Acute Kidney Injury AKI The Clinical Aspects Medicines

Acute Kidney Injury (AKI) The Clinical Aspects & Medicines Involved Kate Webb Renal Advanced Pharmacist Practitioner University Hospital of North Midlands UK Renal Pharmacy Group

Learning Objectives n Understand what is AKI? the clinical issues associated with AKI?

Summary of Presentation n Renal Anatomy + Physiology n AKI Definition Etiology Outcomes Goals Case Study n Conclusion n

Renal Anatomy

Renal Physiology n n n Regulation of water & electrolytes Retention of substances i. e. protein / glucose Excretion of waste, H 2 O soluble & drug products Acid / base balance Endocrine function: Renin, Aldosterone, ADH Erythropoeitin, Vitamin D

AKI n Definition: ‘Abrupt ↓ in kidney function that includes, but is not limited to, Acute Renal failure. ’ n Various etiologies Kidney diseases (nephritis, vasculitis) Non-specific conditions (ischaemia) Extrarenal pathology (post-renal obstruction)

AKI – Outcomes & Goals n Outcomes: - Significant mortality & morbidity n Goals: Prevent further damage Facilitate recovery of renal function “ 20 -30% AKI is predictable & avoidable”

AKI – Prevent further damage n Identify the cause for AKI asap n Avoid nephrotoxic meds Aminoglycosides, Amphotericin, NSAIDs n Avoid nephrotoxic procedures U/S with contrast n Consider ‘drug ACEIs, ARBs holidays’

AKI – Facilitate recovery of Renal function n Identify pts who need dialysis vs. medical management n Give fluids (1. 5 l – 2 l /day) Crystalloids vs. Colloids vs. Blood n Treat cause e. g. drug toxicity n Regular monitoring n Avoid hyperglycemia

AKI – Classification & Alerts AKI Stage Creatinine Criteria Urine Output Criteria Predicted Nos / year of AKI in 1000 - bedded hospital One ↑ > 26 mmol/l above baseline (within 48 hrs) OR ↑ > 1. 5 fold from baseline < 0. 5 ml/kg/hr for at least 6 hrs 2727 Two ↑ > 2. 0 fold from baseline < 0. 5 ml/kg/hr for at least 12 hrs 782 ↑ > 3. 0 fold from baseline OR AKI with Cr > 354 mmol/l OR Initiation of Renal Replacement Therapy (RRT) < 0. 3 ml/kg/hr for at least 24 hrs OR Anuria > 12 hrs 636 Total 4145 Three

AKI – Case Study n ♂, 34 yrs. n PC Collapsed. GCS 12. On admission, Bp 54/30, Tachycardic, Resp Rate > 35, Temp 39. 6 n PMH Asthma n DHx Beclomethasone Inh + Salbutamol Inh n Implication Systemic sepsis ? cause

AKI – Case Study n Biochemistry: Na+ = 138 K+ = 7. 2 Urea = 56. 2 Cr 784 = CRP 160 =e. GFR 11 = Hb 126 = WBC 33. 6 Plts 156 == Alb = 39 Calcium = 2. 2 Phosphate = 1. 3

AKI – Case Study n Biochemistry: Na+ = 138 K+ = 7. 2(High) Urea = 56. 2 (High) Cr = 784 (High) e. GFR = 11 (Low) CRP = 160 (High) Hb=126 WBC=33. 6(High) Plts = 156 Alb = 39 Calcium = 2. 2 Phosphate = 1. 3

AKI – Classification & Alerts AKI Stage Creatinine Criteria Urine Output Criteria Predicted Nos / year of AKI in 1000 - bedded hospital One ↑ > 26 mmol/l above baseline (within 48 hrs) OR ↑ > 1. 5 fold from baseline < 0. 5 ml/kg/hr for at least 6 hrs 2727 Two ↑ > 2. 0 fold from baseline < 0. 5 ml/kg/hr for at least 12 hrs 782 ↑ > 3. 0 fold from baseline OR AKI with Cr > 354 mmol/l OR Initiation of Renal Replacement Therapy (RRT) < 0. 3 ml/kg/hr for at least 24 hrs OR Anuria > 12 hrs 636 Total 4145 Three

AKI – Case Study n CXR R + L sided consolidation Pneumonia (? Microbiology) n Hypoxic + Acidotic Ventilated (Level 3 care) n Urine Output 12 ml/hr, 5 ml/hr, 6 ml/hr (Pt wt = 80 kg) Filter (Level 3 care) CVVHDF

AKI – Classification & Alerts AKI Stage Creatinine Criteria Urine Output Criteria Predicted Nos / year of AKI in 1000 - bedded hospital One ↑ > 26 mmol/l above baseline (within 48 hrs) OR ↑ > 1. 5 fold from baseline < 0. 5 ml/kg/hr for at least 6 hrs 2727 Two ↑ > 2. 0 fold from baseline < 0. 5 ml/kg/hr for at least 12 hrs 782 ↑ > 3. 0 fold from baseline OR AKI with Cr > 354 mmol/l OR Initiation of Renal Replacement Therapy (RRT) < 0. 3 ml/kg/hr for at least 24 hrs OR Anuria > 12 hrs 636 Total 4145 Three

AKI – Case Study n Pneumonia Abx broad + empirical Co-Amoxiclav + Clarithromycin n Ventilated Sedated Morphine + Midazolam vs. Alfentanyl + Propofol n CVVHDF Effects on drug dosing / Clotting / Dialysis fluids n Fluids ? Give / Type n Others VAP meds / GI protection / TEDs

AKI – Case Study 11 Days later…. . n U&Es: Na+ = 138 K+ = 4. 3 Urea = 11. 2 (High) Cr = 284 (High) e. GFR = 32 (Low) CRP = 32 (High) Hb = 126 WBC = 13. 6 (High) n Urine Output: - 42 ml/hr, 54 ml/hr, 47 ml/hr n Pt Discharged n Meds: - Co-Amoxiclax 625 mg TDS for 4 days Clarithromycin 500 mg BD for 4 days Paracetamol 1 gram QDS PRN Becotide® 100 ii puffs BD Salbutamol 100 PRN n

Conclusion n Renal Anatomy + Physiology n Understanding of AKI n AKI Prevent further damage Facilitate recovery n AKI application in Practice

Questions