Acute Kidney Injury - Phase II: Frailty and Confusion PDF

Acute Kidney Injury Phase II: Frailty and Confusion 11th September 2024 Dr Laura Harrison Consultant in Renal Medicine Renal presentations (AKD) Chronic Renal Failure / AKI...

Acute Kidney Injury Phase II: Frailty and Confusion 11th September 2024 Dr Laura Harrison Consultant in Renal Medicine Renal presentations (AKD) Chronic Renal Failure / AKI CKD Proteinuria Acute Kidney Injury / Renal failure Nephritic Fluid and Non / Visible Nephrotic electrolyte Haematur ia abnormalities  Aim: to provide a practical clinical approach to AKI  Objectives What are yours? Now: 1 aspect or clinical question to cover End: 1 learning point Overview  Recognise and describe symptoms and signs  Explain relevant underlying scientific process  Form basic investigation and management plans  Work collaboratively with other HCPs  AKI: Definition and diagnosis Clinical syndrome = only the start of your diagnostic path  NCEPOD - Acute Kidney Injury: Adding Insult to Injury Report ( 2009)  Common: 5-20% of critically unwell patients  Bad: 20% mortality / ↑↑ Length of stay  Not well managed: only 30% “good” care  Expensive! AKI: What is it? RIFLE (2004) AKIN (2007) KDIGO (2012) Definition: Rapid reduction in kidney function resulting in failure to maintain fluid, electrolyte and acid-base homoeostasis Abrupt change in serum creatinine or urine output Evolving definitions over the last 10 years AKI Staging Stag Serum creatinine (SCr) Urine output e ↑ 26 μmol/L in 48hrs 6 hrs 1 ↑ 1.5 – 1.9 x SCr (e.g. 70kg < 200ml) 12 2 ↑ 2 - 3 x SCr hrs (e.g. 70kg < 400ml) 24 ↑ 3 x SCr hrs 3 ↑ 354 μmol/L (e.g. 70kg ~ 500ml) Dialysis Anuria for 12 hrs AKI Staging: What is it? Creatinine over 2 Urine output for days 70kg man 48 ↗ 77 500 ml/16hrs 54 ↗ 156 77 ↗ 291 200mls/24hrs 92 ↗ 126 126 ↗ 291 Not passed urine for 156 ↗ 360 24hrs AKI Staging Stag Serum creatinine (SCr) Urine output e 48 ↗ 77 (x 1.5) 1 92 ↗ 126 (> 26) 54 ↗ 156 (↑ x 2.9) 70kg ~350 ml/16hrs 2 126 ↗ 291 (↑ x 2.3) 77 ↗ 291 (↑ x 3.8) Not passed urine for 156 ↗ 360 (>354) 3 24hrs Fluid overload with K7.3 Abnormal renal bloods: one eGFR ≠ CKD. Result Range Na 138 133-146 mmol/L K 4.7 3.5-5.3 mmol/L But does it mean AKI? Urea 11.3 2.5-7.8 mmol/L eGFR less accurate in rapid change → need to use Creatinine Creat 125 59-104 mmol/L eGFR 53 >60mL/min/ 1.73m2 Acute or Chronic?  Previous blood results o Look back at recent or any previous U+Es o Collateral data – contact GP / local hospital / biochemistry lab  Renal bone disease o ↓Ca and ↑PO4 occur in both o ↑↑ PTH suggests CKD  Anaemia: Can occur rapidly in AKI  Ultrasound: small size, reduced cortex (10cm length, preserved cortical thickness makes CKD less likely  Abnormal renal bloods: one eGFR ≠ CKD. Result Range Na 138 133-146 mmol/L K 4.7 3.5-5.3 mmol/L Baseline Creatinine = 82 Urea 11.3 2.5-7.8 mmol/L - ideally 7 days - otherwise lowest / mean result in last year Creat 125 59-104 mmol/L eGFR 53 >60mL/min/ 1.73m2  Renal function(s) Toxin / waste excretion Water balance / blood volume Acid-base balance Electrolyte balance Drug excretion Blood pressure control Erythropoietin production for RBC formation Vitamin D activation for bone mineral metabolism Chronic kidney disease (CKD) | Ki dney Care UK Acute Renal Complications Metaboli c High Uraemia acidosis potassium Toxin Electrolyte abnormalitie build-up s e.g. Opiate Pulmonary excess oedema Drug Fluid accumul overload ation Hypertensive Emergency Renal assessment and treatment History Symptoms of AKI: causes and consequences Examination General / fluid status / system specific Diagnoses Causes and complications Investigations Bedside / Bloods / Imaging / Speciality and Specific Management Immediate → long-term / Medical ↔ Surgical / MDT AKI: Clinical presentations  Cardiovascular:  Respiratory:  Endocrine:  Metabolic:  Neurology:  Rheum / Derm:  GI: Causes and Consequences  Haematology:  Urology:  Care of the elderly:  Mental health: AKI: Clinical presentations …in CCE learning objectives  CV: Breathlessness, Peripheral oedema, palpitations, hypertension  Resp: Breathlessness, haemoptysis,  Endocrine: abnormal blood sugars, fatigue, weight gain / loss  Metabolic: Acid-base abnormalities, abnormal electrolytes (high K+)  Neurology: Headache, seizure, stroke  Rheum / Derm: Joint pain, pruritus, rashes  GI: nausea, altered taste, reduced appetite  Haematology: Anaemia  Urology: Haematuria, Urinary symptoms, abnormal urinalysis  Care of the elderly: frailty  Mental health: acute confusion / delirium, encephalopathy AKI causes in the history Pre Renal Post Renal history  What are your main symptoms?  Consider causes / complications  PMHx inc AKI risk factors  DHx:  OTC / herbal remedies / supplements  Allergies / AE  PSHx Functional status  ICE: what else would you like to ask me or tell me? Renal history 1: Presenting Complaint What are your main symptoms?  Relevant systems review  CV: dizziness, pre/syncope, palpitations, peripheral oedema  GI: Diarrhoea, vomiting, nausea, PR blood loss  Resp: haemoptysis, dyspnoea  GU: urine output, any LUTS inc visible haematuria  MSk: Arthralgia, myalgia, skin rashes  ENT: epistaxis, conjunctivitis, URTI / sore throat  Systemic symptoms: malaise, weight loss, fever Renal history 2: Past Medical Hx, Drugs, Allergies Age >65?  Risk factors for AKI - Any known CKD? Previous AKI?  Hypertension, Diabetes Mellitus, MI, heart failure, gout  Prostate problems, Renal stones, UTIs  Cancer, immunocompromised, Systemic disease  DHx: Be meticulous, get timescales  NSAIDS  Antihypertensives, in particular ACEi, ARBs, diuretics  Antibiotics, PPIs  Over the counter, herbal remedies, recreational drugs Renal assessment and treatment History Symptoms of CKD: causes and consequences Examination General / fluid status / system specific Diagnoses Causes and complications Investigations Bedside / Bloods / Imaging / Speciality and Specific Management Emergency ↔ Acute / Medical ↔ Surgical / MDT AKI examination  Initial assessment: End-of-the-bed-o’meter and A to E  Observations including lying / standing BP, NEWS  Peripheral signs, systemic disease?  Cardiovascular: Fluid status  Peripheral stigmata, perfusion, pulses, any rub, or murmurs  Respiratory: Respiratory effort, signs of pulmonary oedema  Abdominal: Palpable bladder, Ballotable kidneys, renal bruit?  Complete with Urinalysis: vital yet frequently difficult to achieve  Consider Fundoscopy AKI examination: don’t forget Ren Pre Post al  EWS  Face  Bladder exam  Sepsis recognition  Skin / Rashes  Volume status  Joints Renal assessment and treatment History Symptoms of CKD: causes and consequences Examination General / fluid status / system specific Diagnoses Causes and complications Investigations Bedside / Bloods / Imaging / Speciality and Specific Management Emergency ↔ Acute / Medical ↔ Surgical / MDT AKI causes Renal Pos Pre t Clues for causes Pre Post  Poor PO intake / fluid loss /  Older male thirst  History of LUTS  Medication -diuretics, ACEi  History of malignancy,  Fluid status, Low BP  Skin turgor / cool peripheries especially pelvic  Sepsis/ hypoperfusion  Palpable bladder Rehydrate / treat sepsis Bladder scan Clues for causes Not Sure?  Detailed medication  Urine dipstick  Systemic review Any blood and protein?  Systemically unwell. Malaise, weight loss?  ENT: epistaxis, conjunctivitis  MSK: myalgia, arthralgia, skin rashes  Resp: haemoptysis Something weird and wonderful? Consider intrinsic renal Renal assessment and treatment History Symptoms of AKI: causes and consequences Examination General / fluid status / system specific Diagnoses Causes and complications Investigations Bedside / Bloods / Imaging / Speciality and Specific Management Immediate → long-term / Medical ↔ Surgical / MDT Investigations 1 Diagnose AKI +/- complications Investigate cause  Bedside Urine output Consider VBG / ECG  Bloods U+E (not eGFR): esp Potassium and Urea Acute complications - Acidosis: check bicarbonate - Plus FBC (+haematinics), Bone profile (Ca, PO4),  Imaging CXR Renal Ultrasound: kidney number, size, shape, post micturition residual in bladder sca  Speciality Renal biopsy Investigations 2 Diagnose AKI +/- complications Investigate cause  Bedside Urine output Urine dipstick + uACR Consider VBG / ECG Bladder scan  Bloods U+E (not eGFR): esp Potassium and Urea Pre-renal Renal: Nephritic screen e.g. Acute complications ANCA (MPO &PR3, C3+C4, +/- - Acidosis: check bicarbonate CRP, ESR, dsDNA, anti-GBM. - Plus FBC (+haematinics), Bone Myeloma: Electrophoresis, SFLC profile (Ca, PO4), Post renal: PSA  Imaging CXR Renal Ultrasound: kidney number, size, shape, post micturition residual in bladder scan  Speciality Renal biopsy AKI: Why does wee matter? Bland / negative Pre renal, renovascular, myeloma or TIN Blood Bleeding from uroepithelial tract ?UTI ?catheter Proteinuria Diabetes Mellitus Catheter sample? ?Nephrotic syndrome Blood and protein Esp 2+ blood 2+ protein… GlomerulonephritisRapidly progressive = poor prognosi Needs early specific treatment Leucocytes, Consider UTI nitrites Known diabetes? AKI investigations: don’t forget Ren Pre Post al  Sepsis 6  Urinalysis  Bladder scan  Fluid balance  Immunology  Renal US Plus -acid base status - Monitoring biochemistry Management: general principles  Early identification o Risk assessment and AKI avoidance  Commit to a diagnosis  Treat cause and start renal protection measures  Referral to renal team o Indications for Renal Replacement Therapy o Cause: No clear cause OR possible intrinsic renal disease o Progress: Renal function not improving OR AKI3 o Baseline: CKD 4/5 OR renal transplant Diagnoses AKI Community or Hospital acquired? Stage 1, 2 or 3? Renal Pre-Renal Post-Renal (intrinsic) Hypovolaem ATN Obstruction ia GN Blocked Sepsis IN catheter Cardiogenic Causes: Pre-renal  Renal (intrinsic Causes ) Glomerular Interstitiu Glomerular endotheliu Tubular m m Ischaemia Drugs  Glomerulo-  Vasculitis ATN Autoimmun nephritis Malignant Toxins e HT Haemolysis Infiltrative May need renal biopsy, immunosuppression +/- plasma exchange Causes: Post-Renal  Obstruction  Bladder outflow: prostate, urethral stricture  Ureteric: stones, blood clot, tumours  Blocked catheter AKI Complications Management of AKI complications  Correct fluid status: fluid resuscitation vs diuresis Dietetic: fluid restrict, Loop diuretics (PO > IV), ?dialysis  Metabolic acidosis: oral or IV sodium bicarbonate  Hyperkalaemia: Diet / Drugs / AciDosis / dehyDration Protect the heart Dietetic: K restrict, stop ACE/ARB, correct fluid / pH, consider potassium lowering drugs (e.g. Lokelmer)  Uraemia: treat nausea with antiemetics. If ↑↑ - dialysis Consider capacity in confused patients When these don’t work? ?Dialysis Acute Acute Peritoneal Supportive Haemodialys Dialysis Care is  Principles of management: MDT Input from: ITU / Critical care Primary Rheumatology  Need to think about Renal medical Interventional Radiology psychol / Urology ogist surgical team Frailty AKI nurse Prognosi Renal Patien Nurse practitioners pharmaci specialist CCOT (critical care) s t st s CKD / RRT education Acute HD / PD team Renal Renal Treatme dietician Physician nt goals s s Comorbidit y AKI Management summary Early Patient Treat cause: identification education and General and and correct support, specific diagnosis lifestyle advice Identify and Patient focused, MDT integrated treat individualised approach complications care Cases  Acute Kidney Injury Phase II: Chronic Health Conditions Questions? Comments? + 1 learning point ? 1 question you still have [email protected] AKI: top tips for clinical practice DO DON’T  Review fluid status, think sepsis  Forget to review response to  Arrange initial investigations treatment  Ring renal without reviewing the  Review medications (and stop patient, their fluid status and where appropriate) urine dipstick  Have a differential diagnosis  Forget intrinsic renal causes  Seek help: discuss with your seniors. Talk to renal early Resources KCUK https://kidneycareuk.org/ AKI Toolkit: https://elearning.rcgp.org.uk/mod/book/view.php?id=12897 NICE AKI guidelines https://www.nice.org.uk/guidance/ng148/chapter/Context BMJ best practice https://bestpractice.bmj.com/topics/en-gb/3000117 Edinburgh Renal Unit https://edren.org/ren/education/