Introduction
An acute kidney injury (AKI), acute kidney failure, or acute renal failure is when the kidneys suddenly stop working and cannot filter waste products in the blood. A rise in AKI cases has been observed in the United Kingdom (UK). Still, experts do not explain this trend clearly and continue investigating the field, including its pathophysiology and management (Bien et al., 2022). Despite its complex etiology, AKI remains one of the leading causes of morbidity and mortality, and much attention should be paid to primary-level care offered in an emergency department (ED) (Bien et al., 2022).
Over 67% of all reported cases are in adults, while only 2% occur in children (UK Renal Registry, 2020). In addition, of approximately 500,000 UK citizens, AKI complaints are about 1.5 million, meaning that more than 17% of patients might have two episodes, and 7% have more than two episodes. About 70 AKI cases per 1,000 ED admissions are observed, and 18% of patients die within 30 days without proper treatment (UK Renal Registry, 2020). These numbers prove the importance of learning AKI characteristics to prevent its progress, especially in older adults.
AKI has been a reason for multiple deaths for an extended period, but its definitions and staging criteria were elaborated only in 2012. Its significant symptoms include decreased urine output, fluid retention, fatigue, weakness, nausea, and confusion. The causes may be a specific condition that affects kidneys or direct physical damage.
Hypertension, heart failure, diabetes, sepsis, and postoperative complications are common risk factors for AKI (Yokota et al., 2018). The Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group offered the criteria to classify AKI complications in several stages (Figure 1). Creatinine levels and urine output should be regularly checked in patients with suspected AKI or other kidney problems. This project aims to discuss AKI pathophysiology, diagnosis, pharmacology, and treatment alternatives and improve overall knowledge of the disease.
Figure 1: KDIGO Classification Criteria for AKI
Discussion
Each element in the analysis of AKI in older adults plays an important role. Its pathophysiology shows what changes happen to the patient’s body. Diagnostic steps must be properly followed and explained so as not to miss a single point in clinical assessment at the ED. The discussion of pharmacology is necessary to identify what medications have the best effect. AKI treatment includes lifestyle changes, hospitalization peculiarities, and understanding the impact of other health conditions on the AKI’s progress.
Pathophysiology
AKI’s pathophysiology is complex due to its spontaneous nature and the inability to predict the failure of kidney functions. According to Yokota et al. (2018), three mechanisms should be identified: hemodynamic, oxidative stress, and inflammation. First, renal blood flow decreases, leading to acute cell injury/dysfunction. Second, oxidative stress or tubular ischemia is characterized by the imbalance between reactive oxygen manifestation and antioxidant defense (Yokota et al., 2018).
Inflammatory cells provoke fluid loss and promote proinflammatory cytokine release (Blanco et al., 2019). Vascular damage is hard to predict, but the injury of intrarenal vessels negatively affects renal perfusion. In addition to preventing the progress of vascular and tubular changes, repairing the damaged areas and restoring the body’s functions is essential.
Diagnosis
The case presented in the introduction demonstrates how a physician should examine a patient with suspected AKI. People in ED should take blood and urine tests to check for abnormalities and recent changes. Many hospitals worldwide follow the KDIGO classification to identify the serum creatinine level and the AKI stage at the first examination (Yokota et al., 2018). Even if a slight increase in 0.3 mg/dL within the next 48 hours is observed, treatment should be initiated (Gameiro et al., 2020). In addition, attention is paid to urine output because its decrease to 0.5 mL/kg/h during the next six hours is noticed, and the patient is at risk for AKI (Gameiro et al., 2020).
The National Institute for Health and Care Excellence admits that ultrasound is not commonly used to examine the urinary tract (Yokota et al., 2018). Still, when it is impossible to identify the cause of AKI, and the risk of obstruction is possible, healthcare providers use ultrasound to observe kidney changes (National Institute for Health and Care Excellence, 2010). All these steps are necessary to predict AKI complications and choose the right course of treatment.
Pharmacology
Pharmacological treatment should promote improvements in several directions. First, vasopressor support is possible with Noradrenaline, Vasopressin, or Terlipressin (Gameiro et al., 2020). The second-line treatment focuses on the stabilization of renal functions. It includes non-steroidal anti-inflammatory drugs (NSAIDs), aminoglycosides, or angiotensin-converting enzyme (ACE) inhibitors (National Institute for Health and Care Excellence, 2010). If the levels of potassium or calcium are low, infusions are recommended. Finally, it is necessary to remove toxins from the body with the help of nephrotoxic drugs, including antibiotics.
Treatment
Treatment of patients with AKI must be based on shared decision-making and ethical standards of care. ED healthcare providers must inform the patient about the current condition, possible complications, and other factors affecting recovery. If an inadequate response to the offered medication is observed within the next 48 hours, new counseling with a nephrologist is required (National Institute for Health and Care Excellence, 2010). To deal with hypovolemia complications, individualized fluid therapy and diuretics are prescribed intravenously (Gameiro et al., 2020). The dosage should be reorganized as soon as positive changes in vital signs and laboratory tests are observed.
Conclusion
The evaluation of AKI pathophysiology and diagnosis proves that this condition is not always easy to identify. In most cases, people are diagnosed with AKI when they need care at EDs. To classify the diagnosis and choose a treatment course, attention should be paid to creatinine levels and urinary output. Although mortality and morbidity rates are high in AKI patients, people can completely recover by following pharmacological and lifestyle recommendations.
References
Bien, Z., et al. (2022) ‘Trends in hospital admissions associated with an acute kidney injury in England 1998–2020: a Repeated Cross-Sectional Study. SN Comprehensive Clinical Medicine, 4(1), 53, pp. 1-9.
Blanco, V. E. et al. (2019) ‘Acute kidney injury pharmacokinetic changes and its impact on drug prescription’, Healthcare, 7(1), pp. 1-9.
Gameiro, J. et al. (2020) ‘Acute kidney injury: from diagnosis to prevention and treatment strategies’, Journal of Clinical Medicine, 9(6), pp. 1-21.
National Institute for Health and Care Excellence (2019) Acute kidney injury: prevention, detection and management. Web.
UK Renal Registry (2020) Acute kidney injury (AKI) in England – a report on the nationwide collection of AKI warning test scores from 2018. Web.
Yokota, L. G. et al. (2018) ‘Acute kidney injury in elderly patients: narrative review on incidence, risk factors, and mortality’, International Journal of Nephrology and Renovascular Disease, 11, pp. 217-224.