Episode 30 - Acute Kidney Injury (AKI) in the SICU with kidney_boy aka Dr. Joel Topf

Written By Dennis Kim

Learning Objectives

By the end of Rounds you should be able to:

1. Understand the importance of changes in serum creatinine and urine output on the classification, management, and prognosis of AKI

2. Discuss the potential benefits of balanced crystalloid solutions

3. Describe the physiologic and pathologic effects of antidiuretic hormone (ADH) on water and sodium homeostasis

4. Recognize, evaluate, and institute therapy for patients with hyponatremia

5. Discuss the indications, timing, and appropriateness of performing a DDAVP clamp for patients with severe hyponatremia

6. Understand the role of renal replacement therapy in the management of patients with severe rhabdomyolysis


Take-Home Points

  • For surgical patients at-risk or for whom you are concerned about for the development of AKI, consult your Nephrology colleagues EARLY!!! Do not wait or allow for AKI to get a foothold before calling for help.

  • Trends and changes in urine output and serum creatinine are the best markers for the development of AKI. The role of biomarkers in prognosticating the development and severity of AKI remain to be elucidated.

  • Use of balanced salt solutions in both critically and non-critically ill patients is associated with improved outcomes - where possible, stick with Lactated Ringers or Plasma-Lyte versus Normal Saline

  • For major surgical patients at-risk for complications, a more liberal fluid strategy in the acute peri-operative period may result in a decreased incidence of AKI.

  • Although rare, osmotic demyelination syndrome (previously known as cerebral pontine myelinolyssis [CPM]) can occur if serum Na+ is corrected too rapidly. However, this is extremely uncommon in the absence of severe hyponatremia (<115 meq/L).

  • In the absence of seizures, correct severe hyponatremia SLOWLY!!! Admission to the SICU and implementation of a proactive DDAVP clamp will prevent endogenous overcorrection.

  • For patients with severe metabolic derangements in the face of rhabdomyolysis, initiate intermittent hemodialysis EARLY followed by CVVHDF in the peri- and postoperative period.

Time Stamps

  • 00:12 Introduction

  • 3:25 Recognition & Potential Long-Term Complications of AKI

  • 5:16 Classification of AKI (from RIFLE to AKIN and KDIGO)

  • 10:30 Balanced Solutions (Salt ED, ICU one)

  • 12:33 Chloride & AKI

  • 13:51 NAGMA & AKI

  • 16:18 Utility of eGFR and CrCl

  • 18:15 The importance of urine output

  • 20:20 The Role of ADH & the Stress Response

  • 22:32 RELIEF study

  • 25:13 Case 1: Hyponatremia & CPM

  • 31:34 Physiologic Sequelae of Chronic Hyponatremia 

  • 32:57 Hyponatremia, Fall Risk, and Osteopenia

  • 35:20 Case 2: Severe Hyponatremia in a Patient with Schizophrenia

  • 37:09 Approach to Severe Hyponatremia

  • 43:00 DDAVP Clamp

  • 47:14 Management of Hyponatremia complicated by Seizures (Tweetorial)

  • 51:16 Case #3: Rhabdomyolysis & AKI

  • 53:51 Acute Management of Severe Rhabdomyolysis

  • 54:45 RRT Modalities

  • 59:05 How Much Fluids is Too Much in Patients with Rhabdo Induced AKI

  • 1:00:54 HCO3 & Mannitol for Rhabdomyolysis (BICMAN Trial)

  • 1:04:19 Outro

Recommended Readings & Resources

Journal Articles

AKI in the Critically Ill: Reviews

Bagshaw SM, Bellomo R, Devarajan P, Johnson C, Karvellas CJ, Kutsiogiannis DJ, Mehta R, Pannu N, Romanovsky A, Sheinfeld G, Taylor S, Zappitelli M, Gibney RT. Review article: Acute kidney injury in critical illness. Can J Anaesth. 2010 Nov;57(11):985-98. doi: 10.1007/s12630-010-9375-4. Epub 2010 Oct 8. PMID: 20931312.

Bagshaw SM, Bellomo R, Devarajan P, Johnson C, Karvellas CJ, Kutsiogiannis DJ, Mehta R, Pannu N, Romanovsky A, Sheinfeld G, Taylor S, Zappitelli M, Gibney RT. Review article: Renal support in critical illness. Can J Anaesth. 2010 Nov;57(11):999-1013. doi: 10.1007/s12630-010-9376-3. Epub 2010 Oct 8. PMID: 20931311.

Classification Systems for AKI

Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P; Acute Dialysis Quality Initiative workgroup. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 2004 Aug;8(4):R204-12. doi: 10.1186/cc2872. Epub 2004 May 24. PMID: 15312219; PMCID: PMC522841.

Mehta RL, Kellum JA, Shah SV, et al. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007;11(2):R31. doi:10.1186/cc5713

KDIGO 2012 AKI Guidelines

  • https://kdigo.org/wp-content/uploads/2016/10/KDIGO-2012-AKI-Guideline-English.pdf

Ülger F, Pehlivanlar Küçük M, Küçük AO, İlkaya NK, Murat N, Bilgiç B, Abanoz H. Evaluation of acute kidney injury (AKI) with RIFLE, AKIN, CK, and KDIGO in critically ill trauma patients. Eur J Trauma Emerg Surg. 2018 Aug;44(4):597-605. doi: 10.1007/s00068-017-0820-8. Epub 2017 Jul 17. PMID: 28717983.

Hyponatremia

Baek SH, Jo YH, Ahn S, et al. Risk of Overcorrection in Rapid Intermittent Bolus vs Slow Continuous Infusion Therapies of Hypertonic Saline for Patients With Symptomatic Hyponatremia: The SALSA Randomized Clinical Trial. JAMA Intern Med. Published online October 26, 2020. doi:10.1001/jamainternmed.2020.5519

Spasovski, G., Vanholder, R., Allolio, B., Annane, D., Ball, S., Bichet, D., Decaux, G., Fenske, W., Hoorn, E., Ichai, C., Joannidis, M., Soupart, A., Zietse, R., Haller, M., van der Veer, S., Van Biesen, W., & Nagler, E. (2014). Clinical practice guideline on diagnosis and treatment of hyponatraemia, European Journal of Endocrinology, 170(3), G1-G47.

Balanced Salt Solutions

Semler MW, Self WH, Wanderer JP, Ehrenfeld JM, Wang L, Byrne DW, Stollings JL, Kumar AB, Hughes CG, Hernandez A, Guillamondegui OD, May AK, Weavind L, Casey JD, Siew ED, Shaw AD, Bernard GR, Rice TW; SMART Investigators and the Pragmatic Critical Care Research Group. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018 Mar 1;378(9):829-839. doi: 10.1056/NEJMoa1711584. Epub 2018 Feb 27. PMID: 29485925; PMCID: PMC5846085.

  • Link: https://www.nejm.org/doi/pdf/10.1056/NEJMoa1711584?articleTools=true

Self WH, Semler MW, Wanderer JP, Wang L, Byrne DW, Collins SP, Slovis CM, Lindsell CJ, Ehrenfeld JM, Siew ED, Shaw AD, Bernard GR, Rice TW; SALT-ED Investigators. Balanced Crystalloids versus Saline in Noncritically Ill Adults. N Engl J Med. 2018 Mar 1;378(9):819-828. doi: 10.1056/NEJMoa1711586. Epub 2018 Feb 27. PMID: 29485926; PMCID: PMC5846618.

  • Link: https://www.nejm.org/doi/pdf/10.1056/NEJMoa1711586?articleTools=true

Restrictive versus Liberal Perioperative Fluids

Myles PS, Bellomo R, Corcoran T, Forbes A, Peyton P, Story D, Christophi C, Leslie K, McGuinness S, Parke R, Serpell J, Chan MTV, Painter T, McCluskey S, Minto G, Wallace S; Australian and New Zealand College of Anaesthetists Clinical Trials Network and the Australian and New Zealand Intensive Care Society Clinical Trials Group. Restrictive versus Liberal Fluid Therapy for Major Abdominal Surgery. N Engl J Med. 2018 Jun 14;378(24):2263-2274. doi: 10.1056/NEJMoa1801601. Epub 2018 May 9. PMID: 29742967.

  • Link: https://www.nejm.org/doi/pdf/10.1056/NEJMoa1801601?articleTools=true

Rhabdomyolysis

Eneas JF, Schoenfeld PY, Humphreys MH. The Effect of Infusion of Mannitol-Sodium Bicarbonate on the Clinical Course of Myoglobinuria. Arch Intern Med. 1979;139(7):801–805. doi:10.1001/archinte.1979.03630440059020

Chavez, L.O., Leon, M., Einav, S. et al. Beyond muscle destruction: a systematic review of rhabdomyolysis for clinical practice. Crit Care 20, 135 (2016). https://doi.org/10.1186/s13054-016-1314-5

Nielsen JS, Sally M, Mullins RJ, Slater M, Groat T, Gao X, de la Cruz JS, Ellis MK, Schreiber M, Malinoski DJ. Bicarbonate and mannitol treatment for traumatic rhabdomyolysis revisited. Am J Surg. 2017 Jan;213(1):73-79. doi: 10.1016/j.amjsurg.2016.03.017. Epub 2016 Jun 14. PMID: 27381816.

Textbooks

The Fluid, Electrolyte, and Acid-Base Companion, 1st ed.

  • http://pbfluids.com/2017/09/the-fluid-electrolyte-and-acid-base-companion/

Nephrology Secrets, 4th ed.

  • https://www.amazon.com/Nephrology-Secrets-Edgar-Lerma-FACP/dp/0323478719

Social Media

Twitter: @kidney_boy

Hyponatremia Tweetorial by Joel Topf

  • http://pbfluids.com/2020/09/hyponatremia-tweetorial/

Twitter: @traumaicurounds

Websites

Precious Bodily Fluids - musings of a salt whisperer

http://pbfluids.com

DDAVP Clamp by Joel Topf

  • http://pbfluids.com/2020/10/ddavp-clamp/

Contrast Associated/Induced Nephropathy by Joel Topf

  • http://pbfluids.com/2019/11/contrast-associated-or-contrast-induced-nephropathy-who-the-hell-knows-st-john-ascension-grand-rounds/

emDocs Cases: Evidence-Based Recommendations for Rhabdomyolysis

  • http://www.emdocs.net/emdocs-cases-evidence-based-recommendations-for-rhabdomyolysis/

Taking Care of Severe Hyponatremia with DDAVP

  • https://emcrit.org/pulmcrit/taking-control-of-severe-hyponatremia-with-ddavp/

Dennis Kim
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