Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Start in about two minutes, If that's ok, thank you yeah um dr, jack, please can you see the chat books as well, I can't either chen hong, yes um can you just send in a message just to see, make sure that we're on the same page and no it's fine I think okay uh okay. I think we're going to start now so good evening everyone my name's Debbie um one of the teaching fellows at Wigan um Today, we have Doctor jagdish genius in one of the st ones in medicine. Um We'll be talking us to acute kidney injury some of the causes of acute kidney injury and how we usually manage it as a junior doctor on the wards. Um In my experience, this is one of the most common presentation that we get being referred from emergency medicine to acute medicine. You know when we get our patient's who have really poor kidney functions or just some aki, so I think um I'll not speak much and uh doctor check this. You can take the stage. Please thank you, thank you, thank you for the interruption um Good evening everyone hope everyone is well um so I'm just gonna talk about acute kidney injury um So when when we see acute kidney injury, that's probably one of the most commonest condition being referred as an F one or an f two or an s. U. One as a junior doctor. You'll come across a lot of acute kidney injury, so it's quite a big topic. I've tried to summarize it so that um can fit in within an hour and just to summarize and make it easy today um So we'll start off with the introduction so acute kidney injury. As we all know, it's a rapid and uh reversible decline in renal function uh So that's probably an important key word when you compared to a chronic, it's reversible and evident by a rapid decline in g. F. R, over a period of hours two days. So anyone when you work in the hospital, usually you have if you have a computer system. Uh When you order for an renal function, there will be a g f r. Uh alongside with the u. N. S. So this is usually you get an e. G. F. R. Like an estimated glomerular filtration rate, but sometimes this can be might not be correct as well because this is an estimated reading, so usually for example if the they'll do an estimation reading for a patient, uh for example 80 kg, uh but the patient might be not be 80 kg at all, so that there might be some discrepancy in value, so sometimes it's good to use a creatinine clearance as well. Uh If you go into like creatinine clearance calculator, then you'll get a proper reading and so it can occur with a patient with usually uh with a normal renal function or any patient with chronic kidney disease, so they can have acute on chronic kidney disease, or they can have purely acute kidney injury and uh it's one of a significant problems in the acute medical on a daily basis. So uh this is this sadistic I got it from my trust, so at least 30% of an acute medical patient admitted to Medical Assessment Unit. Uh They have an evidence of AKI to varying degrees of severity and in a reason audit, which was done last year, it shows a mortality rate of 50%. Uh So any patient who comes in with a. K. I. You have to be very careful about it and managed it accordingly, so I'll start off my presentation with a case presentation uh So if anyone I'll just go through like a discussion, so you can just use the chat box in between, uh so that can be like an interactive session, so we got a 36 years old fit and healthy gentleman. Let's say you see this patient in a any who came with who comes with a five days history of diarrhea and warm eating and uh we generalized pathology and abdominal crime. He has a history of travelling one week ago and uh what would be your further history like what do you want to ask this patient. Someone could just post in the comment box and then we can just go through it, so 36 years old, quite quite a young gentleman uh Probably there's no past medical history just came in at a short history of diarrhea and warm eating. Um Because the history of travelling one week ago, anything else you guys want to ask him fever, stool content yeah. Uh yeah, so you probably want to ask more history on the diarrhea and warm eating. You know that it started five days ago, so you want to know uh what is the consistency is there any blood in the diarrhea and uh is it getting better over the five days because you know that's been going on for five days and then obviously you come to warm eating. How I mean how many episodes are they and any is it only food particles, any blood contain, and uh fever is very important and also you want to probe a bit more on the abdominal crime. How bad is how severe is. It will probably use your sockets um for to explain further on the history taking and uh fever is obviously very important uh just to see if there is any ongoing infection. Uh You probably want to ask a bit more on the travel history as well where the patient when uh because likely might be having some castro and society. So with that travel history, you will probably um narrow down your history to what likely the infection to be and uh has he warm. It'd urine output yes, so any patient who comes in with uh GI losses like diarrhea, warm eating, It's in your history taking. It's good to include some questions so that you know what houses hydration status like um so how much of fluids is he drinking, how much of you how good is urine output, um and uh whether there is any signs of symptoms of dehydration, So all this, it's important to be included in the history, so so that's probably the vague history for anyone who comes to diarrhea and warm eating, but let's say if you're suspecting that this patient is a kidney injury. Uh There's some other histories that you want to ask is um obviously alongside with the systemic illness like any other systemic illness and uh any symptoms of outlaw outflow obstruction because later on we'll be looking at the causes of the acute kidney injury, then you know that these symptoms of an outflow obstruction is important to rule out the post renal acute kidney injury. History of malignancy probably not so important in this case uh because of the young age and uh very short history, but it's good to have it in mind that if anyone with an elderly age group with prolonged symptoms and obviously you want to ask history of malignancy um medication this is important as well because there's a lot of medications out there over the counter medication can affect your renal function, so always remember to ask the patient if they have been recently started on a new medication or as they've been taking any over the counter medication history or family history of renal disease. Obviously, this is very important as well and uh past medical history, but in this patient is negative, so clinically, this patient seems to be dehydrated with coated tongue and lips. Uh Blood pressure's fine slightly tachycardic at 96. F febrile saturations are normal. Um examinations pretty normal so so like uh I mean like I explained earlier like um any patient who comes to diarrhea and more meeting it's always important to assess the hydration status and uh do you guys, anyone wants to just utilize the comment box just to say uh what are the symptoms and signs you see in, um How do you assess fluid status in a patient, nice auscult it by vessel, crabs, pitting edema, BP pulse yes, so anyone who comes uh with an acute kidney injury or generally, when you want to assess the fluid status, it's good to establish whether the patient is hypoallergenic or you're anemic or hyperkalemic or fluid overload. Because this is very important in terms of your management, um whether this you you you want to give more fluids for this patient or you think that this patient is you olymic, doesn't need any fluids or you feel that this patient is overloaded and you want to give some diuretics so to assess the fluid status. Obviously, you start from your regular BP pulse um the rate, the character, capillary refill time usually it's less than two second if you dehydrated, probably maybe prolonged, uh simple mucus membrane examination and uh just to see if your tongues are quoted and uh you can check for the skin turgor as well. JVp and then JVp maybe raised in a case of like fluid overload, so that's one of the signs that you know that this patient is overloaded heart sound. In terms of if you're suspecting a heart failure, then um you can listen to some gallop rhythm, or some other murmurs, bread sound just to see if um there is any fluids in the lung, so you might get some crackers and pitting edema. Also to suggest that the patient is overloaded. Uh do check at the sacral and peripheral um g. C. S. Sometimes. Um even when the patient's are dehydrated, they can they can be confused, especially in the elderly H group, so it's good to assess the g. C. S. And uh obviously the urine output so back to our patient uh he had the routine blood tests um so anyone just want to interpret the blood test for me today. The hemoglobin is 134, white cell is 7.2, platelet is 288 urea is 19.6, creatinine is 380 potassium 4.9, sodium 131, crp of 2 70 yes, normal fbc. I agree with that. Normal fbc, um so you can see. The blood gas has been given as well. The PH is 7.29 and bicarbonate is 15.8, but any comment about the renal function okay hi curtin in um reduce renal function, renal function quite bad. We need to compare base right um yes okay, so you can see, I mean some quite obviously know that the renal function is not normal um ideally in a, in a usual situation, you have to compare with the patient's baseline but given that we don't have the history of, I mean the baseline of this patient, but bear in mind that um this patient is quite young without any past medical history, generally fit and healthy, so you assume that this patient might have a normal baseline and um came up with a deranged kidney function, so you're suspecting that might be an a. K. I. Uh crp of 2 70. Obviously, that's not normal so that's ongoing infection, ph of 7.29, bicarbonate of 15.8. So that's a bit of acidosis there as well, so what's the differential with this patient and how would you manage anyone just a wild guess what do you think going on with this patient. Yeah previously, k I do to get through anxiety's yeah that's right, so possibly like this patient um came into the five days history of diary in warm eating, so you might be having some gastroenteritis, had a history of food intake five days, I mean, one week ago when he was traveling so he might be prerenal aki due to the gastroenteritis, um So, yeah that's good so how would you manage this patient, So whenever you see this patient, a any um alongside with the clinical history and examination, uh a two E approach is obviously very essential because with a two e. Obviously you can rule out the cause of the aKI and logistics be careful when you prescribe the energetics because this patient having an 80. I so make sure you check with your trust guideline or the pharmacies just to make sure that your your energetic doesn't interfere with the renal function, IV fluids, so that's that's why it's important to do a fluid status assessment, So um you know that this patient is dehydrated, his tachycardic, He has a coated tongue, dry skin um So you know that he will need a lot of fluids, so catheterized because you want to monitor the urine output. A streak, input output charting is important husband all nephrotoxic six, so any patient's with an a. K. I. Uh you will need to do what we call us. Medication review review all the medication um to see that if this medication needs to be suspended or needs any dose adjustment. If you're not too sure you can always check with the pharmacies, antibiotics were indicated, so make sure when you're prescribing antibiotics, I would say that most of the antibiotics um has its own renal adjusted dose, so do check with the b. N. F. Or with the pharmacies. If you want you're in deep and analysis, um usually any case of aki, especially Aki, stage three will come back to it later on. Uh you would need to do a urine dip analysis, ultrasound k. U. B, mostly for the post renal aki, uh If the patient is not responding for the treatment, so that's the first scenario like patient with a pre renal AKI so come to our definition now, so when you say Aki um it's generally arised in a serum creatinine of 26 micromole per liter or greater within this uh 48 hours, so I got this definition from the k legal guideline, uh so it's either it's either end or or so, it doesn't matter if it has only to fulfill one criteria to say that this patient is a k. Or 50% or greater rise in serum creatinine known or presumed to have occurred within the past seven days and a fall in urine output to less than 0.5 ml per kilogram per hour for more than six hours. Okay. A staging of AKI has been divided to three stages um depending on the serum creatinine and the urine output, so stage 12, and three, stage one when your serum crashing is more than 26 small per liter in 48 hours, or 1.5 to 1.9 times the baseline, so it's good that you have the baseline to know that if this patient is in AKI or not or urine output of less than 0.5 mL per kg power for six hours consecutively, so that's the reason when any patient been admitted with a. K. I. Uh you would need to insert the catheter so that you can monitor the urine output, stage two, when the serum creatinine is uh increased by 2 to 2.9 times the baseline or the urine output is less than 0.5 mL per kg power for more than 12 hours. Stage three. When your crediting level is uh more than three times of your baseline or an increase in serum creatinine to more than 354 or your urine output is less than 0.3 per ml per kg for more than 24 hours or an area for 12 hours, more than 12 hours, so back to our patient now, so let's assume that his bloods five days ago, the urea was five, creating in his 75 I mean and today the urea is 19.6, creating in his 3 80. How would you classify this his aki, which stage do you think he's in now some hospital lab results have been made easy to interpret. The AKI grade is generated. Um Yeah that's right so depending on the hospital you work in, but usually. Um when you request for a new, any so the e. G. F. R will be calculated and generated on the system, so you don't need to do your calculation yourself, but like I said the EGFR is an estimated global role of filtration rate, so sometimes it can be over or an underestimation for someone with a a bigger or a very small size, so in that case you might need to do a creatinine clearance using the calculator, and you can get a accurate loser, okay, so anyone which stage of aki do you think he is in, so let's um let's assume that his creatinine was 75 5 days ago and now it's 380 so we'll go back to the our staging so 75 3 80 that's more than three times isn't it, so we assume that the 75 was his baseline and uh so it's more than three times increase, so is obviously in a stage three a. K. I. So when we talk about acute kidney injury, uh This is a very important point like you need to know. The cause has been divided into three either prerenal uh renal, post renal like intrinsic, is known as the renal cost. So majority of patient comes in with an a. K. I. R. Due to prerenal cost and uh about 40% is intrinsic and 5% is post renal uh to prerenal course, um usually anything that impair the perfusion of the kidney like dehydration, subsys, heart failure, blood loss, vascular occlusion, so any causes that's causing some impaired perfusion to the kidney will lead to a prenatal cause a renal cause. Um usually when there is a damage to the kidney itself, damage to the nephron, damage to the tubules, damage to the glomerular, so this will cost the renal cost like glomerulonephritis, vasculitis, acute tubular necrosis, do two drugs toxins, interstitial nephritis, and uh for post renal due to the obstruction like can be due to a benign prosthetic hyperplasia or due to prostate cancer. It's causing outflow obstruction so that usually causes the post renal AKI can be due to ureteral stricture as well, natal stenosis or calculi. Assess risk factors for AKI, So it's not definitely this group of patient will get AKI, but uh they are usually at a higher risk, so if you encounter any any patient, more than 65 or a background of diabetes, hypertension, reason, surgery, uh drug history, nephrotoxic drugs, if the patient's are nephrotoxic drugs, sepsis, dehydrating illness, pre existing renal disease, so these are the group of patient's who are highly predisposed to get an a. K. I. It's always bear in mind mint in your history and examination uh make sure rule out the causes of the aki, so when when you encounter a patient in a any like, um so you know that you need to have a baseline in order to know that if this patient is having an a. K. I. Or a. C. K. D. But sometimes you do get patient's who's never been to your hospital, probably that's the first visit and you might be having a bit of confusion whether this patient is having an a. K. I. C. K. D. Uh So there are some other factors that you can look into to know that if this patient is having an a. K. I. C. K. D. Like the uh an email usually in a CKD patient, they have usually comes with anemia as well due to the insufficient edit tro pointing uh production, so but this is not there in AKI bone disease. Uh You know that CKD patient usually comes with hypocalcemia with hyper hyper phospho tamia and uh now a few other blood tests that you look at, can look into to know that if this patient is an a. K. I. C. K. D. Um kidney size and neuropathy I think this is like later stages because CKD due to the chronicity, when you do and scan you can see that it's uh if there is a, the kidney size usually is way smaller than the um normal size, so that then you know that this patient might be having something chronic rather than acute, so we go on to the second case today. Um So 70 years old gentleman came in with two days history of confusion, fever, reduce oral intake. Uh Past medical history of BPH on long term catheter, hypertension, So let's say you see this patient in a and e. And uh you saw the blood test done today. The hemoglobin was 120 white cell is 20 sodium is 148, potassium is 4.9, urea 60 creatinine is 200 crp is 99 you're lucky enough to know that this patient actually came into a and e two months ago. So you know that at that time two months ago, his creatinine was 95 his urea is 4.9. Um So you know that obviously it's in the AKI so which stages of AKI and what do you think the possible causes are anyone. Do you want just comment in the chat box, Stage two Yeah that's right, Stage two yeah correct. So first of all, I think um when we look back at the definition, I think stage two is about two times 222.9 times the baseline, so we assume that the baseline is 95 so he came into the creatinine of 200 that's probably around stage two of an achy. I uh but be careful when you, when you use any mean, be careful when you get the baseline of the patient because so these bloods were done two months ago and uh you need to track back what was the reason for admission two months ago because this patient might came in with some infection two months ago and might be having a. K. I. And when he was discharged, that's probably not his baseline so just make sure before you establish a baseline, have a look at what's the reason of admission previously so that um we don't underestimate the renal function, so stage two a. K. I. That's right creatinine increase more than two times, the 2 to 2.9 times to reference value, uh so the causes, so there can be a lot of uh reason here, um you know that it's a 70 years old came in with fever, reduce oral intake, so there's some infection going on, uh which obviously can affect your kidney, reduce oral intake, probably hypovolemia, which also can affect your kidneys. It's on a long term catheter, so you'll probably need to monitor the urine output as well, you're not too sure if that's been blocked and causing some post renal, so I would say this is a mixture of a prerenal and a post renal aki, so management of course uh like we discussed earlier uh full history and examination including a two E. Assessment fluid status um like we said just go through the fluid status assessment, so that we know this patient is um dehydrated or you olympic or hypothalamic and the moment, If you feel that this patient is hypoallergenic, then you can start giving some fluids. It says risk factors for Aki, think this patient probably has a lot of risk factors for aki, uh strict input output chart, optimize the hydration status, IV fluids, and stop nephrotoxin. I think this sets of management usually is the same for every patient who comes soon at AKI and blow it when you monitor the blitz for an a. K. I make sure include your blood gas as well because they can have some metabolic acidosis due to the kidney injury and uh Arenal amazing usually, if there is no improvement with the initial management, uh you will do a renal imaging like ultrasound kidneys just to see if you're missing out any obstruction uh that could be one of the cause of an achy, I send specialized blood tests, so when, when you do your history and examination uh I mean obviously you need to establish the cause of the AKI and if you're suspecting that it could be due to due to the intrinsic factor um like glomerulonephritis, n. T. G, b, m disease, or acute interstitial nephritis, then you have to consider sending the specialized blood test or the renal panel uh like the complement c three c for a, anca, n, t, g, b, m, and myeloma, but I think this is uh not in all cases. you don't usually routinely send these bloods only if it's clinically relevant and any patient with an AK, stage two and above uh consider advice from a kindness or referral to reno. I think this depends on the trust, so the trust where I work. We don't have a renal specialty there, but we do have a AKI nurse, so we uh visualize with AKI nurse or if needed, we usually discuss with self Arenal team why are the renal patient pass, so any patient with an AK stage two, we usually get some input from the renal team in salford, so if you're if you the trust you work in, if they have a renal department, then obviously you can get an input from the renal team, so for AKI stage three um just remember that the management is same as stage one and two, but any patient who comes unit aKI three within 24 hours of AKI, uh make sure to send the urine dip, stop the ACE and arb s. I would say stop the nephrotoxic drugs. If you're not too sure just go through the medication review with your consultant of pharmacies, I repeat creatinine within 24 hours and ultrasound kidney arenal track so these sets of investigation and assessment need to be done within 24 hours of an AKI alert and uh take a three. Obviously you need to discuss with the a. K. I. N. S. And the renal department and you would need what we call us the pharmacies. Medication review within 24 hours of the Ak, let this is just to stop and or reduce the dose of uh any medication that could alter with the renal function, so review medication so a lot of medication out there uh affects the kidney function and uh for example like those nephro toxins like Nsaid Ace inhibitor, arb s, contrast, amphotericin b, or any sort of antifungal uh This group of medical there's many more out there, but this is a few that have listed these medications. We call as nephrotoxin, so it can affect your kidney function. Uh It's good to stop and suspend this medication when the patient is having an AKI and put a note to review again. Once the patient is out of AKI to see if I need to be restarted, risk of reduced renal profusion like some anti hypertensive diuretics, antianginal, so this medication you might need to sort sort of reduce the dose because it might reduce the renal profusion further and uh worsens the AK, so need to review again risk of urinary retention in anticholinergics so that could worsen the AKI and some medication would need adjustment because excretion might be affected by renal impairment, So like for example metformin, you probably need to reduce the dose depending on the severity of the achy, I uh because of the risk of lactic acidosis, uh digoxin, lithium, and opioids. This group of drugs that dose has to be adjusted as well uh because it's usually excreted through renal. So any patient with a. K. I. The medication can accumulate and cause toxicity. So you need to review the dose. Again another question is when to dialyze a patient with a. K. I. Um so just remember that usually a patient with a. K. I. Who comes with uremia like your emmick symptoms, confusion, your emmick, pericarditis, your emmick flab, and careful opathy uh with severe acidosis, fluid overload, refractory hypochelemia like failure to respond to the medical treatment and yet anyway, so this is the five important group of patient's that would probably benefit from dialysis, but obviously you need to discuss with the renal team as well about this. Um renal referral like I said um any patient with stage four or five CKD. If you, if you're tall, you encounter CKD patient obviously stage four and five will need a renal referral because um they probably just to prep them for the dialysis and all intrinsic cause of a k. Like. We discussed earlier global rule on arthritis, interstitial nephritis, so this group of patient would need a renal referral because um the management may vary, they might they might be started on steroids or any any other medication uh with an advice from nephrology's inadequate response to treatment, um and also any renal transplant patient comes in with an a. K. I. Uh or a CKD per se. We need a renal reference and like we saw earlier like any stage two or three of a. K. I will need a renal referral as well depending on your trust guideline and that's my references thank you so much. Any questions, yeah, if there is no questions, then I will see you guys in the next session, So do you remember too log in every wednesday at 6:30 p.m. We do teaching every wednesday, so I think our next teaching is on pediatric respiratory condition next wednesday at 6:30 p.m. Um Thank you so much guys and uh please kindly fill up the feedback form. Anything else did you okay. Thank you. Everyone have a good good evening take care, bye.