3. Dr. Haas invented the first dialysis machine designed
for humans and in 1928 he treated 6 patients.
4. Dr. Haas invented the first dialysis machine designed
for humans and in 1928 he treated 6 patients.
All of them died.
5. In 1943, Willem Kolff’s, working in Nazi
occupied Netherlands created the
second human dialysis machine from
a washing machine, juice cans and
sausage casings.
In 1943 he dialyzed his first patient, a
young man with acute nephritis.
6. In 1943, Willem Kolff’s, working in Nazi
occupied Netherlands created the
second human dialysis machine from
a washing machine, juice cans and
sausage casings.
In 1943 he dialyzed his first patient, a
young man with acute nephritis.
7. In 1943, Willem Kolff’s, working in Nazi
occupied Netherlands created the
second human dialysis machine from
a washing machine, juice cans and
sausage casings.
In 1943 he dialyzed his first patient, a
young man with acute nephritis.
8. In 1943, Willem Kolff’s, working in Nazi
occupied Netherlands created the
second human dialysis machine from
a washing machine, juice cans and
sausage casings.
In 1943 he dialyzed his first patient, a
young man with acute nephritis.
Dr. Haas
9. In 1943, Willem Kolff’s, working in Nazi
occupied Netherlands created the
second human dialysis machine from
a washing machine, juice cans and
sausage casings.
In 1943 he dialyzed his first patient, a
young man with acute nephritis.
Dr. Haas
0 for 22
10. In 1943, Willem Kolff’s, working in Nazi
occupied Netherlands created the
second human dialysis machine from
a washing machine, juice cans and
sausage casings.
In 1943 he dialyzed his first patient, a
young man with acute nephritis.
In 1945, a 67-year-old woman in
uremic coma presented to Dr Kolff.
Dr. Haas
0 for 22
11. In 1943, Willem Kolff’s, working in Nazi
occupied Netherlands created the
second human dialysis machine from
a washing machine, juice cans and
sausage casings.
In 1943 he dialyzed his first patient, a
young man with acute nephritis.
In 1945, a 67-year-old woman in
uremic coma presented to Dr Kolff.
Dr. Haas
Regained consciousness after 11
hours of hemodialysis.
0 for 22
18. Patients with primary diagnosis of AKI have
higher mortality when they are:
admitted on week-ends
admitted to smaller hospitals
James et al. Weekend Hospital Admission, Acute Kidney Injury, and Mortality.
Journal of the American Society of Nephrology (2010) vol. 21 (5) pp. 845-851
19. ICU associated AKI is
characterized by a
d e l a y b e t w e e n
a d m i s s i o n a n d
d e v e l o p m e n t o f
acute renal injury
21. Risk
Increase in Cr of 1.5-2.0 X baseline or
urine output < 0.5 mL/kg/hr for more than 6 hours.
Injury
Failure
Loss of function
End-Stage Renal disease
22. Risk: Inc Cr 50-100% or U.O. < 0.5 mL/kg/hr for > 6 hrs
Injury
increase in Cr 2-3 X baseline (loss of 50% of GFR) or
urine output < 0.5 mL/kg/hr for more than 12 hours.
Failure
Loss of function
End-Stage Renal disease
23. Risk: Inc Cr 50-100% or U.O. < 0.5 mL/kg/hr for > 6 hrs
Injury: Inc Cr 100-200% or U.O. < 0.5 mL/kg/hr > 12 hrs
Failure
increase in Cr rises > 3X baseline Cr (loss of 75% of GFR) or
an increase in serum creatinine greater than 4 mg/dL, or
urine output < 0.3 mL/kg/hr for more than 24 hours or
anuria for more than 12 hours.
Loss of function
End-Stage Renal disease
24. Risk: Inc Cr 50-100% or U.O. < 0.5 mL/kg/hr for > 6 hrs
Injury: Inc Cr 100-200% or U.O. < 0.5 mL/kg/hr > 12 hrs
Failure: Inc Cr > 200% or > 4 mg/dL or U.O. < 0.3 mL/kg/hr >
24 hrs or anuria for more than 12 hours
Loss of function
persistent renal failure (i.e. need for dialysis) for more than 4
weeks.
End-Stage Renal disease
25. Risk: Inc Cr 50-100% or U.O. < 0.5 mL/kg/hr for > 6 hrs
Injury: Inc Cr 100-200% or U.O. < 0.5 mL/kg/hr > 12 hrs
Failure: Inc Cr > 200% or > 4 mg/dL or U.O. < 0.3 mL/kg/hr >
24 hrs or anuria for more than 12 hours
Loss of function: Need for dialysis for more than 4 weeks
End-Stage Renal disease
persistent renal failure (i.e. need for dialysis) for more than 3
months.
26. Risk: Inc Cr 50-100% or U.O. < 0.5 mL/kg/hr for > 6 hrs
Injury: Inc Cr 100-200% or U.O. < 0.5 mL/kg/hr > 12 hrs
Failure: Inc Cr > 200% or > 4 mg/dL or U.O. < 0.3 mL/kg/hr >
24 hrs or anuria for more than 12 hours
Loss of function: Need for dialysis for more than 4 weeks
End-Stage Renal disease : Need for dialysis for more than 3
months
27. nice criteria. do they work?
20,126 consecutive
admissions to a
university hospital
Excluded kids
Kidney transplant and
dialysis patients
Patients admitted for <
24 hours
Using RIFLE:
Risk 9.1%
Injury 5.2%
Failure 3.7%
Uchino S, Bellomo R, Goldsmith D. Crit Care Med 2006 Vol 34 1913-1917.
28. nice criteria. do they work?
20,126 consecutive
admissions to a
university hospital
Excluded kids
Kidney transplant and
dialysis patients
Patients admitted for <
24 hours
Using RIFLE:
Risk 9.1%
Injury 5.2%
Failure 3.7%
No Renal failure
82%
Failure
4%
Injury
5%
Risk
9%
Uchino S, Bellomo R, Goldsmith D. Crit Care Med 2006 Vol 34 1913-1917.
32. nice criteria. do they work in the icu?
University of Pittsburgh
has 7 ICUs
5,383 patients
Excluded dialysis
Subsequent admissions
Frequency of acute
Kidney failure:
No AKD 1,766
Risk 670
Injury 1,436
Failure 1,511
Hoste E, Clermont G, Kersten A. Crit Care 2006 Vol 310
33. nice criteria. do they work in the icu?
University of Pittsburgh
has 7 ICUs
5,383 patients
Excluded dialysis
Subsequent admissions
Frequency of acute
Kidney failure:
No AKD 1,766
Risk 670
Injury 1,436
Failure 1,511
No Renal failure
33%
Failure
28%
Injury
27%
Risk
12%
Hoste E, Clermont G, Kersten A. Crit Care 2006 Vol 310
34. No AKI Risk Injury Failure
0
5
10
15
20
25
30
RRT
LOS
ICU LOS
Mortality
35. No AKI Risk Injury Failure
0
5
10
15
20
25
30
RRT
LOS
ICU LOS
Mortality
36. No AKI Risk Injury Failure
0
5
10
15
20
25
30
RRT
LOS
ICU LOS
Mortality
37. AKIN criteria
refinement of RIFLE criteria
smaller change in Cr 0.3
time constraint of 48 hours for the diagnosis of
AKI
anyone requiring dialysis is stage 3 AKI
38. RIFLE v AKIN
RIFLERIFLE
R
Cr increased by
50-100%
I
Cr increased by
100-200%
F
Cr increased by more
than 200% or Cr > 4
L
Need for dialysis for >
4 weeks
E
Need for dialysis for >
3 months
39. RIFLE v AKIN
RIFLERIFLE
R
Cr increased by
50-100%
I
Cr increased by
100-200%
F
Cr increased by more
than 200% or Cr > 4
L
E
40. RIFLE v AKIN
RIFLERIFLE AKINAKIN
R
Cr increased by
50-100%
1
Cr increased by 0.3 or
50-100%
I
Cr increased by
100-200%
2
Cr increased by
100-200%
F
Cr increased by more
than 200% or Cr > 4
3
Cr increased by more
than 200%, Cr > 4, or
renal replacement
therapyL
Cr increased by more
than 200%, Cr > 4, or
renal replacement
therapy
E
41.
42. AKIN vs RIFLE
120,123 critically ill patients in
57 ICUs in New Zealand and
Australia
43. AKIN vs RIFLE
120,123 critically ill patients in
57 ICUs in New Zealand and
Australia
64%
16%
14%
6%
RIFLE
63%
18%
10%
9%
AKIN
None
Risk / 1
Injury / 2
Failure / 3
44. AKIN vs RIFLE
120,123 critically ill patients in
57 ICUs in New Zealand and
Australia
64%
16%
14%
6%
RIFLE
63%
18%
10%
9%
AKIN
None
Risk / 1
Injury / 2
Failure / 3
2.24
3.95
5.13
2.45
4.23
5.22
Risk / 1
Injury / 2
Failure / 3
mortality odds ratio vs no AKI
45. oliguria: sensitive or specific?
oliguria is a biomarker of ARF
Used in the definition of RIFLE and AKIN
How good is it at predicting AKICreatinine
46.
47. ICU patients and tracked hourly urine
outputs
oliguria: <0.5 ml/kg/hr
primary outcome: how predictive was oliguria
for subsequent AKI as defined by creatinine
239 patients, 723 days, 23 cases of hospital
acquired AKI
48. duration of oliguria AKI the next day No AKI next day
None 5 443
≥1 hour 18 257
≥2 hours 15 194
≥3 hours 13 125
≥4 hours 12 95
≥5 hours 7 75
≥6 hours 5 50
≥12 hours 4 9
49. duration of oliguria AKI the next day No AKI next day
None 5 443
≥1 hour 18 257
≥2 hours 15 194
≥3 hours 13 125
≥4 hours 12 95
≥5 hours 7 75
≥6 hours 5 50
≥12 hours 4 9
50. duration of oliguria AKI the next day No AKI next day
None 5 443
≥1 hour 18 257
≥2 hours 15 194
≥3 hours 13 125
≥4 hours 12 95
≥5 hours 7 75
≥6 hours 5 50
≥12 hours 4 9
51. duration of oliguria AKI the next day No AKI next day
None 5 443
≥1 hour 18 257
≥2 hours 15 194
≥3 hours 13 125
≥4 hours 12 95
≥5 hours 7 75
≥6 hours 5 50
≥12 hours 4 9
52. ICU associated AKI is
characterized by a
d e l a y b e t w e e n
a d m i s s i o n a n d
d e v e l o p m e n t o f
acute renal injury
63. etiologies of arf
Seventy percent have concurrent oliguria
< 400 mL/day
< 0.5 mL/kg/hr in children
< 1 mL/kg/hr in infants
Complicates 5-7% of hospitalizations
64. Community acquired
49.7%
Hospital acquired
50.3%
Hou SH, Bushinsky DA, Wish JB. Am J Med 1983; 74: 243-8.
Nash K, Hafeez A, Hou S. Am J Kidney Dis. 2002; 39: 930-6.
Kaufman J, Dhakal M, Patel B, Et al. Am J Kidney Dis 1991; 17: 191-8.
65. Hou SH, Bushinsky DA, Wish JB. Am J Med 1983; 74: 243-8.
Nash K, Hafeez A, Hou S. Am J Kidney Dis. 2002; 39: 930-6.
Kaufman J, Dhakal M, Patel B, Et al. Am J Kidney Dis 1991; 17: 191-8.
84. Excreted Na
Filtered Na
FENa =
Urine Na x Urine Volume
Serum Na x UrCr x Urine Volume
Serum Cr
FENa =
Urine Na
Serum Na x UrCr
Serum Cr
FENa =
85. Excreted Na
Filtered Na
FENa =
Urine Na x Urine Volume
Serum Na x UrCr x Urine Volume
Serum Cr
FENa =
Urine Na
Serum Na x UrCr
Serum Cr
FENa =
Urine Na x Serum Cr
Serum Na x UrCr
FENa =
87. FENa the easy way
FENa is a small number 0.1% to 3%
88. FENa the easy way
FENa is a small number 0.1% to 3%
So the calculation will be 0.001-0.03 prior to
converting to percent by X 100
89. FENa the easy way
FENa is a small number 0.1% to 3%
So the calculation will be 0.001-0.03 prior to
converting to percent by X 100
So make the fraction small by putting the small
numbers over the big numbers
90. Sr Na
FENa the easy way
FENa is a small number 0.1% to 3%
So the calculation will be 0.001-0.03 prior to
converting to percent by X 100
So make the fraction small by putting the small
numbers over the big numbers
91. Sr Na
Sr Na
FENa the easy way
FENa is a small number 0.1% to 3%
So the calculation will be 0.001-0.03 prior to
converting to percent by X 100
So make the fraction small by putting the small
numbers over the big numbers
92. Sr Na
Sr Cr
Sr Na
FENa the easy way
FENa is a small number 0.1% to 3%
So the calculation will be 0.001-0.03 prior to
converting to percent by X 100
So make the fraction small by putting the small
numbers over the big numbers
93. Sr Na
Sr Cr
Sr Na
Sr Cr
FENa the easy way
FENa is a small number 0.1% to 3%
So the calculation will be 0.001-0.03 prior to
converting to percent by X 100
So make the fraction small by putting the small
numbers over the big numbers
94. Sr Na
Ur Na
Sr Cr
Sr Na
Sr Cr
FENa the easy way
FENa is a small number 0.1% to 3%
So the calculation will be 0.001-0.03 prior to
converting to percent by X 100
So make the fraction small by putting the small
numbers over the big numbers
95. Sr Na
Ur Na
Sr Cr
Sr Na
Sr Cr x Ur Na
FENa the easy way
FENa is a small number 0.1% to 3%
So the calculation will be 0.001-0.03 prior to
converting to percent by X 100
So make the fraction small by putting the small
numbers over the big numbers
96. Sr Na
Ur Na
Ur Cr
Sr Cr
Sr Na
Sr Cr x Ur Na
FENa the easy way
FENa is a small number 0.1% to 3%
So the calculation will be 0.001-0.03 prior to
converting to percent by X 100
So make the fraction small by putting the small
numbers over the big numbers
97. Sr Na
Ur Na
Ur Cr
Sr Cr
Sr Na
Sr Cr x Ur Na
x Ur Cr
FENa =
FENa the easy way
FENa is a small number 0.1% to 3%
So the calculation will be 0.001-0.03 prior to
converting to percent by X 100
So make the fraction small by putting the small
numbers over the big numbers
98. Why is the feNa high in ATN
Normally tubules reabsorb 98-99% of the
filtered sodium
99. serum Na x GFR x minutes in a day
urinary Na excretion
Why is the feNa high in ATN
Normally tubules reabsorb 98-99% of the
filtered sodium
100. Why is the feNa high in ATN
Normally tubules reabsorb 98-99% of the
filtered sodium
140 x 0.1 x 1440
180
101. Why is the feNa high in ATN
Normally tubules reabsorb 98-99% of the
filtered sodium
20160
180
102. Why is the feNa high in ATN
Normally tubules reabsorb 98-99% of the
filtered sodium
0.8%
103. Why is the feNa high in ATN
Normally tubules reabsorb 98-99% of the
filtered sodium
0.8%
So does ATN cause the tubules to fail to
reabsorb the 99%?
104. Why is the feNa high in ATN
Normally tubules reabsorb 98-99% of the
filtered sodium
0.8%
So does ATN cause the tubules to fail to
reabsorb the 99%?
NO
105. false positive FeNa
Contrast nephropathy
Acute glomerulonephritis
ATN with heart failure
ATN with burns
ATN with cirrhosis
106. Contrast nephropathy
Acute glomerulonephritis
ATN with heart failure
ATN with burns
ATN with cirrhosis
Low FeNa not pre-renal
107. Contrast nephropathy
Acute glomerulonephritis
ATN with heart failure
ATN with burns
ATN with cirrhosis
Low FeNa not pre-renal
108. Contrast nephropathy
Acute glomerulonephritis
ATN with heart failure
ATN with burns
ATN with cirrhosis
Low FeNa not pre-renal
these are cases of ATN where the
tubules effectively hold on to sodium
109. Why is the feNa high in ATN
Normally tubules reabsorb 98-99% of the
filtered sodium but now the GFR is 30 not 100
The fena reflects the behavior of the tubules
that are undamaged. Tubules affected by
ischemia have a GFR of zero.
110. serum Na x GFR x minutes in a day
urinary Na excretion
Why is the feNa high in ATN
Normally tubules reabsorb 98-99% of the
filtered sodium but now the GFR is 30 not 100
The fena reflects the behavior of the tubules
that are undamaged. Tubules affected by
ischemia have a GFR of zero.
111. Why is the feNa high in ATN
140 x 0.03 x 1440
180
Normally tubules reabsorb 98-99% of the
filtered sodium but now the GFR is 30 not 100
The fena reflects the behavior of the tubules
that are undamaged. Tubules affected by
ischemia have a GFR of zero.
112. Why is the feNa high in ATN
6048
180
Normally tubules reabsorb 98-99% of the
filtered sodium but now the GFR is 30 not 100
The fena reflects the behavior of the tubules
that are undamaged. Tubules affected by
ischemia have a GFR of zero.
113. Why is the feNa high in ATN
2.9%
Normally tubules reabsorb 98-99% of the
filtered sodium but now the GFR is 30 not 100
The fena reflects the behavior of the tubules
that are undamaged. Tubules affected by
ischemia have a GFR of zero.
114. Acute renal success
GFR is normally 100
mL/min
Total plasma volume
is only 3 liters
without massive
fluid reabsorption,
30 minutes to filter
all the plasma
115. Acute renal success
GFR is normally 100
mL/min
Total plasma volume
is only 3 liters
without massive
fluid reabsorption,
30 minutes to filter
all the plasma
116. Acute renal success
GFR is normally 100
mL/min
Total plasma volume
is only 3 liters
without massive
fluid reabsorption,
30 minutes to filter
all the plasma
117. Acute renal success
GFR is normally 100
mL/min
Total plasma volume
is only 3 liters
without massive
fluid reabsorption,
30 minutes to filter
all the plasma
Tubuloglomerular feedback
118.
119. Kaplan, Kohn. American J Nephrol, 1992; 12: 49-54.
fractional excretion of urea
Based on the physiologic increase in urea
reabsorption with pre-renal azotemia
Normal FE Urea is 50-65% in well hydrated
individuals
In prerenal azotemia this falls below 35%
Not affected by diuretics
Sr Na
Sr Cr x Ur Na
x Ur Cr
FENa =
120. Kaplan, Kohn. American J Nephrol, 1992; 12: 49-54.
fractional excretion of urea
Based on the physiologic increase in urea
reabsorption with pre-renal azotemia
Normal FE Urea is 50-65% in well hydrated
individuals
In prerenal azotemia this falls below 35%
Not affected by diuretics
Sr Urea
Sr Cr x Ur Urea
x Ur Cr
FEurea =
121. Kaplan, Kohn. American J Nephrol, 1992; 12: 49-54.
fractional excretion of urea
Based on the physiologic increase in urea
reabsorption with pre-renal azotemia
Normal FE Urea is 50-65% in well hydrated
individuals
In prerenal azotemia this falls below 35%
Not affected by diuretics
Sr Urea
Sr Cr x Ur Urea
x Ur Cr
FEurea =
122.
123.
124.
125.
126.
127. Carvounis, Sabeeha, Nisar, Et al. Kidney Int, 2002 Vol 62. p 2223-2229
FEurea in the differential diagnosis
of atn
102 patients with ARF
Gold standard was consultants full analysis
and retrospective analysis of response to
treatment.
Divided the cases into:
ATN
Prerenal without diuretic
Prerenal treated with diuretics
135. Acute kidney injury
as a cause of CKD
3,679 diabetic veterans
baseline creatinine 1.1, average age 61
primary outcome: development of CKD 4
secondary outcome: all-cause mortality
1,822 hospitalized
530 developed AKI at least once
88% AKIN 1
12% AKIN 2, 3
136.
137.
138.
139. 39,805 Kaiser Permanente
Hospitalized 1996-2003
all had pre-hospitalization GFR <45
among those who developed ARF (50%
increase in Cr and dialysis)
26% died in the hospital
among survivors:
GFR 30-44 42% required permanent dialysis within a
month of discharge
GFR 15-29 63% required permanent dialysis within a
month of discharge
151. Patient empowerment
talk to patients about what to do if they
become acutely ill
increase fluid intake
decrease diuretics
monitor blood pressure
172. Ronco’s landmark dialysis dose
study
425 patients with dialysis dependent acute
renal failure were randomized to one of three
doses of CVVH
20 mL/kg/hr of effluent
35 mL/kg/hr
45 mL/kg/hr
174. Ronco
425 CVVH 20/h vs. 35-45 ml/kg/h*
Bouman
106 CVVH 20ml/kg/h* vs. 48 ml/kg/h
Schiffl
160 Alternate day vs. daily hemodialysis
Saudan
206 CVVH 25 ml/kg/h vs. CVVHDF 42 ml/kg/h
Total (fixed effects)
Total (random effects)
1 10
Odds ratio
Study
n
treatment groups
*For purposes of analysis the two high-dose arms in Ronco were combined, as were the two low-dose arms in
Bouman. If these groups are removed the odds ratio is unchanged (1.94; P <0.001).
Kellum J. Nature Clin Practice Nephrol 2007 3: 128-9.
175. Ronco
425 CVVH 20/h vs. 35-45 ml/kg/h*
Bouman
106 CVVH 20ml/kg/h* vs. 48 ml/kg/h
Schiffl
160 Alternate day vs. daily hemodialysis
Saudan
206 CVVH 25 ml/kg/h vs. CVVHDF 42 ml/kg/h
Total (fixed effects)
Total (random effects)
1 10
Odds ratio
Study
n
treatment groups
*For purposes of analysis the two high-dose arms in Ronco were combined, as were the two low-dose arms in
Bouman. If these groups are removed the odds ratio is unchanged (1.94; P <0.001).
Kellum J. Nature Clin Practice Nephrol 2007 3: 128-9.
179. endpoint
Primary Endpoint:
All-cause mortality at day 60.
Secondary endpoints:
In-hospital death
Recovery of renal function (CrCl>20)
defined as complete if Cr was <0.5 over the baseline
Duration of renal replacement therapy
Dialysis free at 60 days
Duration of ICU stay
Return to previous home at day 60
193. Patients stratified by net fluid gain from
admission to initiation of CRT
Fluid in – fluid out
ICU admit weight X 100
194. longer ICU stay
higher mortality
more multi-organ
dysfunction
more likely to be
intubated
more inotropes
more sepsis
higher PRISM score
More fluid. More sick.
195. Worse fluid overload severity remained
independently associated with mortality (OR,
1.03; 95% CI, 1.01-1.05). The relationship
was satisfactorily linear and the OR suggests a
3% increase in mortality
for each 1% increase
in degree of fluid overload
at CRRT initiation.
196. 80 kg adult
Is and Os: 2,400 mL in (100 mL/hr) and
1,600 mL of urine (67 mL/hr)
Positive balance of 800 mL. If after 3 days the
patient becomes oliguric with 200 mL of
urine output for two days (2,200 mL positive
per day) before initiating CRT.
That patient would be up 6,800 mL or 8% of
bodyweight
24% increase in mortality compared to
someone with matched ins and outs
197.
198. observational data from SOAP study of ICU
care in Europe
198 ICUs
24 countries
147 patients
1120 had AKI
ARF defined as a Cr >3.5 or urine output <
500 mL
199.
200.
201.
202. Moreover, this would suggest that
prevention or management of
fluid overload is evolving as a
primary trigger/indicator for
extra-corporeal fluid
removal, and this may be
independent of dose delivery or solute
clearance.
Critical Care 2008, 12:169
203. summary
Prognosis is grim
We have two validated, consensus definitions
R isk
I njury
F ailure
L oss of function
E srd
Outpatient and inpatient acquired ARF differ in
etiology
Hospital acquired disease is your fault
AKIN
Stage 1
Stage 2
Stage 3
204. summary
FE of Urea is a validated way to separate pre-renal
from AKI even in the presence of diuretics
Use of high dose dialysis regardless of methodology
offers no survival benefit
Do not fluid overload your patient
Dopamine doesn’t work
205. Acute kidney injury is not a
specialist’s emergency; it is seen
commonly in acute medicine
and, as such, it is essential
that all physicians have the
confidence and skills to
identify and manage it.