AN OVERVIEW OF :
ACUTE KIDNEY INJURY (AKI
Hasan Basri
ACUTE KIDNEY INJURY (AKI)
(Cedera Ginjal Akut)
Another term : Acute Renal Failure
Many references / literatures still use this term
DEFINITION :
AKI is an abrupt (less then 7 days) and sustained decrease in
kidney function.
• changes in blood biochemistry : increased of serum
creatinine, blood urea nitrogen
• decreased of urine out put in 80-90% cases (10-20%
normal or increase) or both
• kidney function used to be normal
When the patient has a previous episode of kidney disease,
the term is : Acute on Chronic Kidney Injury (ACKI)
CLASIFICATION
AKI classified according to degree and outcome of renal
function by RIFLE criteria
R = Risk I = Injury F = Failure
L = Loss E = End Stage
1. Risk of Renal Dysfunction (R)
• serum creatinine increased 1.5 fold, or
• GFR decreased by more than 25%
• Less than 0.5 ml/kg/h of urine production for 6 hours
2. Injury of the Kidney (I)
• doubling of serum creatinine or
• GFR decreased by more by 50% or
• urine production less than 0.5 ml/kg/h in 12 hours
3. Failure of Kidney Function
• serum creatinine increased 3 fold, or
• GFR decreased by more than 75%
• less than 0.3 ml/kg/h of urine for 24 hours
4. Loss of Kidney Function
• Complete loss of kidney function for longer
than 4 weeks
5. End Stage Renal Disease
• The need for dialysis for longer than 3 month
GFR Criteria AND/OR Urine output Criteria
Risk of renal 50% decrease in creatinine or Urine output < 0.5 ml/kg/hr for
dysfunction > 25% decrease in GFR at least 6 hours
Two-fold increase in Urine output < 0.5 ml/kg/hr for
Injury to the creatinine or > 50% at least 12 hours
kidney decrease in GFR
Three-fold increase in creatinine Urine output < 0.3 ml/kg/hr
Failure of or > 75% decrease in GFR or for 24 hours (or anuria for
creatinine > 350 (acute rise) 12 hours)
kidney function
Loss of kidney Loss of kidney function > 4 weeks but
function < 3 months
ERF Established renal failure (loss of
function > 3 months)
Acute renal failure (ARF) classified according to degree and outcome by RIFLE criteria
CAUSES OF AKI
Causes of AKI divided into three matter :
1. Prerenal :
Decreased of renal perfusion (hypoperfusion)
2. Renal (Intrinsic)
Damage of parenchyma of the kidney (glomeruli,
tubules, intra-renal vasculature, interstitial nephritis)
3. Post-renal
Obstruction of urinary tract
PRERENAL CAUSES OF AKI
1. Shock :
• cardiogenic ahock
• distributive shock (e.g.sepsis, anaphylactic)
2. Hypovolemia – hypovolemic shock
• haemorhage
• gastrointestinal loss (vomiting, diarrhea)
• cutaneous losses (e.g.burns)
3. Renal hypoperfusion
• renal artery stenosis
• hepatorenal syndrome
4. Changes of water distribution (oedema)
• congestive hearth failiure
• hepatic failure
• nephrotic syndrome
RENAL / INTRINSIC CAUSES OF AKI
1. Glomerular disease
• glomerulonephritis
2. Tubular injury
• prolonged renal hypoperfusion
• toxin (snake venom), drugs (aminoglycosides),
3. Vascular
• vasculitis
• arterial or venous thrombosis
4. Interstitial nephritis
• infiltrative malignancy
• toxin (alcohol, metal)
• infection (leptospiral)
POST-RENAL CAUSES OF AKI
Obstruction :
• stone
• urethral stricture
• prostate hypertrophy
• pelvic tumor
• retroperitoneal fibrosis
Prerenal
Renal
Postrenal
DIAGNOSTIC
1. History of disease
• gastroenteritis, bleeding ?
• hearth disease
• toxin ? post infection ?
• stone disease ?
2. Investigation
A. Physical examination.
• blood pressure (hypotension/shock)
• anemic, dehydration
• renal colic, ballotment, full vesica urinaria
B. Blood chemistry
• haemoglobine, white blood cell
• blood ureum, serum creatinine
• potassium (K), sodium (Na)
• blood gas analysis
C. Radiology
• plain photo abdomen
• ultrasonography
DIGNOSTIC STEP OF AKI
Patient with :
Oligouria / Anuria
• Prerenal
History of Disease • Renal
• Post renal
• Shock
• ballotment
Physical Examination
• pain angulus
costovertebtalis
• full of VU
Imaging Laboratory test • BPH
BNO Routine
USG Abdomen BUN/SC
Electrolyte (K,Na
COMPLICATIONS
1. Volume overload
• acute pulmonary oedema
• acute left hearth failiure
2. Metabolic acidosis
3. Electrolyte imbalance
• hyperkalemia
MANAGEMENT
A. Manage the initial causes / initial disease properly
B. Patient must be hospitalized and admit in
Intensive Care Unit
• water, electrolyte and acid-base balance
• antibiotic
C. Renal Replacement Therapy
• dialysis
• ultrafiltration
PREVENTION
• Identify and treat patients most at risk
• gastroenteritis
• bleeding
• hearth failure
• pre- operation
• drugs / toxin
• infection
SUMMARY
• Acute Kidney Injury is an abruptly decrease of
kidney function characteristic by increase of BUN,
SC, K, and volume overload
• The causes divided into prerenal, renal /intrinsic
and post renal
• The most emerging complication are metabolic
acidosis, acute heart failure electrolyte imbalance
• The patients must admitted to Intensive Care Unit
• Prevention is the most important thing
