Abeer elnakera
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Abeer elnakera

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  • There is no evidence that pharmacological interventions are effective in protecting renal function during surgery.
  • There is no evidence that pharmacological interventions are effective in protecting renal function during surgery.
  • There is no evidence that pharmacological interventions are effective in protecting renal function during surgery.
  • Several Studies show that AKI progression is reversible by appropriate interventions implemented in the early stages of the disease. This finding has prompted interest in identifying diagnostic biomarkers for early AKI detection.
  • Interleukin-18:Urine IL-18 increased at 4-6 h after CPB, peaked at over 25 fold at 12 h, and remained markedly elevated up to 48 h after CPB. NeutrophilGelatinase-Associated Lipocalin:The urinary NGAL at 2 h after cardiopulmonary bypass was a powerful independent predictor of AKI.Kidney Injury Molecule-1 (KIM-1):An advantage of KIM-1 over NGAL is that it appears to be more specific to ischemic or nephrotoxic kidney injury and is not significantly affected by chronic kidney disease or urinary tract infections.Tubular Enzymes:Measurement of tubular enzymuria is inexpensive and easy to measure.Cystatin C:Serum cystatin C increased by more than 50% at 0.6 days earlier than the increase in serum creatinine, but it’s not highly specific for renal injury.
  • It offers high volume ultrafiltration using replacement fluid
  • CVVHDs are new modifications of continuous replacement therapy, most useful in patients who are haemodynamically compromised. They offer a smooth way of instituting dialysis treatment where conventional dialysis is difficult to perform
  • This mode is used where large amounts of fluid are removed and replaced per hour, as a means of ‘cleaning’ the plasma, for example to remove inflammatory cytokines
  • CAVHD was developed to augment the solute clearances obtainable with continuous arteriovenoushaemofiltration (CAVH). Although CAVH provides excellent volume control, solute clearances are frequently insufficient to provide satisfactory control of azotemia, particularly in hypercatabolic patients.

Abeer elnakera Abeer elnakera Presentation Transcript

  • Presented By Abeer elnakera Lecturer of anesthesiaFaculty of Medicine-Zagazig University RC (UK)
  • ObjectivesTo• Describe RIFLE classification of AKI• Identify the risk factors and causes of AKI after cardiac surgery• Explain how to – Predict – Prevent and – Manage acute renal injury after cardiac surgery RC (UK)
  • Introduction Acute kidney injury (AKI) following cardiac surgery with cardiopulmonary bypass (CPB) is a serious complication associated with high morbidity, mortality and resource utilization. The incidence of cardiac surgery- associated AKI (CSA-AKI) in Canada ranged between 5-30%. RC (UK)
  • Acute Renal Injury and Cardiac SurgeryRIFLE classification defines: Three grades of increasing severity of acute kidney injury which are:  Risk (class R).  injury (class I).  failure (class F). Two outcome classes:  Loss and end-stage kidney disease. RC (UK)
  • Acute Renal Injury and Cardiac SurgeryRisk: In which there is increased creatinine×1.5 from base line and there is 25% reduction in GFR and urine output become<0.5 ml/kg/h over 6 h.Injury: In which there is increased creatinine 2 from base line and there is 50% reduction in GFR and urine output become<0.5 ml/kg/h over 12 h.Failure: In which there is increased creatinine 3 from base line and there is 75% reduction in GFR and urine output become <0.3 ml/kg/h over 24h. RC (UK)
  • Acute Renal Injury and Cardiac SurgeryLoss: Persistent acute renal failure(ARF). Complete loss of kidney functionfor> 4 weeks.ESRD: End stage kidney disease> 3months. RC (UK)
  • Acute Renal Injury and Cardiac SurgeryUnderlying Causes of Acute Renal Failureafter cardiac surgery:•Hypoxia, hypotension, hypovolemiaand dehydration.•The imbalance between pro and anti-inflammatory cytokines. RC (UK)
  • Acute Renal Injury and Cardiac SurgeryPre-operative Risk Factors Elderly and female patients. Obesity (BMI>30kg/ m2). Low left ventricular ejection fraction, Congestive heart failure (CHF), presence of extra cardiac arteriopathy and the need for intra-aortic balloon pump (IABP) RC (UK)
  • Acute Renal Injury and Cardiac SurgeryPre-operative Risk Factors (cont.): Insulin dependent diabetes mellitus Pre-operative significant reduction in creatinine clearance. Pre-operative medications like ACE inhibitors which has been associated with a 28% increase in post-operative AKI in cardiac surgery patients. RC (UK)
  • Acute Renal Injury and Cardiac SurgeryOperative Risk Factors: Non-isolated CABG surgeries and emergency/salvage operations. Complex cardiac cases including aortic root replacement, aortic surgery and simultaneous CABG with valve replacement carry higher risk of CRRT than CABG alone. RC (UK)
  • Acute Renal Injury and Cardiac SurgeryCardiac Risk Scoring System:High mean EURO score and Parsonnet score can predict the need for CRRT after cardiac surgery. RC (UK)
  • Acute Renal Injury and Cardiac SurgeryOperative Risk Factors (cont.): Prolonged CPB time. The increase in the length of cross-clamp time >2hrs. The increased number of red blood cell units given. RC (UK)
  • Effect of Cardio-Pulmonary Bypass On Renal Function CPB is associated with the precipitous fall in MAP upon commencement of CPB which causes activation of renin- aldosterone system and sympatho- adrenal axis, leading to increased sodium retention and renal vasoconstriction. RC (UK)
  • Effect of Cardio-Pulmonary Bypass On Renal Function Other vasoactive substances released during CPB include complement, kallikrein and bradykinin contribute to generalized inflammatory response that increases capillary permeability. RC (UK)
  • Effect of Cardio-Pulmonary Bypass On Renal FunctionHemodilution with CPB:The incidence of ARI is higher with severe hemodilution (nHct <21%) and mild hemodilution (nHct >25%).Hypothermia during CPB:All studies suggest that hypothermia is not detrimental to renal function. RC (UK)
  • Acute Renal Injury and Cardiac Surgery Early Post Operative Risk Factors Increase Post Prolonged post- Post operative operative operative pulmonaryextubation time. ventilation. complication. RC (UK)
  • Prevention of AKI after Cardiac Surgery A practical approach to Perioperative renal protectionPreoperative:1. Optimize volume status, cardiac output and systemic arterial pressure.2. Withhold nephrotoxic drugs.3. Maintain adequate glycaemic control in diabetic patients.4. Correct metabolic and electrolyte disturbances.5. Delay surgery until recovery of acute renal dysfunction if possible.6. Arrange pre-operative dialysis for dialysis-dependent patients.7. Administer isotonic i.v fluids and N-acetylcysteine for prevention of radiocontrast-induced nephropathy. RC (UK)
  • Prevention of AKI after Cardiac Surgery A practical approach to Perioperative renal protection (cont.)Intraoperative:1. Optimize volume status, cardiac output and systemic arterial pressure.2. Avoid nephrotoxic drugs.3. Consider maintaining adequate glycaemic control in all patients.4. Maintain adequate flow and mean systemic arterial pressure during CPB.5. Limit the duration of CPB.6. Avoid excessive haemodilution.7. Avoid red cell transfusion.8. Consider extra-corporeal leucodepletion.9. Consider haemofiltration during CPB.10. Consider off-pump coronary artery bypass surgery. RC (UK)
  • Prevention of AKI after Cardiac Surgery A practical approach to Perioperative renal protection (cont.)Post-operative:1. Avoid nephrotoxic drugs.2. Maintain adequate glycaemic control in all patients.3. Promptly treat acute cardiac dysfunction.4. Control haemorrhage.5. Manage sepsis aggressively.6. Recognize and treat rhabdomyolysis.7. Recognize and treat intra-abdominal hypertension.8. Provide appropriate organ support for multiple organ dysfunction syndrome.9. Institute renal replacement therapy for RIFLE grade F acute renal dysfunction. RC (UK)
  • Prediction of AKI after cardiac surgery• Progression is reversible when early appropriate interventions implemented diagnostic biomarkers early AKI detection. RC (UK)
  • Diagnosis of AKI after Cardiac SurgeryCharacteristics of an Ideal Biomarker: Should be non invasive (blood or urine sample), easily measured, inexpensive and produce rapid results. Highly specific. Highly sensitive. RC (UK)
  • Diagnosis of AKI after Cardiac SurgerySome of the Biomarkers Used forDiagnosis of AKI:•Interleukin-18•Neutrophil-Gelatinase-AssociatedLipocalin (NGAL)•Kidney Injury Molecule-1 (KIM-1)•Tubular Enzymes•Cystatin C RC (UK)
  • Treatment of AKIIndications for RRT:The usual renal indication for RRT: Fluid overload unresponsive to diuretic treatment. Hyperkalaemia (>6.5 mmol/L or rapidly rising level). Azotaemia (urea>36 mmol/L). Sever acidaemia (PH<7.1). Oliguria (urine output<200ml in 12 hours) or anuria (urine output<50ml in 12 hours). Uraemia complication like bleeding, pericarditis or encephalopathy. RC (UK)
  • Treatment of AKIIndications for RRT (cont.):Non renal indication for RRT: Removal of endogenous toxins as in severe lactic acidosis. Patients requiring a large amount of fluid, parenteral nutrient or blood product but at risk of developing pulmonary oedema or acute respiratory distress syndrome (ARDS). Heart failure. Hyperthermia or hypothermia (core temperature>39.5c or<30c). Severe dysnatraemia (Na>160mmol/L or<115mmol/L). Sepsis and other inflammatory syndromes as ARDS to remove the inflammatory mediators by hemofiltration. RC (UK)
  • Treatment of AKI Continuous renal replacement therapy(CRRT) is often the preferred choice overintermittent renal replacement therapy(IRRT) and peritoneal dialysis in the ICU. RC (UK)
  • Treatment of AKICVVH set RC (UK)
  • Treatment of AKICVVHD set RC (UK)
  • Treatment of AKICVVHDF set RC (UK)
  • Treatment of AKICAVHD set RC (UK)
  •  The pathogenesis of kidney injury during CPB is complex and involves hemodynamic and inflammatory mechanisms Intravascular volume expansion, maintenance of renal blood flow and renal perfusion pressure, avoidance of nephrotoxic agents, strict glycemic control and appropriate CPB management are highly efficient measures for renal protection Early prediction and establishment of CRRT are beneficial RC (UK)
  •  Early prediction Usage of the off-pump technique when possible. Perioperative renoprotective measures Early establishment of CRRT when indicated RC (UK)
  • RC (UK)