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Acute
Kidney Injury and Chronic Kidney Disease as an Interconnected Syndrome

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Acute
Kidney Injury and Chronic Kidney Disease as an Interconnected Syndrome

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Management of modifiable health predictors such as obesity and hypertension can minimise the progression of AKI to CKD.

Although the progression of AKI to CKD is a relatively new finding with relatively limited literature, there is enough evidence to imply that the two conditions are intertwined.

Management of short-term complications such as hypovolaemia, hypervolaemia and hyperkalaemia are important, but long-term health is also an important consideration

Hence, risk factors such as hypertension and obesity, which can contribute to the progression of AKI to CKD should be well-managed.

Nurses can promote education on how patients can manage these risk factors, in both medical and lifestyle aspects.

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Renal hypoxia in the pathophysiology of the acute kidney injury (AKI)-to-chronic kidney disease (CKD) transition.

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Renal hypoxia in the pathophysiology of the acute kidney injury (AKI)-to-chronic kidney disease (CKD) transition.

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Shinji Tanaka et al. Am J Physiol Renal Physiol 2014;307:F1187-F1195

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AKI

Declining in renal function characterised by a decrease in glomerular filtration in the kidneys leading to accumulation of waste, such as creatinine and urea in the blood.  (Bullock & Hales, 2012)

CKD

The MDRD-derived estimated glomerular filtration rate (eGFR) is less than 60ml/min on at least two occasions over a period of no less than 90 days

The urine albumin to creatinine ratio (ACR) is greater than 30mg/mmol or the urine protein to creatinine ratio (PCR) is greater than 50mg/mmol.(Lewis, Robert, 2009)

Mechanisms underlying progression of AKI to CKD

Nephron loss and glomerular hypertrophy.

Interstitial inflammation and fibrosis.

Endothelial injury and vascular rare faction.

Cell cycle and maladaptive repair. (Chawla & Kimmel,2012)

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Obesity and high central body fat increase the risk of developing CKD. This helps to increase risk of predisposing conditions such as hypertension, diabetes and chronic inflammatory disorders (Hall et al., 2014) .

Evidence shows that being obese increase chances of AKI-CKD. AKI is more likely to develop in patients with obesity.

Primary prevention measures aim to eliminate or reduce exposures to factors which causes CKD it involves strategies to reduce the incidence and prevalence of risk factors such as obesity and high blood pressure (Mount, Davies, Choy, Cook & Power, 2015).

Give patients a list of permitted food or fluids and encourage involvement in menu choices.

Provide patients with a measure of control with dietary restrictions food from home may enhance appetite.

Review disease process, prognosis and precipitating factors if known provides knowledge base from which patient can make informed choices(Endre et al., 2010).

Encourage patient to observe characteristics of urine and amount frequency of output because changes may reflect alternations in renal function and need for dialysis (Hall et al., 2014).

Provide emotional support to the patients and family.

Review fluid restriction. Remind patient to spread fluids over entire day and it include fluids in daily fluid counts (Endre et al., 2012).

Identify symptom requiring medical intervention decreased urinary output sudden weight gain, presence of edema, lethargy, bleeding, sign of infection, altered medication (Rahman, Shad & Smith, 2012).

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The risk of progression of AKI to CKD is increases with more severe and repeated episodes of AKI (Chawla & Kimmel, 2012). Therefore, the early and appropriate management of kidney function to prevent repeated episodes of AKI is major priority to minimize the progression from AKI to CKD.

1.  Hypoxia as a key player in the AKI-to-CKD transition.

Progression from AKI to CKD has complex mechanisms (Heung & Chawla, 2014).

Renal hypoxia is caused by decreased expression of vascular factors or associated with pericyte detachment then it lead to tubulointerstitial fibrosis, resulting in the progression to CKD (Shinji, Tetsuhiro & Masaomi, 2014). (See diagram below).

2. Age-related factor

After the age of 30 years, the Glomerular Filtration Rate (GFR) declines progressively and this age-related decline in kidney function can attribute to the effects of hypertension or other comorbidities such as cardiovascular disease (Phoon, 2012)

3.    Medication   management

All patient’s prescribed medications and over-the-counter products will be reviewed by healthcare provider including doses of medicines (Thakar, Christianson, Himmelfarb & Leonard, 2011).

Patient must also stop or avoid all unnecessary medicines include amphotericin or NSAIDs or herbal remedies or supplements that have significant nephrotoxic properties could further damage patient’s kidneys (Coca, Singanamala & Parikh, 2012).

4.Follow-up  plan

To prevent repeated episodes of AKI, the understanding of kidney health status is important.

Patient should follow-up which check the level of serum creatinine, estimated glomerular filtration rate (eGFR), and the amount of protein in the urine to detect reversible causes of renal ischemia within the next 6 to 12 weeks after discharge (Chawla, Amdur, Amodeo, Kimmel & Palant, 2011).

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The link between acute kidney injury and chronic kidney disease

AKI has been strongly linked to progressing or later developing CKD. (Chawala, Eggers, Star & Kimmel, 2014)

Risk factors in kidney diseases in general are very similar, as seen in the evidence provided (i.e. CKD and AKI risk factors are very similar). So by preventing one, you prevent the other.

Risk factors of Acute Kidney Injury vs Chronic Kidney Disease

|   Risk factor     |   AKI     |   CKD
|   Obesity            |   X         |   X
|   Hypertension  |   X        |   X
|   Smoking           |             |   X
|   Diabetic            |   X        |   X

Hypertension has been linked to the negative prognosis of AKI

Numerous studies have shown this link (Williams, Manias, Walker, & Gorelik, 2012)

Hypertension leads to stretched blood vessels in kidneys due to higher pressure of blood flow

This damages kidney vessels, preventing proper function of waste and fluid removal

Extra fluid vessels may further raise blood pressure, creating a dangerous cycle.

Obesity has been linked to the progression of AKI

Numerous studies have demonstrated this link (Danziger, et al., 2016)

Obesity increases blood pressure (Hall et al., 2014)

Increase in blood pressure increases sodium reabsorption in kidneys

This increases pressure in kidneys, causing volume expansion and hence damage.

Physical compression of kidneys from fat also causes damage.