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Acute Kidney Injury

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Information about Acute Kidney Injury

Published on July 5, 2008

Author: galegoo

Source: slideshare.net

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Acute Kidney Injury André Lopes R2 – Clínica Médica EPM UTI / PS - HSP

“ Azotemia and oliguria represent not only disease but normal responses of the kidney to extracellular volume depletion or decreased renal blood flow” Crit Care Med 2008 Vol. 36, No. 4 (Suppl.)

RIFLE criteria Time for consensus Intensive Care Med 2001 Acute renal failure. The Second International Consensus Conference of the AcuteDialysis Quality Initiative (ADQI) Group. Crit Care 2004 Necessidade : - Definir critérios diagnósticos - Injúria com alto VPP de mortaildade - Classificação em severidade

Crit Care Med 2008 Vol. 36, No. 4 (Suppl.)

- Abosaif et al. - Hoste et al. - Uchino et al. - Ali et al. Uchino 20,126 Risk 2.5 (OR) <0,001 (mortalidade) Injury 5.4 <0,001 Failure 10.1 <0,001 Validação : vários estudos Crit Care Med 2008 Vol. 36, No. 4 (Suppl.)

Ostermann and Chang - 41.972 pacientes admitidos em UTI na Alemanha e Inglaterra - 10 anos de seguimento - Injúria Renal Aguda : 15.019 pacientes – 35,8 % R 17,2 % 20,9 % I 11,0 % 45,6 % F 7,6 % 56,8 % - Mortalidade sem AKI : 8,4 % - Terapia de substituição renal : não se mostrou fator independente de mortalidade Ostermann M, Chang RW: Acute kidney injury in the intensive care unit according to RIFLE. Crit Care Med 2007 ; 35:1837–1843

Crit Care Med 2008 Vol. 36, No. 4 (Suppl.)

Crit Care Med 2008 Vol. 36, No. 4 (Suppl.) - Aproximadamente 60 – 70 % dos pacientes admitidos em UTI apresentam AKI seguindo os critérios do escore RIFLE; - Cinco por cento ( 5 % ) de todos pacientes em UTI necessitam de TRS; - Incidência aumentando progressivamente; - AKI tem forte relação com tempo de permanência em UTI; - AKI é fator independente de mortalidade ; - AKI com TRS – mortalidade de 50-60 %, sendo que de 5 a 20 % dos sobreviventes necessitam de TRS.

Crit Care Med 2008 Vol. 36, No. 4 (Suppl.)

Crit Care Med 2008 Vol. 36, No. 4 (Suppl.)

Crit Care Med 2008 Vol. 36, No. 4 (Suppl.) Mais usados : creatinina, uréia e bioquímica urinária; Têm grandes limitações quando usados isoladamente, e mesmo associados no intuito de diagnosticar “the real-time changes in the GFR “; Consequência : atraso no diagnóstico e no suporte terapêutico ; Necessidade imediata de novos exames.

Mais usados : creatinina, uréia e bioquímica urinária;

Têm grandes limitações quando usados isoladamente, e mesmo associados no intuito de diagnosticar “the real-time changes in the GFR “;

Consequência : atraso no diagnóstico e no suporte terapêutico ;

Necessidade imediata de novos exames.

Crit Care Med 2008 Vol. 36, No. 4 (Suppl.)

Crit Care Med 2008 Vol. 36, No. 4 (Suppl

Troponin – like ??? A multinational, multicenter study. JAMA 2005; 294:813–818

Cystatin C - Proteína endógena de baixo peso molecular produzida por células nucleadas; - Produção constante ; - 99 % tem filtração glomerular, com degradação tubular proximal ; - Não secretada ou reabsorvida; - Relação inversa com a TFG ; - Grande vantagem : Detecção precoce da queda na TFG; - Atualmente sendo testada em múltiplos estudos clínicos ; - Melhores indicações : idosos, crianças, transplantados, cirróticos e desnutridos. Cystatin C-based calculation of glomerular filtration rate in kidney transplant recipients. Kidney Int 2006.

Crit Care Med 2008 Vol. 36, No. 4 (Suppl.)

Neutrophil gelatinase-associated lipocalin “ Tremendous potential for early diagnosis” Produção epitelial ( rins, pulmões e TGI ) Elevação muito precoce – 2 a 3 horas após início da injúria Atualmente dois grandes estudes multicêntricos em andamento Identification of neutrophil gelatinase-associated lipocalin as a novel early urinary biomarker for ischemic renal injury. J Am Soc Nephrol 2003 ; 14:2534–2543

Neutrophil gelatinase-associated lipocalin

“ Tremendous potential for early diagnosis”

Produção epitelial ( rins, pulmões e TGI )

Elevação muito precoce – 2 a 3 horas após início da injúria

Atualmente dois grandes estudes multicêntricos em andamento

Crit Care Med 2008 Vol. 36, No. 4 (Suppl.)

Crit Care Med 2008 Vol. 36, No. 4 (Suppl.)

Crit Care Med 2008 Vol. 36, No. 4 (Suppl.)

Ostermann M, Chang RWS: Acute kidney injury in the intensive care unit according to RIFLE. Crit Care Med 2007 ; 35:1837–1843

Septic acute kidney injury accounts for close to 50% of all cases of acute kidney injury in the intensive care unit and, in its various forms, affects between 15% and 20% of intensive care unit patients Etiologia Multifatorial : - fatores hemodinâmicos : ischemia x hyperemic acute renal failure - Mecanismos não hemodinâmicos : injúria celular Combination of immunologic, toxic, and inflammatory factors that may affect the microvasculature and the tubular cells. . Crit Care Med 2008 Vol. 36, No. 4 (Suppl.)

Crit Care Med 2008 Vol. 36, No. 4 (Suppl.)

NECROSE TUBULAR AGUDA APOPTOSE TUBULAR Crit Care Med 2008; 36[Suppl.]:S198–S203

McCullough PA, Adam A, Becker CR, et al: Risk prediction of contrast-induced nephropathy. Am J Cardiol 2006; 98:27K–36K

“ Risk marker ” : - Mais importante : baseline renal filtration ( TFG < 60 mL/min ) - Outros fatores contributivos : Diabetes mellitus Insuficiência Cardíaca Drogas nefrotóxicas Instabilidade hemodinâmica / Hipovolemia Anemia – independentemente da etiologia - Fatores são ADITIVOS - Risk scoring in the ICU : ainda não validado Até o momento : DRC – risco de 50 % de AKI Crit Care Med 2008 Vol. 36, No. 4 (Suppl.)

A meta-analysis of the renal safety of isosmolar iodixanol compared with low-osmolar contrast media. J Am Coll Cardiol 2006; 48: 692–699

Crit Care Med 2008 Vol. 36, No. 4 (Suppl.) S205

Crit Care Med 2008 Vol. 36, No. 4 (Suppl.) S219

Management of renal replacement therapy in acute kidney injury: A survey of practitioner prescribing practices . Clin J Am Soc Nephrol 2007; 2:623–630

Crit Care Med 2008 Vol. 36, No. 4 (Suppl.)

Acute Dialysis Quality Initiative Web site. www.adqi.net . Accessed January 2008

 

Tian ZM, Miranda DR: Quality of life after intensive care with the sickness impact profile. Intensive Care Med 1995; 21:422–428

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