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

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). 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

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

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

Biomarkers for AKI

Biomarkers for AKI Kashani et al

Biomarkers for AKI Kashani et al

Biomarkers for AKI

Biomarkers for AKI • NGAL • KIM-1 TIMP2*IGFBP7 • L-FABP • IL-18

Clinical Utility of TIMP2*IGFBP7 Am J Kidney Dis 68: 19 – 28, 2016

Future of Biomarkers Combination with other biomarkers: • Furosemide stress test (FST) • Renal Angina Index (RAI)

Nephro imitation of cardiology Kidney injury biomarker (e.g. TIMP2*IGFBP7)  Our Troponin + Kidney functional biomarker (e.g. FST)  Our Stress test

Novel therapies for AKI?

E-Alert systems

E-Alert systems

E-Alert : Not Helpful

E-Alert Not Helpful Wilson et al

E-Alert Helpful : NHS

NHS Studies

E-Alert Helpful: NHS

Aki Care bundle

Novel therapies for AKI? No magic pill yet! But we can do much better if apply what we already know!

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.

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.

Early Vs Late CRRT (When no Abs Indication) • Retrospective studies: ?Benefit from early initiation of CRRT ELAIN Vs AKIKI

Overall Survival among Patients Assigned to Early Renal- Replacement Therapy and Delayed Renal-Replacement Therapy. SD Barba bar et al. N Eng nglJ Med d 2018;379:1431-1442.

Awaiting STARRT-AKI Results!

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

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

THE PRESERVE STUDY

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

Forest Plot of Treatment Effects in Prespecified Subgroup Analyses. SD Weisbo sbordet al. N Eng nglJ Med d 2018;378:603-614.

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)

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)

KDIGO Guidelines 2012 Wha hat t type type of of Cr Crystalloids??? ystalloids???

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

SALT-ED Results WH Self et al. N Eng ngl J Med d 2018;378:819-828. 828.

SAMRT Trial Clinical Outcomes.* MW Semler et al. N EnglJ Med d 2018;378:829-839. 839.

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

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

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

TAKE HOME MESSAGE • Better detection of AKI: (Biomarkers, Prediction scores, E-Alerts) AND Linking them to: • AKI care bundles

THANK YOU