Acute Kidney Injury. Crush Injury

• Dr. Rodriguez Jose L. Nephrologist

• Dr. F. Nakanduungile Medical Intern

13-05-2014

• 45 yrs, Male , Referred from Engela Hospital, with a history of aggressive behavior , with and onset of 3\7, at home and was bitten by police officer and security guards before arrival at Engela Hosp.

Past medical Hx

• Hx of Schizophrenia on Rx but defaulter Largatil 100mg po note but defaulter.• ALERGIES: UNKNOWN

• SOCIAL HX: SMOKING (+) ALCOHOL (+++)

Presentation

• O\E pct was alert, swollen left ankle , blisters on both lower limbs due to friction when he was tied on to the trolley and as well multiple soft tissue injuries and anuric.

• BP 162\106mmHg• P 97 Bpm• Temp 35.6⁰C• Other sx: NAD

• He was admitted to Ward 16 due to his previous medical Hx for substance abuse.

• And than was transferred to ward 7 on the 21/05/2014.

• Myoglobinuria and/or haemoglobinuria, was presenting in urine, as tea-coloured.

Investigations

• CXR and other x-Rays• FBC• U&E• LFT’S• Abd sona

21-05-2014

• S-Potassium 7.3 ↑• S-Sodium 136 • S-Urea 39 ↑ ↑

• S-Creatinine 1408 ↑ ↑ ↑

• Hep Screen Neg• HIV Neg

ABD SONA

• Both kidneys are enlarged .• Rt kidney- 10.8×6cm• Lt kidney-11.5×5.5cm• In bipolar length with increased echoparttern

Lt larger then Rt.

23-05-2014

• IVI fluids to rehydrate pct.• Daily U&E was order to be done. • Pct went for his first dialysis session.• Catheter Incertion. • Hemodialysis Therapy.• Strict Intake and output fluids

U&E21-5- 14 K Na Urea Creatinine

23-5-14 7.9 135 44.6 1753

24-5-14 5.1 134 28.4 1075

26-5-14 4.1 136 12.6 587

28-5-14 3.8 138 11.6 511

29-5-14 3.8 141 5.5 385

30-5-14 3.8 141 4.5 123

Crush Injuries and Rhabdomyolysis

• Occurs in up to 85% of patients with traumatic injuries. • Those with severe injury who develop rhabdomyolysis-induced

renal failure have a 20% mortality rate• Multiple orthopedic injuries• Crush injury to any part of the body (eg: hand)• Laying on limb for long period of time –patient “found down”• Long surgery• Brown urine

When to suspect Rhabdo• Clinical: Mm pain, weakness, dark urine

• Hypovolemia, shock

• Electrolyte abnormalities : ↑K+, ↓ Ca++ (sequestered in injured tissues), acidemia upon reperfusion

Pathophysiology of ARF• CONTRIBUTORS:

• Dehydration (hypovolemia)

• Aciduria• Renal vasoconstriction• Cast formation• Heme-induced toxicity

to tubule cells

Diagnosis • Serum CKMM• Correlates w/severity of rhabdo• Normally 145-260 U/L• Levels peak w/in 24h• >5000 high correlation with renal failure • #’s in 100,000’s not uncommon• high t(1/2): 1.5 days

• Serum myoglobin• t(1/2) 2-3 h• Excreted in bile• Ca++• UA-myoglobinuria• dipstick will be (+) for hemoglobin, RBC’s and

myoglobin• Microscopy: no RBC’s, brown casts, uric acid

crystals • Other measures: carbonic anhydrase III,

aldolase

Early Treatment• FLUIDS• Begin early, even on the field-Damaged muscles attract a lot of fluid -Up to 10L/day• Ideally ½ NS with 100mmol/L -bicarb prevents tubular precipitation -reduces risk of hyperkalemia from damaged mm -corrects acidemia -not proven beneficial however not deleterious• 10ml/h 15% mannitol -renal vasodilator -free radical scavenger• Forced diuresis w/in 6 hrs of admission

ARF

• Definitions:– An increase in the serum creatinine of 0.5 mg/dl

over baseline value– An increase in the serum creatinine of more than

50% over base line value– A reduction in the calculated creatinine clearance

of 50%– A decrease in the renal function that results in the

need for dialysis.

Category

• 1. urine output– Anuric: <100 mL/d– Oliguric: 100-500 mL/d– Nonoliguric: >500 mL/d

• 2. the more common – Pre-renal– Intrinsic– Post-renal

Signs and symptoms

• When high levels of urea;– Vomiting and/or diarrhea which may lead to dehydration– Nausea– Weight loss– Nocturnal urination– More frequent urination, or in greater amounts than usual,

with pale urine– Less frequent urination, or in smaller amounts than usual,

with dark coloured urine– Blood in the urine– Pressure, or difficulty urinating

Signs and symptoms

• A buildup of phosphates in the blood that diseased kidneys cannot filter out may cause: – Itching– Bone damage– Nonunion in broken bones

• Muscle cramps

Signs and symptoms

• A buildup of potassium in the blood that diseased kidneys cannot filter out (called hyperkalemia) may cause: – Abnormal heart rhythms

• Muscle paralysis• Failure of kidneys to remove excess fluid may cause: – Swelling of the legs, ankles, feet, face and/or hands

• Shortness of breath due to extra fluid on the lungs .

Anemia

– Feeling tired and/or weak

– Memory problems– Difficulty concentrating– Dizziness– Low blood pressure

Criteria for initiation of Dialysis

• Anuria • Oliguria • Pulmonary edema• Hyperkalemia >6.5mmol/L• Severe acidemia <7.2• Uremic encephalopathy• Uremic pericarditis• Drug overdose with dialyzable

toxins

The differential diagnosis • Making the distinction between AKI and CRF can be very difficult. • Is the renal failure acute, acute on chronic, or chronic?• -A history of chronic symptoms of fatigue, weight loss, anorexia,

nocturia, and pruritus all suggest CKD.• Is there evidence of true hypovolemia or reduced effective arterial

blood volume, that is, prerenal AKI?• -Dehydration, hypovolemia present, suggest AKI• Is there renal tract obstruction, that is, postrenal AKI?• -Enlarge prostate, tumor, stones• Renal abnormalities on ultrasound, such as small kidneys in chronic

glomerulonephritis or large cystic kidneys in adult polycystic kidney disease, will almost always be present in patients with CKD.

• Chronic renal failure• Urinary obstruction• Urinary tract infection• Dehydration• Diabetic ketoacidosis

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