A session blog from Day 1 of State of the Art, London December 2015. See the full list.
Blogger: Tom Heaton
AKI: Who will get it?
The session started with a great introduction to the problems with AKI from Lui Forni, bringing together a lot of what we know about predicting AKI.
- The lack of a clear universal definition of AKI is a hindrance.
- Risk can be stratified according to susceptibility and exposures. Some of these are fairly well know e.g. CKD.
- We are probably looking at current biomarkers wrong – creatinine useful in CKD but less so in AKI – many impacting factors such as muscle wasting in the ICU.
- When we think about the aetiology of AKI in ICM, there are so many impacting factors.
- We should probably abandon the search for the renal troponin.
- Critical Care – Diagnosis, evaluation and management of AKI: a KDIGO summary – 2013 –
- The Renal Association AKI guideline –
Does it kill you?
After a brilliant opening session delivering the Gilston Lecture, Rinaldo Bellomo returned to provide a critical look at the impact of AKI on outcome.
- The key opening question: Do people die of AKI or with AKI?
- There is evidence of association, but not causation – indeed will we ever find this without randomising people to be given an AKI.
- Again the multiple different causes of AKI make it difficult to start with a clear biological model. The biological models we do have are very complex.
- If we do know that is kills you, there is little we can do about it at the moment.
- CKJ – The RIFLE & AKIN classifications for AKI – 2013 – http://ckj.oxfordjournals.org/content/6/1/8.full
- Kidney International – AKI in the ICU – http://www.ncbi.nlm.nih.gov/pubmed/21975865
Can you treat it?
Peter Pickkers followed on from these important questions by taking up the point made by Professor Bellamo; what can we actually do about it?
- Can we do anything about it? No
- Only current therapy is dialysis – support and not a treatment.
- Interventions so far have not lived up to intervention – latest one being investigated is alkaline phosphatase
- Again a lot of problems come back to definitions and understanding – can we target minimising initial injury or promoting recovery?
- NICE guidance on AKI – https://www.nice.org.uk/guidance/cg169
What are the long term effects?
Wrapping up the session, John Prowle really emphasised the importance of AKI on the long term health of the patient – this isn’t something that just gets completely better a lot of the time.
- The mechanism of injury and recovery in AKI is complex and our medical school models describing full recovery are probably inadequate.
- There is a clear association between AKI and the development of CKD.
- There are several impacting factors on this e.g. duration of insult, repeat injury.
- We should be aware that a ‘normal’ creatinine after an ITU stay doesn’t necessarily mean normal function – often significant muscle wasting through their illness.
- The impact of CKD on morbidity and mortality is significant, we need to be aware of it as a risk following ITU and think about follow up – could this be in the ITU clinic or GP?
- NEJM – Acute kidney injury and chronic kidney disease as interconnected syndromes – 2014- http://www.nejm.org/doi/full/10.1056/NEJMra1214243
- Nature – AKI; what’s the prognosis? – http://www.nature.com/nrneph/journal/v7/n4/full/nrneph.2011.13.html