Acute Kidney Inj ury Focus on Perioperative S etting Oct ober 10, - - PowerPoint PPT Presentation
Acute Kidney Inj ury Focus on Perioperative S etting Oct ober 10, 2018 Banff, Albert a Disclosures Part icipat e in a research group wit h funding from several sources including indust ry funding is at arms lengt h, no overlap wit h
Oct ober 10, 2018 Banff, Albert a
Part icipat e in a research group wit h funding from several sources including indust ry – funding is at arms lengt h, no overlap wit h AKI
A lot of t he dat a discussed t oday is populat ion dat abase derived- met hodology varies , definit ions vary, and analysis varies. I am aware of t he issues but am not an expert in t hese met hodologies.
Increase awareness of t he import ance of AKI event s and survivors
Review some aspect s of diagnosis and management
Review some emerging processes in diagnosis and management
Meht a RL, et al. Lancet 2015; 385: 2616-2643 S usant it aphong P et al. Clin J Am S
RIFLE (2004), AKIN (2007), KD:IGO (2012)
Consensus Definitions for AKI criteria Stage Serum Creatinine or eGFR Urine Output RIFLE KD:IGO AKIN RIFLE KD:IGO AKIN
Risk 1 Increased sCr ≥ 1.5 x baseline or GFR > 25% Increased sCr 1.5 – 1.9 x baseline within prior 7 days
Increased sCr x 26.4 µmol/ L [0.3 mg/ dl] within 48 hours
< 0.5 ml/kg/h ≥ 6 h
Inj ury 2 Increased sCr ≥ 2 x baseline or GFR > 50% Increased sCr 2– 2.9 x from baseline
< 0.5 ml/kg/h ≥ 12 h
Failure 3 Increased sCr ≥ 3 x baseline or GFR > 75% ,
≥ 354 µmol/L], with an acute ≥ 44
µmol/ L Increased sCr 3 x from baseline,
≥ 354 µmol/L, with an acute ≥ 44
µmol/ L
receiving RRT
< 0.3 ml/kg/h ≥ 24 h
anuria ≥ 12 h
Bellomo R, et al. RIFLE. Crit Care 2004; 8(4): R204-12 Meht a RL, et al. AKIN. Crit Care 2007; 11: R31-38
Minj ae K et al Anest hesia & Analgesia 2014; 119(5): 1121-1132
S usant it aphong P et al. Clin J Am S
Definition:
“ abrupt and sustained decrease in glomerular filtration, urine output, or both.”
S ubclinical AKI
does not meet AKI criteria and Biomarker concentration increased
AKI
Meets AKI criteria and rapid reversal within 48 hrs up to 7 days (renal
recovery)
AKD
S
ustained reduced renal function > 7 days
CKD
S
ustained reduced renal function > 90 days
upplement s 2012; 2(S uppl 1): 19-36
Forni LG et al Int ensive Care Med (2017) 43:855– 866
Dedhia P and Thakar CV . Core Concept s in Acut e Kidney Inj ury. S . S . Waikar et al. (eds.) S pringer S cience+Business Media, LLC 2018
Deat h Deat h Deat h?
uppl 1): 19-36 Ferenbach DA and Bonvent re JV . Nephrologie & Therapeut ique 2016; 12S : S 41– S 48 Y ang Y et al. Pharmacology and Therapeut ics 2016;163: 58-73
Pannu N et al Clin J Am S
202 Bucaloui ID et al Kidney Int 2012; 81: 477-485 Heung M et al Am J of Kidney Dis 2015; 67(5):742-
No AKI AKI - R AKI- NR
Bihorac A et al Annals of S urgery 2009; 249 (5):851-858
Kork F et al Anest hesiology 2015; 123(6): 1301-1311
Normal kidneys wit h minimal risk can develop AKI
The more risk fact ors for AKI, t he great er t he risk for an AKI event
Wit h AKI t here is an increased risk of
S
hort erm and longt erm mort alit y,
repeat AKI, hospit al readmission, Incident CKD progression t o CKD and ES
RD
CKD is a significant AKI risk fact or
Hx:
Co-morbidit ies, prior AKI event s/ CKD, FHx, acut e clinical set t ing, Medicat ion exposure
Px:
Hemodynamic st at us, infect ion, sepsis, anemia, hypovolemia, chronic organ dysfunct ion (Heart , Lung,
Liver), presence of 3rd spacing
Invest igat ions:
urine dipst ick/ micro, +/ - renal U/ S
, and as indicat ed
Management
S
t op Nephrot oxins, renal dose remaining medicat ions
Volume resuscit at e, do not volume overload Serial follow-up; volume st at us, Cr/ eGFR, manage associat ed complicat ions Treat hyperglycemia Consult colleagues as required (Nephro, Cardio, hepat ol, ICU)
Ult rasonography should be performed:
when t here is no ident ified cause of acut e kidney inj ury when pt s present wit h risk fact ors/ sympt oms of urinary t ract obst ruct ion when an infect ed and obst ruct ed kidney is suspect ed, or when t hey are at medium or high risk of
Rout ine ult rasonography of t he urinary t ract is not required:
when a non-obst ruct ive cause of t he acut e kidney inj ury has been ident ified for pat ient s wit hout sympt oms of obst ruct ion, wit hout risk fact ors when at low risk of urinary t ract obst ruct ion based on t he risk scoring syst em
Provincial Clinical Knowledge Topic Acut e Kidney Inj ury, Adult – Inpat ient V 2.0 December 2017, page 7
Incidence overall 2-23% (more recent ly 2-9% ) (Albert a 20-30% )
Varies wit h set t ing – ICU, ward, surgery
ICU 22- 57% Medical ward (18%
)
Incidence of in-hospit al (non-ICU/ S urgical) AKI likely plat eauing (4% )
mort alit y rat es have generally fallen by 50% wit h and wit hout dialysis
Bellomo R et al. Lancet 2012; 380: 756-766 Host e EA et al. Int ensive Care Med 2015; 41: 1411- 1423 Finlay S et al. Clin Med 2013; 13(3): 233-238 Bihorac A, et al. Crit Care Med 2013; 41(11): 2570- 2583 O’ Neal JB et al. Crit Care 2016; 20: 187-195 G ME t l A J Kid Di 2016 67(6) 872 880
For general surgery 1-2% (7% )?
Higher risk surgeries:
Cardiac 15% Trauma 26% Transplant 71% Neuro 13%
AKI is associat ed wit h higher rat es of all post op complicat ions, including CV
Bellomo R et al. Lancet 2012; 380: 756-766 Host e EA et al. Int ensive Care Med 2015; 41: 1411-1423 Finlay S et al. Clin Med 2013; 13(3): 233-238 Bihorac A, et al. Crit Care Med 2013; 41(11): 2570-2583 O’ Neal JB et al. Crit Care 2016; 20: 187-195 Grams ME et al. Am J Kid Dis 2016; 67(6): 872-880 Wang HE et al. Am J Nephrol. 2012;35:349– 355
64 yr old male, married, ret ired handyman, present ing wit h sympt oms of bowel obst ruct ion x 24 hours and 6 mont h hx of int ermit t ent BRBPR) wit h progressive const ipat ion.
PMHx – HTN, obesit y, ex-smoker (age 57, 40+ pk yrs). Ret ired 7 years ago due t o chronic low back pain. Had gained 10 kg since t hen but loss 5 kg recent ly. No prior S x or hospit alizat ions.
FHx - Only child, mot her 84 (T2DM, HTN, Chol, CAD, prior TIA). Fat her died of lung cancer remot ely
Meds – perindopril 4/ 12.5, aodipine 2.5 mg (t ook yest erday) NKDA
ROS
dyspnea (t rue? ), no obvious OS A, no oral int ake last 24 hours
Non-drinker,
Vit als: 115/ 85 P 95 (reg) afebrile O2sat 93%
PX: conj unct iva pale, dist ended abdomen(BS ), JVP low, no S 3S 4, no carot id bruit , prolonged exp phase, no edema, no rash, no nodes, no hepat osplenomegaly
Lab: Cr 98, K 3.9, Na 132, CO2 21, Cl 96 ; Hgb 120, Plt 276, WBC 14, cholest at ic liver profile, albumin 38, INR/ PTT normal
What do you t hink his risk is high, low, somet hing else?
What are his risk fact ors for AKI?
What t o do preop?
Investigations interventions
Hypovolemia
Hypoalbuminemia
Advanced age >60, >75
Female
Black
Prior AKI
CKD (wit h or wit hout prot einuria)
DM
CHFrEF (35% cardiac S x) (50% CIN)
COPD
Cirrhosis
Hypotension
MM
CTD
Cancer
Sepsis
CIN
Drugs
General S x Cont rast Cardiac S x Communit y AKI
Wilson T et al. Nephrol Dial Transplant (2016) 31: 231– 240
Comparison of 3 perioperative AKI evaluations Biteker M et al 2014 Bell S et al 2015 Keterpal S et al 2009 N = 1200 prospect ive single acut e care facilit y 2010-2012 N = 10,615 (6220 development cohort , 4395 validat ion cohort ) N = 15,102 from 65,043 cs ret rospect ive single acut e care facilit y 2003-2006 AKI 6.7% N = 80 AKI 10.8 and 6.7 % AKI 0.8% N = 121 Age Age Age RCRI Male S ex Male DM DM DM AS A AS A CHF NS AID/ Cox-2 Renal insufficiency Tot al #of drugs Int raperit oneal S x ACEI/ ARB Ascit es Emergency S x
Bit eker M et al Am J of S urgery 2014; 207(1): 53-59 Ket erpal S et al Anest hesiology 2007; 107: 892-902 Bell S et al BMJ 2015;351:h5639
Age
Male
ACE-I
Hypovolemic
Intraperitoneal S x
Emergency S x?
What we added:
HgbA1C 6.3% Urine dispstick +1; ACR 22 Urinalysis
James MT et al Am J of Kidney Dis 2015 66(4): 602-612
Dipstic k ACR Neg <10 Trace 10-29 +1 30-299 +2 300-999
≥ +3 ≥ 1000
Part ridge JS et al Age and Ageing 2012; 41: 142– 147
TJA S ilva Clinics(S ao Paulo)2009 Jul; 64(7): 613– 618
Meas perioperat ive High-sensit ivit y TNT , TNI, CK-MB, and NT-proBNP in AKI high risk CV pt s:
≥ 1 of emergency surgery, preop sCr >177 mmol/L, ejection fraction ≤35% or less or
grade 3 or 4 left vent ricular dysfunct ion, age > 70, diabet es mellit us, concomit ant CABG and valve surgery, or repeat revascularizat ion surgery.
NT-proBNP had t he best predict ion rat e for post op AKI and 1 yr mort alit y.
Belley-Cot e EP et al Journal of Thoracic and Cardiovascular S urgery 2016; 152(1): 245-251
AKI risk assessment tools have not been externally validated and most have been focused on identifying severe AKI.
The largest group of AKI pts S tage 1, may be under appreciated and misdiagnosed
Post op AKI has significant short and longterm consequences on par with perioperative MIs
Identifying the AKI risk pt preop may help reduce postop incidence +/ or severity, LOS and readmission rates.
Preoperatively linking AKI risk assessment to risk reducing measures intra and post
Risk factors for AKI, MI, and frailty overlap in the elderly
Consider the usefulness of preop ACR , +/ - your NT-proBNP level in the right patient
Hypot ension
Anemia, Transfusion PRBCs
Prot ect ive measures
Time, MAP , BP sys t hresholds
Valmasi
Accumulative time > 90 min at ≥ 20% drop from preop sys BP If > 50% below preop sys BP for ≥ 5 min incr risk AKI/ MI
S un (ret rospect ive)
MAP < 60 for > 20 min; MAP < 55 for 10 min
Walsh
MAP < 55 incr AKI/ MI < 55 for 1-5 6-10 11-20 AKI HR 1.18; > 20 min HR 1.51
S un YS et al Anest hesiology 2015; 123: 515-523 S almasi V et al Anest hesiology 2017; 126: 47-65 Walsh M et al Anest hesiology 2013; 119(3): 507-515 Hallqvist L et al Eur J Anest hesia 2018;35: 273-279
Hgb
Preop anemia ≤ 80 assoc wit h post AKI risk PRBCs during and aft er cardiac S
x (TAVI)(CABG) increase AKI risk
Also increases IL-18 and NGAL levels post op (≥ 2 units)
No evidence for prot ect ive medicat ions or “ ischemic precondit ioning” Thongprayoon C et al World J Nephrol 2016; 5(5): 82-88 Tewari P et al J Cardiot horacic S urgery2015; 10(S uppl1): A168
More t han 50, urine and/ or serum
No funding for NGAL in Calgary
Int ended t o find t he sub-clinical AKI, rest rat ify AKI and underst and it ’s nat ural Hx.
More likely cost effect ive in t he ICU
Molit oris BA and Reilly E, S emin Nephrol 2016; 36(1): 31- 41
Forni LG et al Int ensive Care Med (2017) 43:855– 866
Ort ega LM and Heung M Nefrologia 2018; 38(4): 361-367
Risk
Recognit ion
Response
Recovery
Rehabilit at ion
Ebah L et al BMJ Qualit y Improvement Report s 2017;6:u219176.w7476.
Ebah L et al BMJ Qualit y Improvement Report s 2017;6:u219176.w7476.
Out comes: 2015 t o dat e
31%
reduct ion new AKI
23%
reduct ion in LOS
40%
reduct ion in t ime t o AKI recovery
10%
reduct ion in AKI deat hs
Ebah L et al BMJ Qualit y Improvement Report s 2017;6:u219176.w7476.
Clinical approaches t o Dx and manage AKI at risk pt s will
Cont inue t o evolve along pt “ care bundles” Be more mult i-disciplinary t han present Int roduce new t echnologies and t ypes of informat ion int o t he clinical spaces Require more cooperat ion and t eamwork in t he spirit of proact iveness
For now
If you haven’ t been, focus preop more specifically on perioperat ive AKI risk Discuss ways t o improve Dx and management wit h your colleagues Ensure appropriat e follow up
Day 1 post op
u/ o down overnight , 300 ml over 10 hrs IV running NS
150 hr for t he last hr, overnight IV went int erst it ial
Clinically hypovolemic Foley cat het er in sit u sCr 155 What do you t hink is going on? What are you going t o do?
E-alert s (KDIGO st age 1, 2, 3)
Clinical pat hway based on pre- int ra- and post - renal evaluat ion for AKI and init ial response
Order set s – diet , monit oring laborat ory (focus on day 2 & 3), diagnost ic imaging and fluid t herapies
Disposit ion planning
Rural considerat ions
Minj ae K et al Anest hesia & Analgesia 2014; 119(5): 1121-1132
A possible diagnosis that may need specialist treatment (eg., presence of proteinuria or hematuria on urinalysis can suggest kidney vasculitis or glomerulonephritis; white blood cell casts can suggest tubulointerstitial nephritis; anemia, hypercalcemia, and fractures can suggest multiple myeloma)
* Acute kidney inj ury of unclear etiology (no pre-renal or post-renal cause identified)
* Progressive AKI despite correction of pre-renal/ post-renal factors
* A kidney transplant
* Pre-existing advanced chronic kidney disease, eGFR less than 30mL/ min/ 1.73m2
* Complications associated with AKI which may require renal replacement therapy:
Calculate the pt’s “ Advanced CKD after AKI Risk Index” Refer to nephrology, as necessary