Acute kidney Injury

Question 1

A 78 year old man has been hospitalised for one week following a stroke complicated by pneumonia. Routine biochemistry shows that his serum creatinine has increased to 280umol/L (60-120) from 110 on admission. How would you manage this situation?

Answer 1

Impression
With recent hospital admission and elevated creatinine from baseline, I am predominantly concerned about an acute kidney injury in this elderly gentleman. Causes of AKI can be grouped into pre-, renal, and post-renal causes. Most likely this man has a pre-renal AKI, and in particular given his pneumonia I am concerned about sepsis as the underlying cause and would want to assess for and treat this emergently.

Pre-renal
- dehydration
- poor oral intake in setting of stroke
- sepsis, other causes of shock
Renal
- ATN
- AIN
- HUS, other vasculitis
Post-renal
- catheter blockage

Question 2

AKI - Assessment

Answer 2

Assessment
Would assess for evidence of systemic toxicity/HD instability, emergently manage if so using A to E approach, call MERT etc.

Question 3

AKI - History

Answer 3

History

• PC: oliguria/anuria,
• REDS: LOC, confusion, fever, rigors, tachy/palps
• renal: exposure to toxins, other causes of glomerular disease
• post-renal: sx of bladder retention

Question 4

AKI - Examination

Answer 4

Examination

• Appearance + vitals
• hydration status
• abdo examination: tenderness
• assess IDC for obstruction

Question 5

AKI - Investigation

Answer 5

Investigations
Key
- UEC (creatinine, eGFR)
- CMP
- septic screen

Bedside: urinalysis, VBG (sepsis, lactate), Urine MCS
Bloods: FBC, UEC, LFT, CRP/ESR, blood cultures, CMP
Imaging: CXR as part of septic screen, renal US

Question 6

AKI - Management

Answer 6

Management
- call for senior help, renal consult

Supportive management is mainstay (Pre-renal)
- appropriate fluid resus if low fluid volume, and for sepsis
- cease reno-toxic and GFR reducing meds in this setting including ACEi, NSAIDS, ABx
- consider prescribing diuretics to increase flow
Post-renal
- unblock Catheter
- bladder scan, introduce Catheter if bladder retention

Definitive

• empirical ABx for sepsis
• refer to renal for definitive treatment of renal causes of AKI and kidney injury.