Management of Acute Kidney Injury
Acute Kidney Injury (AKI) in the ICU is commonly caused by hypotension, shock, inflammation, and microcirculatory dysfunction. Reversal of shock through intravenous fluids and vasopressors while avoiding harm from volume overload is the first step in mana
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Fadi A. Tohme and John A. Kellum
Case Presentation A 58-year-old female with a history of obesity, type 2 diabetes mellitus, essential hypertension and locally advanced uterine cancer was admitted to the intensive care unit with fevers, malaise, nausea and decreased urine output over the last 2 days. Her initial evaluation was relevant for a blood pressure of 87/48, pulse of 92/min and temperature of 101.3 F (38.5 C). She was alert, but appeared ill and confused. There was an implantable venous infusion ‘port’ in the right chest, no rales, costovertebral angle tenderness or lower extremity edema. Laboratory exam revealed a WBC count of 17.8 × 109/L, Hemoglobin of 8.8 g/dL, Platelets of 212,000 × 106/L. Serum sodium was 135 mEq/L, potassium 6.3 mEq/L, chloride 100 mEq/L, total carbon dioxide 12 mEq/L, blood urea nitrogen (BUN) 97 mg/dL and serum creatinine (SCr) 4.3 mg/ dL. Serum glucose was 270 mg/dL and lactic acid 4.6 mEq/L. She had an indwelling urinary catheter placed which yielded 50 cc of urine. Blood and urine cultures were sent. She was
F.A. Tohme Renal & Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, PA, USA J.A. Kellum (*) Critical Care Research, Center for Critical Care Nephrology, Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA e-mail: [email protected]; [email protected]
started on broad-spectrum intravenous antibiotics and a continuous infusion of insulin. Question What are the basics of management of Acute Kidney Injury (AKI) in this case? Answer Ascertainment and treatment of the underlying cause together with prevention of further injury and supportive care including renal replacement therapy. In this patient with septic shock the treating physician must simultaneously resuscitate and treat the source of sepsis while ruling out other treatable causes of AKI. This patient is in shock as evidenced by a low arterial blood pressure (made more profound by the history of hypertension) and hyperlactatemia which in a resting patient is evidence of cellular stress likely a function of inadequate tissue perfusion. The initial management involves the infusion of intravenous isotonic crystalloids and if necessary, vasopressors may be added to preserve tissue perfusion, if hypotension persists despite restoration of intravascular volume. Care should be taken to avoid fluid overload which is a significant risk in a patient with AKI. At the same time unresuscitated shock will injure multiple tissues including the kidneys. Sepsis is a leading cause of AKI and the most likely etiology given the case presented. However, other etiologies need to be excluded. For example, what medications was the patient taking? In addition, timely detection and relief
© Springer International Publishing Switzerland 2017 R.C. Hyzy (ed.), Evidence-Based Critical Care, DOI 10.1007/978-3-319-43341-7_43
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of urinary obstruction is important, especially in this patient with a history of locally advanced gynecologic cancer, which puts her at risk for ureteral obstruction
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