Acute kidney injury

The primary endpoint was death, MI, stroke, or ischemia-driven revascularization.

The primary safety outcome was a composite of contrast-associated AKI, acute kidney injury, or major bleeding.

And all this seems reasonable on the surface, doesn't it? But it assumes that complete revascularization is the strategy of choice.

And I've talked about this issue a lot, so I'm not going to go on forever, but I do think that we need to talk about it a little.

All components of the primary outcome except stroke, which was rare in both arms, was lower in the physiology-guided arm.

Safety, too, was impressively lower.

Both bleeding and AKI were lower with the physiology-guided approach, and the authors concluded that physiology-based PCI was better.

Of course, it's the only conclusion you can make from this trial.

Well, to wrap up our deep dive today, I want to leave everyone with a broader concept to analyze on your own.

Think back to our 68-year-old man who induced acute kidney injury simply by sweating in a 105-degree garage.

Yeah, poor guy.

Right.

But was and remain amazed at how difficult it is when you have more than one patient, because in anesthesia, often we just have one patient at a time, more often, not always.

then if you're a hospitalist, then if you're an emergency physician, to keep track of your patients and know what the next thing is that's coming up for them, but also when are they deteriorating? And I think if you had asked any of these physicians towards the end of this patient's care when they were clearly sick, If you had just jumped them in right away, they would have said, oh, this is a patient with sepsis or whatever the issue was and AKI, et cetera.

They would have been able to deal with that in a reasonable way.

But if you give them the patient three days prior and give them 29 other patients and then have them go through with limited nursing because they're always short-staffed, you can see how the situation arises.

Welcome back to the One Stem at a Time podcast, where we go through one clinical vignette at a time.

Today we're talking about acute kidney injury.

AKI is incredibly high yield because questions often give you a rise in creatinine and then ask you to determine where the problem is and what's occurring.

Is the kidney not getting enough blood flow? Is the kidney itself damaged? Or is the urine unable to get out? That gives us the classic framework of pre-renal, intrinsic, and post-renal AKI.

But before we get into those, let's start with a question.

A 72-year-old man presents to the emergency department with weakness and decreased urine output for the past two days.

Which of the following best explains this patient's renal dysfunction? Is it A, acute tubular epithelial cell injury, B, decreased renal perfusion with intact tubular function, C, immune-mediated inflammation of the renal interstitium, D, bilateral obstruction of urinary outflow, or E, immune complex deposition within the glomerulus? Take a few minutes to think about your answer.

And the correct answer is B, decreased renal perfusion with intact tubular function.

It also reduced ICU length of stay without an increased risk for renal failure or the need for renal replacement therapy.

And I think the last part matters, and that's where a lot of our earlier fears were, is that if we start to diurese them too early, we might be contributing to AKI or acute kidney injury.

And the FACT trial says that fear is not really something we need to worry about.

about.All right, now how do we bring this into our clinical practice?

Certainly, patients, their ARDS may have started with a pneumonia, and certainly they're gonna be at risk for hospital-acquired or ventilator-acquired pneumonia as well.

We've talked about the widespread systemic effects of ARDS.

And so not surprisingly, a lot of these patients may develop an AKI.

But I think the one thing that we always wanna think about is the impact on hemodynamics, because the physiologic link between our right ventricle and lung injury really impacts our ventilator choices.