
Recognition of AKI
Learn classification of causes and
common examples
Identification of appropriate
investigations
Understand principles of
management of AKI
Knowledge of indications for dialysis
Awareness of complications and
management of hyperkalaemia

Definition
Rapid impairment in renal function resulting in raised
plasma urea/creatinine, fluid and/or acid-base imbalance
which is reversible.
AKIN Criteria for diagnosis of AKI
1. Time course rapid (<48hours)
2. Reduction in Kidney function
1. Rise in serum creatinine (absolute increase of >0.3mg/dl or
percentage increase of > 50%)
2. Reduction in urine output (<0.5ml/kg/hr for >6hours)

. RIFLE criteria (prosposed by ADQI) for staging of AKI:

Risk, Injury, Failure, Loss, End stage kidney disease

Staging RIFLE Criteria

Proposed by ADQI
Severity (Stage 1-3)

Risk: GFR decrease >25%, serum creatinine

increased 1.5 times OR urine production of
<0.5 ml/kg/hr for >6 hours
Injury: GFR decrease >50%, doubling of
creatinine OR urine production <0.5 ml/kg/hr
for 12 hours
Failure: GFR decrease >75%, >tripling of
creatinine or creatinine >355 mol/l
(>4mg/dl) OR urine output below 0.3 ml/kg/hr
for 24 hours

Outcome

Loss: persistent AKI or complete loss ofkidney

function for more than 4 weeks
End-stage renal disease: need for renal
replacement therapy (RRT) for more than 3

Aeitology

http://www.medicalassessmentonline.net/terms.p

Presentation
Symptoms

Malaise
Anorexia, Nausea and Vomiting
Pruritis
Dehydration
Confusion, convulsions

Signs
Hypertension
Fluid overload: peripheral oedema, SOB/
bibasal crackles/raised JVP
Dehydration: postural hypotension, poor urine
output (palpable bladder)

Investigations
Bedside: BP (lying and standing), urine dip
(?haematuria ?proteinuria), ECG
Biochemistry: ABG, FBCs, U+Es, LFTs,
CRP/ESR, Ca2+, blood culture
Imaging: CXR, USS KUB or CT KUB
Special tests:
CK, blood film, Myeloma screen (Bence-Jones protein), Renal
Screen (ANA, ANCA, anti-BM)
Urine osmolality and cast cells
Renal biopsy
Doppler Renal USS and/or Angiography

Management
Assess fluid status
Fluid resuscitation
Stop nephrotoxic drugs
Treat the cause
Infection give antibiotics, renal doses
Intrinsic renal disease R/v medication
Obstruction- ?catheters ?calculus
removal ?nephrostomies ?surgery

Complications Indication for

Immediate Dialysis!!
Hyperkalaemia
(persistent >7mmol/L)
Metabolic Acidosis
(if pH<7.2,
bicarbonate <12)
Pulmonary Oedema
(refractory)
Pericarditis
Symptomatic ureamia
- Encephalopathy
http://homeopathyexpert.blogspot.co.uk/2011/05/chronic-renalfailure.html

Hyperkalaemia
Potassium range is 3.5 5mmol/L
Rise in serum K+ >5mmol/l
Signs/symptoms: muscle weakness
ECG changes:
Flattened P waves
Broad QRS complex
Slurring of ST segment
Tall tented T waves
http://www.aafp.org/afp/2006/0115/p283.
html

Hyperkalaemia
Potassium >6.0 mmol/L
Calcium resonium 15g QDS PO
If septic or rising quickly treat as though
K+ 6.5

Potassium >6.5 mmol/L

Dextrose-insulin (50ml 50% Dextrose
with 10units Actrapid insulin, IV over
5mins) Monitor BM
Calcium resonium 15g QDS PO

Hyperkalaemia
Potassium >7 mmol/L
Calcium gluconate (10ml of 10% solution into
central vein or diluted into 40ml 0.9% saline
into peripheral vein over 10mins, with cardiac
monitor)
Dextrose insulin
Nebulised salbutamol 5mg
IV sodium bicarbonate (50ml 8.4% over 5mins
centrally or 500mls 1.26% over 30mins
peripherally
Calcium resonium