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Acute Kidney Injury (AKI) occurs in

approximately 7%-10% of all hospitalized
patients

The incidence increase in ICU: 33%-60%

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Major risk factors for acute kidney injury (AKI)
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Comprehensive Clinical Nephrology, 4th ed. Elsevier, 2010
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JAMA, August 17, 2005Vol 294, No. 7, 813-818
 AKI is a clinical syndrome denoted by an
abrupt decline of GFR sufficient to decrease
the elimination of nitrogenous waste
products (Urea and creatinine) and other
uremic toxins.

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 The traditional paradigm divides AKI into:
Prerenal
Renal (intrinsic)
Postrenal

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International Journal of Nephrology and Renovascular Disease 2010:3 129140
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International Journal of Nephrology and Renovascular Disease 2010:3 129140
International Journal of Nephrology and Renovascular Disease 2010:3 129140
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International Journal of Nephrology and Renovascular Disease 2010:3 129140
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Comprehensive Clinical Nephrology, 4th ed. Elsevier, 2010
Tubular factors in the development of acute tubular necrosis.
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Comprehensive Clinical Nephrology, 4th ed. Elsevier, 2010
Vascular factors contributing to the development of acute tubular necrosis.

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Comprehensive Clinical Nephrology, 4th ed. Elsevier, 2010
International Journal of Nephrology and Renovascular Disease 2010:3 129140
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 Include:
Identification and monitoring of at-risk
populations
Development of more sensitive bio markers

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 Risk stratification scoring systems for AKI
The Acute Physiology and Chronic Health
Evaluation (APACHE) I, II
The Cleveland Clinic Foundation (CCF) score

CCF score : gender, CHF, LVEF, use of intra-

aortic balloon, chronic lung disease, insulin-
requiring DM, previous cardiac surgery,
emergency surgery, valve surgery, and serum
creatinine
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 Requires a careful of history and record
review, physical examination, and
interpretation of laboratory data
The history should include type and duration
of symptoms for urinary difficulty, estimates
of volume of urine, history of UTI or stone
disease, recent surgery and drug used
The record review should include nephrotoxic
medications or radiocontrast agents
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 Physical examination will reveal signs
important for diagnosis of the etiology of
AKI, sepsis or malignant disease, volume
status, skin or pulmonary manifestations of
systemic disease, cardiac rhythm
abnormalities or CHF, edema or ascites, mass
in flank or suprapubic mass.

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 Prerenal causes should be suspected
especially in AKI patients with clinical
symptoms of thirst or orthostatic
hypotension or tachycardia, reduced JVP,
decreased skin turgor and reduced axillary
sweating

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 In any patients with AKI, an obstructive cause
must be excluded because prompt
intervention to relieve obstruction can result
an improvement or complete recovery renal
function

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Assessment of urinalysis is valuable for DD/ of AKI

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Comprehensive Clinical Nephrology, 4th ed. Elsevier, 2010
The most important clinical and laboratory variables in the DD/
between prerenal and renal AKI are listed below

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Comprehensive Clinical Nephrology, 4th ed. Elsevier, 2010
Successful management of AKI requires early
recognition of the diagnosis, investigation of
the causes of AKI, management of
complications, timely of RRT, prevention of
ongoing kidney injury, aggressive supportive
care and correction of primary disorders.

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 Monitor the adequacy of fluid replacement
The goal is to achieve and maintain
euvolemia
Isotonic saline is the appropriate replacement
fluid for plasma losses
No significant difference noted between
isotonic saline and albumin 4% for fluid
resuscitation

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 K supplementation of replacement fluids
should not be given unless there is
hypokalemia
CVP between 8-12 mmHg, MAP > 65 mmHg,
and urine output > 0.5 ml/kg/min

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 Diuretics may be useful in volume overload in
AKI
Their use is not associated with reduced
mortality or better kidney recovery

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Comprehensive Clinical Nephrology, 4th ed. Elsevier, 2010
 AKI patients have an increase risk of PEM
Nutritional support should be directed to
ensure adequate nutrition, to prevent PEM,
to promote wound healing and tissue repair,
to support immune system function, to
accelerate recovery, and to reduce mortality

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 Protein and non protein calories should be
provide calculated energy expenditures
Protein = 1.4-2.5 gr/kg/day
Calories = 25-40 KCal/kg/day
Lipid = 30% of total calories
Enteral feeding is the preferred of nutritional
supplementation

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 Modalities of RRT include IHD, CRRT, hybrid
therapies such SLED
The main considerations are:
Timing of initiation of dialysis
The modality of dialysis
Dose of dialysis

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 Cause of AKI quite frequent found in hospital
Mortality of AKI is still high especially in ICU
The factors which influence the mortality are
delay of diagnosis, failed to determine the
severity of AKI, inadequate of management
and delay to administer RRT
The management of AKI include fluid
replacement, diuretic and vasoactive agents,
setting of nutrition, RRT, and treatment of
primary disorder
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