Kidney Injury A Quick Guide for Medical Professionals #kidneyinjury #medicine #medicaleducation #surgeryeducation

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"Trauma Surgery: Questions and Answers." By Dr. Atef Ahmed

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A 65-year-old woman with well controlled type 2 diabetes mellitus presents with perforated appendicitis. She is taken to the operating room for exploration, drainage of intraabdominal abscess, and ileocecectomy. She is admitted to the surgical intensive care unit postoperatively in septic shock.
Overnight, she is resuscitated with 9 L crystalloid. She is now on norepinephrine and vasopressin infusions to keep her mean arterial pressure above 65 mm Hg. On postoperative day 1, she is hypoxic with pulmonary edema on chest x-ray.
Her serum potassium is 5.9 mmol/L, her serum creatinine increased from 1.5 to 5.4 mg/dL (0.4-1.3 mg/dL), her serum blood urea nitrogen is 60 mg/dL (7-20 mg/dL), her serum bicarbonate is 13 mmol/L (20-29 mmol/L), and her pH is 7.21. Her urine output is 0.3 mL/kg/hour for the last 12 hours.

What is the next step in managing her renal failure?

A. Continuous renal replacement therapy
B. Intermittent hemodialysis
C. Furosemide 80 mg intravenously
D. Dopamine infusion
E. Sodium bicarbonate infusion

ANSWER: A
Acute kidney injury in the postoperative period is associated with increased morbidity and mortality. Two classification systems were proposed in the early 2000s: the RIFLE criteria
and the Acute Kidney Injury Network (AKIN) staging system. These systems provide concise definitions of the extent of injury and prognosis. Both systems consider increases in serum creatinine, either an absolute number or an
increase from baseline, and urine output criteria. This patient had a marked increase in serum creatinine and has oliguria.
According to the RIFLE criteria, she has Failure; she is in AKIN stage III.
Additionally, she is acidemic, with a serum pH of 7.21 and bicarbonate of 13 mmol/L (20-29 mmol/L), and hyperkalemic. She also shows evidence of volume overload with hypoxemia and radiographic evidence of pulmonary
edema.
This patient has several indications for renal
replacement therapy.


Data regarding the optimal modality and timing of renal replacement therapy are conflicting. However, when patients are hemodynamically abnormal and require vasopressor support, a continuous mode of renal replacement therapy is preferred. Continuous modes require smaller volumes of
blood to be removed at a time compared with intermittent hemodialysis and are better tolerated in hypotensive patients.
A sodium bicarbonate infusion is used for patients with acidosis; however, starting a sodium bicarbonate infusion is generally not recommended until the serum pH is less than
7.15. Also, there are no data confirming any reduction in morbidity and mortality for its use in renal failure.
Aggressive diuretic therapy used in the early stages of AKI to treat volume overload and hyperkalemia is possible.
However, once a patient advances to renal failure, renal replacement therapy is the preferred modality of management. Low-dose dopamine infusions were once
erroneously thought to be renal protective via a mechanism of increased renal blood flow. There are currently no data to support the use of a dopamine infusion as prevention or
treatment of AKI.