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Azotemia – silent
Uremia – symptomatic
Oliguria - < 400 mL/24
Anuria - < 100 mL/24 h
Nonoliguric ARF - > 400 ml / 24 h
Mortality in AKI
40-70% 10-50%
10%
Etiology-Prerenal
Hypovolemia
Hemorrhage
Skin losses (burns, sweating)
Gastrointestinal losses (diarrhea, vomiting)
Renal losses (diuretics, glycosuria)
Extravascular pooling (peritonitis, burns)
Ineffective arterial volume
Congestive heart failure
Neurogenic hypotension
cardiac arrhythmias
sepsis
anaphylaxis
liver failure
Vascular disease:
Renal artery stenosis
Intrinsic Renal Azotemia
Large Renal Vessel Disease
Thrombo-embolic disease
Renal Microvasculature and Glomerular Disease
Inflammatory: glomerulonephritis, allograft rejection
Vasospastic: malignant hypertension, scleroderma crisis, pre-
eclampsia, contrast
Hematologic: HUS-TTP, DIC
Tubulo-interestitial Disease
Acute Interestitial Nephritis (AIN), Acute cellular allograft rejection,
viral (HIV, BK virus), infiltration (sarcoid)
Intratubular Obstruction
myoglobin, hemoglobin, myeloma light chains, uric acid, tumor lysis,
drugs (indinavir, acyclovir, foscarnet, oxalate in ethylene glycol
toxicity)
Etiology-Intrarenal/Intrinsic
Intrinsic parenchymal damage of kidney
Blood clots
Prostate disease
Bladder disease
80
GFR
(mL/min)
40
6
Serum
4
Creatinine
(mg/dL)
2
0
0 7 14 21 28
Days
Figure: The abrupt drop in GFR but the S.Cr. does not start going up
for 24 or 36 hours after the acute insult .
the Acute Dialysis Quality Initiative group(2004)
Continuum of the renal injury
STAGEI I
STAGE STAGEIIII
STAGE
STAGEIIIIII
STAGE STAGEIV
STAGE IV STAGEVV
STAGE
LOSS
LOSS ESRD
ESRD
INJURY
INJURY FAILURE
FAILURE (L)
(L) (E)
(E)
RISK
RISK (I)
(I) (F)
(F)
(R)
(R)
Severity Outcome
RIFLE criteria/staging system
Definition of AKI based on “Acute Kidney
Injury Network” (AKIN-2007)
PaO2
20 mm of Hg
PaO2
10 mm of Hg
Granular cast
Granular cast
WBC cast
Classification
Hemodialysis
Hemofiltration
Continuous venovenous hemofiltration (CVVH)
Continuous arteriovenous hemofiltration
(CAVH)
Continuous arteriovenous hemodiafiltration
(CAVHD)
Peritoneal dialysis
Indication
Serum Cr>442μmol/L
Serum K+>6.5mmol/L;
Water intoxication
Azotemia
Serious metabolic acidosis
Hemodialysis Hemofiltration Peritoneal
dialysis
Assessment Rapid- Slow- Slow-
intermittent continuous intermittent
Vascular A、V A、V Abdominal
access catheter
Anticoagulation Usually required None required
required
Solute removal excellent excellent excellent