Management of Acute Kidney Problems

667 Pages·2010·34.37 MB·English

by  Vijay Karajala

Management of Acute Kidney Problems
Achim Jörres
Claudio Ronco
John A. Kellum (Eds.)
Management of
Acute Kidney Problems
Achim Jörres, MD John A. Kellum Jr., MD, FACP, FCCM
Professor of Medicine Professor of Critical Care Medicine,
Deputy Director University of Pittsburgh
Chief, Department of Nephrology and School of Medicine
Medical Intensive Care Department Critical Care Medicine
Charité University Hospital 3550 Terrace Street, 606 Scaife Hall
Campus Virchow-Klinikum Pittsburgh, PA 15261
Augustenburger Platz 1 USA
13353 Berlin [email protected]
Germany
[email protected]
Claudio Ronco, MD
St. Bortolo Hospital
Director, Department of Nephrology
Dialysis and Transplantation
Viale Rodolfi, 16
36100 Vicenza
Italy
[email protected]
ISBN: 978-3-540-69413-7 e-ISBN: 978-3-540-69441-0
DOI: 10.1007/978-3-540-69441-0
Springer Heidelberg Dordrecht London New York
Library of Congress Control Number: 2009926256
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To Dinah, Marc, and Ann-Kristin; you are always at the center of my
heart and my thoughts.
Achim
To my wife, Paola, who gives true meaning to all my efforts.
Claudio
To my sister, Janine, whose tireless care at the bedside of critically ill
patients has made a world of difference and reminds me that all
intensive care nurses are our great unsung heroes.
John
Preface
Acute kidney disease (from injury to failure) is an important clinical area particu-
larly in the intensive care unit setting. As many as two thirds of critically ill patients
experience an episode of acute kidney injury during the course of their illness, and
about 5% of patients admitted to an intensive care unit will eventually require renal
replacement therapy. In these patients, in-hospital mortality is extremely high,
exceeding 50%, with acute kidney failure constituting a significant independent risk
factor for death.
As intensive care practitioners are often the initial or even sole providers of care to
seriously ill patients at risk for acute kidney injury, it is their responsibility to ensure
that adequate measures to prevent its occurrence are taken. Moreover, it is their task
to diagnose and evaluate incipient acute kidney disease, to initiate optimal supportive
care, and where possible, definitive treatment of this disorder.
It is the editors’ hope that this book will provide a reference for clinicians prac-
ticing in the intensive care unit, to help guide their care of patients with acute
kidney disease. In addition, we would like to address clinicians from many other
fields who are regularly involved in the care of patients at risk for acute kidney
injury. To that end we have brought together a group of international authors to
cover the most recent information on definition, epidemiology, pathophysiology,
and clinical causes of acute kidney injury and failure. Their understanding is a
fundamental prerequisite for the prevention of this disorder. Moreover, the earlier
parts of this book present differential diagnostic approaches for patients with acute
kidney disease and a detailed outline of important measures for its clinical man-
agement and the prevention of complications. The subsequent parts are dedicated
to the diagnosis and management of acute kidney disease in specific patient groups
and in particular disorders. Finally, the various key aspects related to the adequate
delivery of acute renal replacement therapy are detailed in the final parts of the
book.
The chapters included in this book are derived from clinical experience and report
the evidence for current clinical practice extracted from consensus statements or sys-
tematic analyses of the literature. We are truly indebted to the authors for their timely
and expert contributions. We very much hope that the present book will be a tool for
clinicians and a reference for investigators, students, and fellows.
The enormous effort of putting together such compilation of information and
references should stimulate all colleagues to use this book as a starting point for
good clinical practice that will certainly be enriched day by day in the coming
vii
viii Preface
months and years, by the expanding body of literature that the field of acute kidney
disease requires and also as a resource for continuous progress toward better care for
our patients.
Berlin, Germany Achim Jörres
Vicenza, Italy Claudio Ronco
Pittsburgh, Pennsylvania, USA John A. Kellum
Contents
Part I Definition and Classification of Acute Kidney Failure
1.1 Definition and Classification of Acute Kidney Injury ............ 3
Vijay Karajala and John A. Kellum
1.1.1 Introduction ........................................ 3
1.1.2 What Is Acute Kidney Injury? Current Controversies........ 3
1.1.3 Renal “Failure” or Renal “Success”...................... 4
1.1.4 Oliguria and Anuria.................................. 4
1.1.5 Prerenal Azotemia and Acute Tubular Necrosis ............ 4
1.1.6 Limitations of Biomarkers............................. 5
1.1.7 Renal Failure Defined by RIFLE Criteria ................. 5
1.1.8 The Concept of Acute Kidney Injury: A Paradigm Shift...... 6
1.1.9 Validation Studies Using RIFLE ........................ 6
1.1.10 Conceptual Development and Future Directions............ 8
1.1.11 Conclusions ........................................ 8
References ................................................ 8
Part II Overview of Pathophysiology, Etiology and Epidemiology
2.1 Mechanisms of Acute Kidney Injury and Repair................ 13
Joseph V. Bonventre
2.1.1 Introduction ........................................ 13
2.1.2 Injury ............................................. 14
2.1.3 Inflammation ....................................... 15
2.1.4 Paracrine Effects of Bone Marrow–Derived Stem Cells . . . . . . 17
2.1.5 Other Mechanisms to Limit or Stop Inflammation .......... 17
2.1.6 Repair............................................. 18
2.1.7 Conclusions ........................................ 18
References ................................................ 19
2.2 Uremic Toxins............................................. 21
Griet Glorieux, Wim Van Biesen, Norbert Lameire,
and Raymond Vanholder
2.2.1 Introduction ........................................ 21
2.2.2 Interfering Factors Due to Renal Replacement Therapy...... 21
2.2.3 Biochemical Alterations............................... 22
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x Contents
2.2.4 Factors Responsible for the Uremic Syndrome............. 23
2.2.5 Major Low-Molecular-Weight Uremic Retention Products.... 24
2.2.6 Middle Molecules ................................... 27
2.2.7 Factors Influencing Plasma
Concentration of Uremic Solutes........................ 28
2.2.8 Conclusions and Therapeutic Implications ................ 28
References ................................................ 28
2.3 Prerenal Acute Kidney Failure............................... 33
Eric A. J. Hoste
2.3.1 Introduction ........................................ 33
2.3.2 Pathophysiology..................................... 34
2.3.3 Causes of Prerenal Acute Kidney Failure ................. 34
2.3.4 Diagnosis of Prerenal Acute Kidney Injury................ 35
2.3.5 Epidemiology of Prerenal Acute Kidney Failure............ 35
References ................................................ 36
2.4 Intrinsic Acute Kidney Injury ............................... 39
Norbert Lameire
2.4.1 Epidemiology of AKI in the ICU Focusing
on Non-ATN Etiologies............................... 40
2.4.2 Clinical Evaluation of the Critically
Ill Patient with AKI .................................. 41
2.4.3 Summary of General Therapeutic Principles
of AKI in the ICU ................................... 50
References ................................................ 51
2.5 Urinary Tract Obstruction .................................. 53
Angela D’Angelo and Dorella Del Prete
2.5.1 Introduction ........................................ 53
2.5.2 Causes of Obstruction ................................ 54
2.5.3 Renal Damage Induced by Urinary Tract Obstructions....... 56
2.5.4 Clinical Signs....................................... 57
2.5.5 Diagnostic Approach................................. 58
2.5.6 Instrumental Diagnostics.............................. 58
2.5.7 Radiologic Investigations.............................. 59
2.5.8 Renal Function After the Removal of an Obstruction........ 60
2.5.9 Treatment.......................................... 60
References ................................................ 61
2.6 Epidemiology of Acute Kidney Injury......................... 63
Tariq Ali and Paul Roderick
2.6.1 History ............................................ 63
2.6.2 Incidence .......................................... 64
2.6.3 Outcomes.......................................... 67
2.6.4 Summary .......................................... 71
References ................................................ 71
Contents xi
2.7 Economic Impact of Acute Kidney Failure..................... 75
Joseph F. Dasta and Sandra L. Kane-Gill
2.7.1 Quantifying Costs in the Intensive Care Unit .............. 75
2.7.2 Overview of Studies Reporting Costs
Associated with Acute Kidney Injury .................... 75
2.7.3 Clinical Studies of Costs Associated with AKI............. 78
2.7.4 Take Home Pearls ................................... 80
References ................................................ 80
Part III Diagnostic Evaluation and Procedures
3.1 Clinical and Laboratory Evaluation .......................... 83
Robert J. Anderson
Objectives to Understand..................................... 83
3.1.1 Introduction ........................................ 83
3.1.2 Presenting Manifestations of AKI....................... 83
3.1.3 Causes of AKI ...................................... 86
3.1.4 Evaluation of AKI ................................... 87
3.1.5 Summary .......................................... 91
References ................................................ 91
3.2 Kidney Function Tests and Urinalysis......................... 95
Sean M. Bagshaw
Objectives to Understand..................................... 95
3.2.1 Introduction ........................................ 95
3.2.2 Overview of Kidney Function .......................... 96
3.2.3 Assessment of Kidney Function ........................ 96
3.2.4 Summary .......................................... 105
References ................................................ 105
3.3 Renal Ultrasound.......................................... 109
Vicki E. Noble, Andrew Liteplo, and David F. M. Brown
3.3.1 Introduction ........................................ 109
3.3.2 Ultrasound Basics ................................... 110
3.3.3 Anatomy........................................... 110
3.3.4 Scanning Techniques................................. 111
3.3.5 Applications........................................ 111
3.3.6 Summary .......................................... 115
References ................................................ 116
3.4 Management of Acute Kidney Problems:
Indications for Renal Biopsy in Acute Renal Disease............. 117
Alan D. Salama
3.4.1 Introduction ........................................ 117
3.4.2 Renal Biopsy in Acute Renal Failure..................... 119
3.4.3 Complications of Biopsies............................. 120
3.4.4 Biopsy Processing and Adequacy ....................... 121