Updates on Acute Kidney Injury Yousif Bahbahani Nephrologist, - - PowerPoint PPT Presentation

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Updates on Acute Kidney Injury Yousif Bahbahani Nephrologist, - - PowerPoint PPT Presentation

Aug 02, 2023 168 likes •632 views

Updates on Acute Kidney Injury Yousif Bahbahani Nephrologist, Mubarak Al-Kabeer Hospital How important is AKI? How important is AKI? Question 36 years old gentleman in ICU on mechanical ventilation. Has slightly elevated AKI (Stage I).

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Updates on Acute Kidney Injury

Yousif Bahbahani Nephrologist, Mubarak Al-Kabeer Hospital

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How important is AKI?

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How important is AKI?

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Question

  • 36 years old gentleman in ICU on mechanical ventilation. Has slightly

elevated AKI (Stage I). Family asking if patient will develop “Kidney Failure” and asking if there is a test you can do to tell?

  • 1. Plasma Ngal
  • 2. TIMP2*IGFBP7
  • 3. Urine KIM-1
  • 4. Urine Ngal
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Question

  • 36 years old gentleman in ICU on mechanical ventilation. Has slightly

elevated AKI (Stage I). Family asking if patient will develop “Kidney Failure” and asking if there is a test you can do to tell?

  • 1. Plasma Ngal
  • 2. TIMP2*IGFBP7
  • 3. Urine KIM-1
  • 4. Urine Ngal
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Biomarkers for AKI

Lag between AKI and rise in serum creatinine Many limitations for the use of serum creatinine Need for New Biomarkers for:

  • Earlier detection of AKI
  • Identifies those who will progress to severe AKI
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Biomarkers for AKI

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Biomarkers for AKI

Kashani et al

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Biomarkers for AKI

Kashani et al

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Biomarkers for AKI

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Biomarkers for AKI

  • NGAL
  • KIM-1
  • L-FABP
  • IL-18

TIMP2*IGFBP7

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Clinical Utility of TIMP2*IGFBP7

Am J Kidney Dis 68: 19–28, 2016

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Future of Biomarkers

Combination with other biomarkers:

  • Furosemide stress test (FST)
  • Renal Angina Index (RAI)
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Nephro imitation of cardiology

Kidney injury biomarker (e.g. TIMP2*IGFBP7)  Our Troponin

+

Kidney functional biomarker (e.g. FST)  Our Stress test

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Novel therapies for AKI?

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E-Alert systems

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E-Alert systems

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E-Alert : Not Helpful

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E-Alert Not Helpful

Wilson et al

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E-Alert Helpful : NHS

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NHS Studies

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E-Alert Helpful: NHS

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Aki Care bundle

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Novel therapies for AKI?

No magic pill yet! But we can do much better if apply what we already know!

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Question

48 years old lady known HTN and DMt2, admitted to ICU with severe

  • sepsis. Blood pressure is 95/60 Her creatinine is rising from 110 to 360

micromol/L and has decreased urine output. K:4.2, HCO3: 20, Na: 143, Phos: 1.7, Ca: 2.1. What is your next step in management?

  • 1. Start IHD immediately.
  • 2. Start CRRT immediately.
  • 3. Start CRRT within 48 hrs.
  • 4. Start IHD within 48 hrs.
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Question

48 years old lady known HTN and DMt2, admitted to ICU with severe

  • sepsis. Blood pressure is 95/60 Her creatinine is rising from 110 to 360

micromol/L and has decreased urine output. K:4.2, HCO3: 20, Na: 143, Phos: 1.7, Ca: 2.1. What is your next step in management?

  • 1. Start IHD immediately.
  • 2. Start CRRT immediately.
  • 3. Start CRRT within 48 hrs.
  • 4. Start IHD within 48 hrs.
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Early Vs Late CRRT (When no Abs Indication)

  • Retrospective studies: ?Benefit from early initiation of CRRT

ELAIN Vs AKIKI

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SD Barba bar et al. N Eng nglJ Med d 2018;379:1431-1442.

Overall Survival among Patients Assigned to Early Renal- Replacement Therapy and Delayed Renal-Replacement Therapy.

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Awaiting STARRT-AKI Results!

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Question

  • 65 years old gentleman with DM, HTN CKD and CAD. Admitted with

NSTEMI and scheduled for PCI tomorrow. What would you like to do?

  • 1. N-Acetyl cystine 1200mg PO BD for 48 hrs
  • 2. N-Acetyl cystine 1200mg IV BD for 48 hrs
  • 3. Normal saline Drip before & after PCI.
  • 4. NaHCO3 drip Drip before and after PCI
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Question

  • 65 years old gentleman with DM, HTN CKD and CAD. Admitted with

NSTEMI and scheduled for PCI tomorrow. What would you like to do?

  • 1. N-Acetyl cystine 1200mg PO BD for 48 hrs
  • 2. N-Acetyl cystine 1200mg IV BD for 48 hrs
  • 3. Normal saline Drip before & after PCI.
  • 4. NaHCO3 drip Drip before and after PCI
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THE PRESERVE STUDY

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SD Weisbo sbordet al. N Eng nglJ Med d 2018;378:603-614.

Enrollment and Randomization.

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SD Weisbo sbordet al. N Eng nglJ Med d 2018;378:603-614.

Forest Plot of Treatment Effects in Prespecified Subgroup Analyses.

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Question

  • 45 years old lady admitted to ICU with septic shock. What is your fluid

prescription for this lady?

  • 1. Ringer’s Lactate
  • 2. Normal Saline
  • 3. Human Albumin
  • 4. HES (Starch)
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Question

  • 45 years old lady admitted to ICU with septic shock. What is your fluid

prescription for this lady?

  • 1. Ringer’s Lactate
  • 2. Normal Saline
  • 3. Human Albumin
  • 4. HES (Starch)
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KDIGO Guidelines 2012 Wha hat t type type of

  • f Cr

Crystalloids??? ystalloids???

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SALT-ED & SMART Trials

  • Same center: Comparing Saline Vs Balanced (Ringer’s or Plasmalyte A)
  • SALT-ED: Non-Critically ill : Primary end-point: LOS
  • SAMRT: Critically ill: Primary end-point: MAKE30
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WH Self et al. N Eng ngl J Med d 2018;378:819-828. 828.

SALT-ED Results

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MW Semler et al. N EnglJ Med d 2018;378:829-839. 839.

Clinical Outcomes.*

SAMRT Trial

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Question

  • 64 years old gentleman presented to ER with rapidly rising serum

creatinine, hemoptysis and arthralgia. ANCA serology is +ve. What is your management?

  • 1. Pulse steroids
  • 2. Oral Prednisone + Cyclophosphamide
  • 3. Pulse steroid + Cyclophosphamide
  • 4. Pulse steroid + Cyclophosphamide + Plasma exchange
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Question

  • 64 years old gentleman presented to ER with rapidly rising serum

creatinine, hemoptysis and arthralgia. ANCA serology is +ve. What is your management?

  • 1. Pulse steroids
  • 2. Oral Prednisone + Cyclophosphamide
  • 3. Pulse steroid + Cyclophosphamide
  • 4. Pulse steroid + Cyclophosphamide + Plasma exchange
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PEXIVAS Trial

  • Largest ever AAV trial: 702 patients
  • 2 X 2 Factorial design
  • Compared:
  • PLEX Vs No PLEX
  • High Vs Low dose steroids NO DIFFERENCE in Death or ESRD Composite
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TAKE HOME MESSAGE

  • Better detection of AKI: (Biomarkers, Prediction scores, E-Alerts)

AND Linking them to:

  • AKI care bundles
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THANK YOU