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The kidneys in critical care

The kidneys in critical care






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    The kidneys in critical care The kidneys in critical care Presentation Transcript

    • The Kidneys In Critical Care
      Dr HalaAbuzeid Ahmed, MRCP(Lon), FRCP(Lon), FRCP(Glasg), FRCP(Edin), MSc.(Lon), DTM&H(Lon), CCST(UK)
      Consultant in Critical care
    • Acute Kidney InjuryA disease Spectrum….
      Was acute renal failure!!!.
      Sudden decline in renal functions causing sudden decline in renal jobs, fluid, acid and electrolyte balance.
      Due to reduction in GFR, and small solute clearance
      Subclinical injury to complete organ failure
    • “The do no harm attitude”
      Significant morbidity and mortality
      $8 billion yearly as a cost in the USA
    • Epidemiology
      7% of hospitalized patients
      36-67% of ICU admissions
      5% of ICU patients with AKI require renal replacement therapy (RRT)
      Mortality increases with increasing severity,
      AKI is an independent risk factor for in hospital mortality
      Morbidity is associated with increase days of stay, cost, increased risk of chronic kidney disease
    • Definition of AKI in ICU
      35 Definitions exist!!!!!
      RIFLE (Risk, Injury, Failure, Loss, End stage kidney disease)
      AKIN (Acute Kidney Injury Network)
      AKIN doesn’t improve the sensitivity of diagnosis
    • Mortality Vs RIFLE
    • Causes
      The weeping kidney ( Bleeding)
      The drugged kidney
      The strangulated kidney
      The infected kidney
      The diseased kidney
      Kidneys and other organs, Hepatorenal Syndrome
      Kidneys and crush injuries, Rhabdomyolysis
    • Conventional Markers of AKI
      Serum Creatinine
      Fractional excretion of sodium
      Changes in urine output
    • Novel Biomarkers for AKI
      Should be easy to use, bed side use, non invasive
      Rapid, reliable
      High sensitivity to facilitate early detection
      IL18, NGAL (NeutrophilGelatinase-Associated Lipocalin, KIM-1 (Kidney Injury Molecule)
      Only tested in small clinical studies and in limited clinical situations
    • Prevention of Kidney Injury
      Goals :
      To preserve renal function and to prevent complications such as fluid overload, electrolyte imbalance, progression to CKD, and death.
      Conservative strategies :
      Prevent dehydration, Hypotension, exposure to nephrotoxins
      Adequate fluids, maintaining MABP, avoid nasty drugs
    • Hydration in ICU
      Important in the initial phase of AKI
      Be ware of ARDS: positive fluid balance is a risk factor of mortality
      CVP monitoring
    • Maintaining Renal perfusion pressure
      Targets: COP, CVP, UOP
      Goal directed therapy, volume expansion
      Sepsis and leak of capillaries
      Organ edema and poor perfusion, ischemia
      IAP leading to more renal shortage
    • Abdominal Compartment Syndrome
      Abnormal >12mmHg
      MABP, IAP and abdominal perfusion pressure
      Similar to CPP and ICP/CVP
      Increased IAP oliguria, and renal injury occur
      Relieving the abdominal compartment by laparatomy is the standard
    • Nephrotoxins
      Aminoglycosides contribute to 19-25% of cases of severe renal failure
      Cell death and decreased GFR
      Amphotericin B, causes AKI in 30%
      Vancomycin 30%
      Drug levels, trough levels and dosing frequency
    • Radiological Contrast Media
      Increase in serum creatinine in the first 24 hrs following contrast administration and peaks after 3 days
      Specific risk factors include DM, CCF, Volume depletion, nephrotoxic drugs, and unstable heamodynamics
      Use of low osmolality agents, Naceytelcysteine
    • Pharmacology to Prevent AKI
      Use of loop diuretics, Controversial !!
      May be should be tailored to the patient according to heamodynamics
      Dopamine: No Role!!!
      Increases the renal blood flow by splanchinicvasodialtion and increasing COP and improving perfusion pressure
      But it doesnot improve mortality
    • Natriuretic Peptides
      Been evaluated in cardiac surgery
      In low doses
      Small studies
      May decrease the need for dialysis
    • N-acetylcysteine
      Decreased CIN
      Nacetylcysteine with Fenoldopam (selective dopamine receptor stimulator) may have a better outcome
    • Renal Replacement Therapy for AKI
      Intermittent Haemodialysis / CRRT
      No overall difference in outcome
      Fluid volume excess
      Metabolic acidosis
      Drug overdose
    • Summary
      AKI is a serious and common in the ICU
      Even in mild forms it is associated with high mortality
      A new classification system is to identify kidney injury and outcome
      New biomarkers Vs conventional biomarkers
      Methods to prevent AKI are the BASICS!!
    • Thanks