ACUTE KIDNEY INJURY (AKI) (Cedera Ginjal Akut)

Another term : Acute Renal Failure Many references / literatures still use this term

DEFINITION :
AKI is an abrupt (less then 7 days) and sustained decrease in kidney function. changes in blood biochemistry : increased of serum creatinine, blood urea nitrogen decreased of urine out put in 80-90% cases (10-20% normal or increase) or both kidney function used to be normal When the patient has a previous episode of kidney disease, the term is : Acute on Chronic Kidney Disease (ACKD)

CLASIFICATION
AKI classified according to degree and outcome of renal

function by RIFLE criteria

R = Risk L = Loss I = Injury F = Failure E = End Stage

1. Risk of Renal Dysfunction (R)

serum creatinine increased 1.5 fold, or GFR decreased by more than 25%

Less than 0.5 ml/kg/h of urine production for 6 hours

2. Injury of the Kidney (I) doubling of serum creatinine or GFR decreased by more by 50% or urine production less than 0.5 ml/kg/h in 12 hours

3. Failure of Kidney Function serum creatinine increased 3 fold, or GFR decreased by more than 75% less than 0.3 ml/kg/h of urine for 24 hours 4. Loss of Kidney Function

Complete loss of kidney function for longer

than 4 weeks 5. End Stage Renal Disease The need for dialysis for longer than 3 month

GFR Criteria Risk of renal dysfunction

50% decrease in creatinine or > 25% decrease in GFR
Two-fold increase in creatinine or > 50% decrease in GFR

AND/OR

Urine output Criteria

Urine output < 0.5 ml/kg/hr for at least 6 hours
Urine output < 0.5 ml/kg/hr for at least 12 hours

Injury to the kidney

Failure of kidney function

Three-fold increase in creatinine or > 75% decrease in GFR or creatinine > 350 (acute rise)

Urine output < 0.3 ml/kg/hr for 24 hours (or anuria for 12 hours)

Loss of kidney function ERF

Loss of kidney function > 4 weeks but < 3 months

Established renal failure (loss of function > 3 months)

Acute renal failure (ARF) classified according to degree and outcome by RIFLE criteria

CAUSES OF AKI
Causes of AKI divided into three matter :
1. Prerenal : Decreased of renal perfusion (hypoperfusion) 2. Renal (Intrinsic) Damage of parenchyma of the kidney (glomeruli,

tubules, intra-renal vasculature, interstitial nephritis)

3. Post-renal Obstruction of urinary tract

PRERENAL CAUSES OF AKI

1. Shock : cardiogenic ahock distributive shock (e.g.sepsis, anaphylactic) 2. Hypovolemia hypovolemic shock haemorhage gastrointestinal loss (vomiting, diarrhea) cutaneous losses (e.g.burns) 3. Renal hypoperfusion renal artery stenosis hepatorenal syndrome 4. Changes of water distribution (oedema) congestive heart failiure hepatic failure nephrotic syndrome

RENAL / INTRINSIC CAUSES OF AKI

1. Glomerular disease
glomerulonephritis 2. Tubular injury

prolonged renal hypoperfusion

toxin (snake venom), drugs (aminoglycosides), 3. Vascular vasculitis arterial or venous thrombosis 4. Interstitial nephritis infiltrative malignancy

toxin (alcohol, metal)

infection (leptospiral)

POST-RENAL CAUSES OF AKI Obstruction : stone urethral stricture prostate hypertrophy pelvic tumor retroperitoneal fibrosis

Prerenal

Renal

Postrenal

DIAGNOSTIC
1. History of disease gastroenteritis, bleeding ? heart disease toxin ? post infection ? stone disease ?

2. Investigation
A. Physical examination. blood pressure (hypotension/shock)

anemic, dehydration
renal colic, ballotment, full vesica urinaria

B. Blood chemistry

haemoglobine, white blood cell

blood ureum, creatinine serum potassium (K), sodium (Na)

blood gas analysis

C. Radiology plain photo abdomen

ultrasonography

COMPLICATIONS
1. Volume overload acute pulmonary oedema

acute left heart failure

2. Metabolic acidosis 3. Electrolyte imbalance hyperkalemia

MANAGEMENT
A. Manage the initial causes / initial disease properly B. Patient must be hospitalized and admit in Intensive Care Unit water, electrolyte and acid-base balance antibiotic C. Supportive Therapy dialysis ultrafiltration

PREVENTION
Identify and treat patients most at risk
gastroenteritis bleeding heart failure pre- operation drugs / toxin infection

Deferential diagnosis between

Acute Kidney Injury (AKI) and Acute on Chronic Kidney Disease (ACKD) :

AKI
History of kidney disease Physical examination
- hypertension
- oedema No/unknown

ACKD
Yes

rare
rare

mostly
mostly

Blood biochemistry :
- anaemic - hyperphosphatemia (PO4) rare rare normal mostly mostly small kidney

Ultrasonographic

SELF ASSESSMENT 21 years old man, came with oligouria since 2 days ago. His urine just 250 mk/24 hrs. Since days ago he has profuse diarrhea and vomiting. On physical examination the patient look severe ill, dehydration, blood pressure 90/60 mmHg, pulse 118/mnt, temp. 38 C, body weight 50 kg, urine volume 120 ml/12 hrs

What is the assessment for this patient ? What examination have we take more ?

Laboratory examination shows : Hb. 16 mg%, WBC 14.000.

Urine: proteinuria +, eryth 1-2/HPF, lecocyt 1-3/HPF

BUN 45 mg%, creatinin 2.2 mg%, Kalium 5.7 meq/lt, Na 140 mq/kt What is the diagnosis for the patient ? Clinical diagnosis Etiology Complication

What is the management ?