Acute Kidney Injury; A case study with detailed etiology and management

1. Acute kidney Injury
Presenter: Taremwa Ronald JHO

2. Case Scenario
MF, 57 yo F, newly Dx ISS, ART naive, referral from
Entebbe Regional Referral Hospital for dialysis
Managed at peripheral clinic for Severe malaria with no
noted improvement hence referral to Entebbe and
subsequently KNRH. .
Presented with :
Loss of conciousness 1/7
Decreased urine output 2/7
vomiting 3/7

3. HPC
• Loc preceded by fever, headache then later
confusion with uncodinated speech however no
convulsions, neck stiffness, photophobia limb
weakness paraesthesias.
• Also reported non bloody vomiting around
3times/day of small volume, anorexia but denied
loose stool
• Decreased urine output, tea coloured, denied
dysuria , Increase in frequency

4. Clinically:
VITALS:
BP- 104/60mmHg, Pulse Rate 75 b/m, RR 18b/m,
Temp 36.4c , Spo2 95%, GCS 8/15
RBS 6.5 mmol/L, urine output 100ml/48hrs
General exam: Unconscious, afebrile, moderate
pallor, mild jaundice, mild dehydration, Echymoses,
no edema, no respiratory distress.
CHEST: clear, HS 1+2+0
CNS: GCS 8/15, neck soft , PEARL,

5. Investigations
• Bs mps: ++ seen
• CBC: HB 7.1 g/dl, MCV 82.8 fl, thrombocytopenia
(45), lymphocytosis 5.61
• RFT:
• Se creatinine 987umol/L, Se urea 26.7
• HCO3 19.9 mmol/L, normal K+, Na+
• Urinalysis: pus cells++, trace protein
• Cd4 196 cells per microliter, Se crag +ve, csf crag -
ve, TB lam negative.

6. MGT
• Iv artesunate 180 mg q12h for 3 doses then
Ducotecxin (3×1) for 3/7
• Iv paracetamol 1g q8h 3/7
• Iv NS: D5 500 MLS 1:1 q6h
• Iv levofloxacin 500mg OD 5/7
• P.O CTX 960 mg 1/12
• NGT FOR FEEDING
• Urine output monitoring, RBS monitoring, daily RFT
• Hemodialysis: 5 sessions

7. • Acute kidney injury (AKI) is an abrupt decreas
e in kidney function
• Results in;
– retention of urea and other nitrogenous waste pro
ducts and in the
– dysregulation of extracellular volume and electrol
ytes.

8. • The Kidney Disease Improving Global Outcom
es (KDIGO) definition and staging system is the
most recent and preferred definition
• Other criteria include the RIFLE criteria (Risk, I
njury, Failure, Loss of kidney function, and End
-stage kidney disease)

9. The KDIGO guidelines define AKI as follows
• Increase in serum creatinine by ≥0.3 mg/dL (≥
26.5 micromol/L) within 48 hours, or
• Increase in serum creatinine to ≥1.5 times bas
eline, which is presumed to have occurred wit
hin the prior seven days, or
• Urine volume <0.5 mL/kg/hour for 6 hours

10. RIFLE classification: ARF lancet 2005 vol 365
GFR criteria Urine output criteria
Risk Serum creatinine increased 1·5 times <0·5 mL kg–1 h–1
for 6 h
Injury Serum creatinine increased 2·0 times <0·5 mL kg–1 h–1
for 12 h
Failure Serum creatinine increased 3·0 times <0·3 mL kg–1 h–1
for 24 h or anuria
for 12 h
Loss Persistent acute renal failure; complete
loss of kidney
function for longer than 4 weeks
End stage
renal failure
End-stage renal disease for longer
than 3 months

13. CLINICAL FEATURES
• • Decreased urine output (oliguria) or complete
lack of urine production (anuria).
• Changes in urine color
• • Edema
• • Nausea, vomiting, and loss of appetite.
• • Confusion or altered mental state.
• • Shortness of breath

14. History with special attention to
– Last known serum creatinine
– New medications ,
– Over the counter medications, herbal
– Radiocontrast studies
– Fatigue, fever, skin rash , arthralgia

15. Investigations

16. • Etiology; ANA, anti dsDNA, ENA, p anca,
c anca, anti GBM, c3,4,Ck, ASO,
HBV/HCV, RF, uric acid, Ig, SpE, UpE,
urine esinophils, cryoglobulin.
• Microbiology: blood c&s, urine c&s
• Imaging: U/S . Aortorenal angiography to
rule out renal artery stenosis and renal
atherothrombotic disease
• Special: CXR, Echo, Renal biopsy

17. Features suggestive of CKD
• Known elevated serum creatinine in the past
• Presence of anemia
• Presence of hyperphosphatemia
• Small kidneys on renal ultrasound

18. •MANAGEMENT
• In addition to treating the underlying etiology,
maintenance of volume homeostasis and
• correction of biochemical abnormalities remain the
primary goals of AKI treatment
• supportive care may include the following
measures:
• • Correction of fluid overload with loop diuretics
and fluid restriction
• • Correction of severe acidosis with alkali
administration
• • Correction of life-threatening hyperkalemia
• • Correction of hematologic abnormalities (eg,
blood loss anemia, uremic platelet dysfunction)

20. Restrict salt intake (<2 g or half teaspoonful daily)
Restrict potassium intake e.g. oranges, bananas,
vegetables, meat, fizzy drinks
Moderate protein intake
Ensure adequate calories in diet
Check urine and electrolytes frequently

21. Treat any complications (e.g. infections,
hypertension, convulsions), adjusting drug
dosages according to the clinical response where
appropriate
If oliguria, furosemide IV according to response
(high doses may be necessary)