Updates on Acute Kidney Injuryimupdateskw.com/presentation/dr-yousuf-behbehani/AKI... ·...
Transcript of Updates on Acute Kidney Injuryimupdateskw.com/presentation/dr-yousuf-behbehani/AKI... ·...
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
• L-FABP
• IL-18
TIMP2*IGFBP7
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
SD Barbar et al. N Engl J Med 2018;379:1431-1442.
Overall Survival among Patients Assigned to Early Renal-Replacement Therapy and Delayed Renal-Replacement
Therapy.
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
SD Weisbord et al. N Engl J Med 2018;378:603-614.
Enrollment and Randomization.
SD Weisbord et al. N Engl J Med 2018;378:603-614.
Forest Plot of Treatment Effects in Prespecified Subgroup Analyses.
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
What type of Crystalloids???
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
WH Self et al. N Engl J Med 2018;378:819-828.
SALT-ED Results
MW Semler et al. N Engl J Med 2018;378:829-839.
Clinical Outcomes.*SAMRT Trial
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