AKI: The Long Term Effects - Prowle
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AKI: The Long Term Effects - Prowle
- 1. John R Prowle MA MSc MD MRCP FFICM Senior Lecturer in Intensive Care Consultant in Intensive Care & Renal Medicine AKI: The long-term effects?
- 2. Modes of Recovery from AKI J Clin Invest. 2011;121(11):4210–4221. Good Bad
- 3. Outcomes after AKI • Is AKI a risk factor for CKD? • What are this implications of this association? • What should we do during follow-up? – How do we recognise patients for treatment and follow- up? – What treatments are available?
- 4. Long-term risk of mortality and acute kidney injury during hospitalization after major surgery Bihorac A, et al (2009) Annals of surgery 249: 851-858
- 5. Kidney International (2011) 79, 1361–1369
- 6. Cumulative Incidence of CKD by Exposure Status (Recovered AKI vs. Controls) in Patients With Normal Baseline Kidney Function Bucaloiu ID, Kirchner HL, Norfolk ER et al. Kidney Int. 2012 Mar;81(5):477-85. 1.0 0.8 0.6 0.4 0.2 0 ProportionofPatientsWithoutCKD Months Since Index Hospitalization 0 6 12 18 24 30 36 42 48 54 60 66 72 AKI Controls Apparent ‘recovery’ after AKI does not remove association with later CKD
- 7. J Am Soc Nephrol 25: 2014. doi: 10.1681/ASN.2013060610 AKI is a major risk factor for Cardiovascular morbidity
- 8. CKD, GFR Proteinuria and Population Morbidity/Mortality Alb ++ Alb + Alb - Kidney International (2011) 80, 17–28;
- 9. Estimated glomerular filtration rate and albuminuria for prediction of cardiovascular outcomes: a collaborative meta-analysis of individual participant data Kunihiro Matsushita et al The Lancet Diabetes & Endocrinology May 2015 DOI: 10.1016/S2213-8587(15)00040-6 Adjusted for age, sex, race or ethnic origin, smoking, systolic blood pressure, antihypertensive drugs, diabetes, total and HDL cholesterol concentrations, and albuminuria (ACR or dipstick) or eGFR.
- 10. PLOS Medicine | www.plosmedicine.org 1 February 2014 | Volume 11 | Issue 2 | e1001601 Follow-up of patients from the RENAL study
- 11. PLOS Medicine | www.plosmedicine.org 1 February 2014 | Volume 11 | Issue 2 | e1001601 45%
- 12. Venkatachalam M A et al. Am J Physiol Renal Physiol 2010;298:F1078-F1094 Histology after AKI
- 13. Pechman K R et al. Am J Physiol Regul Integr Comp Physiol 2009;297:R1358-R1363 ©2009 by American Physiological Society Sodium intake and mean arterial blood pressure, creatinine clearance rate, and albumin excretion rate in sham or I/R rats 35 days after surgery
- 14. Summary 1 • CKD is common after AKI • More severe AKI is associated with more severe CKD • Development of CKD is associated with adverse outcomes – Death – Cardiovascular disease • Overt CKD may be delayed • Development of Proteinuria may be associated with adverse outcomes
- 15. Prevention of CKD after AKI • Prevent AKI • Minimise severity of initial episode • Prevent recurrent AKI
- 16. • 624 patients, 296 (47%) had AKI and 216 (73%) recovered • Of these, 68 (31%) developed Recurrent AKI J Trauma Acute Care Surg 76:
- 17. Recurrent AKI & Development of CKD 4 Thakar C V et al. CJASN
- 18. Kidney International (2011) 80, 17–28;
- 19. Treatment of CKD after AKI • Requires recognition of CKD!
- 20. East London ICU CRRT Follow-up • 5544 ICU admissions, 394 RRT survivors, 219 ‘de-novo’ AKI for follow-up • 182/219 (83%) were offered a hospital follow-up appointment • 142/182 (78%) attended their appointment • Only 78 of those (55% of those attending) had their creatinine measured at this visit. • Only twenty-six patients (12%) were reviewed in nephrology out-patients (creatinine was checked in all)
- 21. 104 RRT Survivors with Baseline and 6/12 eGFR 0 30 60 90 120 150 0 30 60 90 120 150 Baseline eGFR eGFRatsixmonths Median 60 Median 49
- 22. Reasons for poor rates of follow-up • Perception of renal recovery • Lack of specialist nephrology input as in-patient • Misapprehension of longer term implications of AKI
- 26. 0.20.51.02.05.010.0 Creatinine(mg/dl) No AKI AKI 1 AKI 2 AKI 3 Admission Peak Discharge ** ** ** **** ** ** NS Versus Admission: NS p > 0.05; * p < 0.05; ** p < 0.01 Prowle, J.R. et al. Clin J Am Soc Nephrol 9, 1015-23 (2014).
- 27. Patients with No AKI: Creatinine & Urea
- 28. Reduced Production of Creatinine Limits Its Use as Marker of Kidney Injury in Sepsis Doi, JASN 20: 1217–1221, 2009
- 29. 1221 Patients in hospital ≥5 days after Major Surgery
- 30. AKI No AKI Baseline eGFR 78.0 (32.4) 89.2 (23.6) Discharge eGFR 76.3 (33.65) 95.9 (24.0) p 0.72 <0.001
- 31. Scheme for AKI Follow-up Kirwan, Prowle. Nephron 2015
- 32. Specialist follow-up may be beneficial
- 33. Managing Patients after AKI • Minimise severity of initial injury • Avoid secondary injury – Provide least harmful RRT – Avoid fluid overload • Recognize incidence and severity of CKD • Arrange appropriate follow-up • Treat CKD risk factors • Avoid recurrent AKI
- 34. UK / Aus&NZ Fluid Removal Survey……. https://www.surveymonkey.com/r/VPNT8XB
Notas del editor
- The severity of AKI has been linked with the risk of subsequent CKD in another analysis of US Veterans Health Administration patients [12], with greater odds of CKD associated with the a more severe AKI category in the RIFLE classification, and with the greatest odds for those patients requiring RRT.
- In a cohort of 1610 patients who had AKI and recovered to normal serum creatinine, half developed CKD after 36 months. In addition, these patients had a 1.5-fold higher risk of death during follow-up compared to matched controls without AKI [14]
- A total of 45 cohorts, including 1,555,332 people, were included in the meta-analyses, grouped into four study populations: a general population with ascertainment of albuminuria as ACR, a general population with ascertain- ment of albuminuria by dipstick, a high-risk population, and a chronic kidney disease population.
- Sections of kidneys 14 days after right nephrectomy to remove 50% of renal mass and 45 min of ischemia of left kidney followed by reperfusion (right) or corresponding nonischemic nephrectomy controls (left). Paraffin sections of tissue perfusion fixed with periodic acid-lysine-paraformaldehyde were stained with hematoxylin and eosin (H&E; top) or immunohistochemically stained for the differentiation marker Na+-K+-ATPase (middle) or PDGF-B (red) and PDGFR-β (green; bottom). The images are from the outer stripe of the outer medulla, chief site of original ischemic damage. Top and middle: reproduced from Ref. 48 with permission from the American Society for Investigative Pathology. Bottom: unpublished archival tissue from Ref. 48. Original magnifications: ×100 (top); ×200 (middle and bottom).
- Relationship between sodium intake by intravenous infusion of isotonic saline and mean arterial blood pressure (top), creatinine clearance rate (middle), and albumin excretion rate (bottom) in sham or I/R rats 35 days after surgery. *P < 0.05 compared with I/R rats at the same sodium intake.
- For example, in a cohort of 3679 patients with diabetes followed for 10 years, hospitalization complicated by AKI of any severity was associated with an independent 3.6-fold increase in rate of developing CKD stage 4, with a doubling of risk for each further AKI episode [13].
- Figure 2: Hospital Admission, Peak and Hospital Discharge Creatinine (log scale) in 700 hospitalizations involving an ICU stay of 5 or more days with survival to hospital discharge. Boxes 25% to 75% centiles with solid line at median, whiskers 1.5x interquartile range from box. Non-overlap of notches suggests significant difference in medians at the 0.05 level. Asterisks indicate statistical difference between paired creatinine values, Wilcoxon Signed Rank Test.