Acute Kidney Injury and its Relationship with NSAIDs and ACE Inhibitors

Reminders and Housekeeping

IPE
EVENT/WORKSHOP - week 32
PSA DEBRIEF -
Lecture week 33 -
18th March
Midday
CMISGO timetable
reminder

• Objectives today

●
Revision
(pharmacology)
Acute Kidney Injury
(objectives for this
later
Pre-workshop
preparationAcute kidney injury (AKI) is associated with increased
patient morbidity and mortality, and represents a
significant financial burden for the NHS. The National
Confidential Enquiry into Patient Outcomes and Death
(NCEPOD)'s report, adding insult to injury, demonstrated
that only 50% of patients who died from
AKI received good care and 30% of
patients had predictable and avoidable
AKI.
It is therefore essential to identify patients at
risk of AKI early and to treat patients who develop it
promptly.
Clinical Medicine (RCoP); 2012, Prescott et al

Function of the Kidneys

• Location?

. How many ?!
· What size?
. Nearby organs?
Liver
Spleen
0
Left
kidney
Right
kidney
Adrenal
gland
Kidney
Adrenal
gland
Cortex
Medulla
Kidney

●
Which blood
vessel supplies
the Kidney?
●
Which blood
vessel supplies
the glomerulus?
●
How is blood
supplied to the
Glomeruli?
●
What takes blood
away from the
glomeruli?
●
What takes blood
away from the
kidney?

Kidney Blood Supply Diagram

Peritubular capillaries
Efferent
arteriole
Glomerulus
Afferent
arteriole
Interlobular
artery
Arcuate
artery
Interlobar
artery
Interlobular
vein
Arcuate
vein
Segmental
artery
Interlobar
vein
Renal
artery
Renal vein

Key Kidney Functions

. Maintain the proper balance of water and
minerals (including electrolytes)
· Filtration & excretion of waste (food, drugs, etc)
· Regulation of BP (Na, renin, etc)
· Secretion of certain hormones (Epo, Vit D)
. Acid base balance = maintaining pH of blood

Kidney Function and Supplementation

Acute Kidney Injury (AKI) Objectives

Pharmacy Year 2 AKI Learning Goals

• Familiarise yourself with the prevalence &
  epidemiology of AKI
• Familiarise yourself with the symptoms, risk factors
  and diagnosis of AKI
• Drugs which contribute to AKI
• Be familiar with guidelines for the treatment of AKI
• Have knowledge of the management regimens
• Pharmacists role in AKI

AKI Presentation in Practice

• New AKI

AKI on the
background of
CKD (CRF)
AKI in the
background of
ESRD

Definition of AKI

Acute kidney injury (AKI) is a
condition in which there is
rapid decline in kidney
function over a period of
hours to days, resulting in a
rapid reduction in kidney
function . Effectively this
means the kidney is unable to
maintain fluid, electrolyte and
acid-base homoeostasis.

Terminology & Definition of AKI

• ARF

AKI (universal definition)
"The term acute kidney injury has replaced
the concept of acute renal failure as it more
accurately describes that injury to the kidney
can occur before function fails" [Prescott et al,
2012]
· AKI - considered to be a spectrum of injury
(next slide)
. Even small increase in SCr is associated with
decreased long term survival in the critically ill
[Linder et al 2014]

The AKI Spectrum

• Decreased
  glomerular
  filtration
• Minimal
  elevations in
  serum
  creatinine
  (Cr)
• To complete
  anuric
  kidney
  failure

Anuria is non
passage of
urine,

What is Serum Creatinine (SCr)?

●
Creatinine is a waste
product generated
from the normal
metabolism of muscle
tissue
. Healthy kidneys freely
filter creatinine out of
your blood through
urine
●
SCr is measured via a
blood test

Classification of Chronic Kidney Disease

Classification of chronic
kidney disease using GFR
and ACR categories
GFR and ACR categories
and risk of adverse
outcomes
ACR categories (mg/mmol), description and range
<3 Normal to mildly
increased
3-30 Moderately
increased
>30 Severely
increased
A1
A2
A3
>90 Normal
and high
G1
No CKD in the
absence of markers
of kidney damage
GFR categories (ml/min/1.73 m2), description and range
60-89 Mild
reduction related
to normal range
for a young adult
G2
45-59 Mild-
moderate
reduction
G3a1
30-44
Moderate-
severe reduction
G3b
15-29 Severe
reduction
G4
<15 Kidney
failure
G5
Increasing risk
Increasing risk
1 Consider using eGFRcystatinC for people with CKD G3aA1 (see KDIGO recommendations 1.1.14 and 1.1.15)
Abbreviations: ACR, albumin:creatinine ratio; CKD, chronic kidney disease; GFR, glomerular filtration rate
Adapted with permission from Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group (2013) KDIGO
2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney International
(Suppl. 3): 1-150

Prevalence & Impact of AKI

Whilst this is partially true, in that AKI has not been picked up or
focussed on as it should have been

AKI Prevalence Data

The HES (Hospital Episode Statistics) data indicated that;
AKI was recorded for 2.4% of hospital admissions during 2010/11 (142,705 out of
3,792,951 admissions).
Prevalence ranged from 0.3% of patients aged 18 to 39, to 5.7% of people aged
≥80.
During the six-month period of EKHUFT (East Kent Hospitals University Foundation
Trust) data, laboratory research indicated that AKI was present in 15% of
admissions, though the EKHUFT population is older than the overall HES (hospital
episode statistics) population. When standardising for age, it was 14% of
admissions. Over a third of patients (38%) in EKHUFT who had AKI during the
study period had pre-existing chronic kidney disease.
When using HES data, the average duration of hospital stay was 16.5 days for AKI-
admissions, compared to just 5.1 days for admissions without AKI recorded. A
person with AKI had a length of stay 2.6 times longer than someone without AKI;
Using the HES data, just over a quarter (28%) of people with AKI recorded during
their admission died before hospital discharge. The odds of in-hospital death were
10-fold greater in a person with AKI compared to those without.
Analysis from HES data suggests that AKI was associated with around 12,000
excess deaths among inpatients in England

BBC News Report on Kidney Deaths

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Health
Flawed NHS care 'leads to 12,000 kidney
deaths a year'
By Prof Donal O'Donoghue
Former National Clinical Director for Kidney Care
@ 21 June 2013 Health
The quality of patient care in the NHS
is once again under the spotlight as
part of the investigation into
complaints after deaths at Furness
General Hospital.
In this week's Scrubbing Up, Prof
Donal O'Donoghue, National Clinical
Director for Kidney Care from 2007-
2013, warns a simple-to-avoid kidney
disorder is being missed leading to
around 12,000 unnecessary deaths a
year.
SPL
Keeping patients hydrated is a simple way of
preventing the condition

AKI Statistics (UK)

• Approximately one fifth of hospital admissions are
  associated with AKI [Argyropoulos et al 2019 BMC Nephrology]
• ~ third of in-patients develop AKI during their time
  in hospital [Argyropoulos et al 2019 BMC Nephrology]
• A fifth of these cases are considered avoidable
  [Argyropoulos et al 2019 BMC Nephrology]
• 100,000/year deaths associated with AKI. = to ten
  people every hour [KidneycareUK]
• A person with AKI length of stay 2.6 times longer
  than someone without AKI [HES data]