Acute Kidney Injury(AKI) is the term that has newly displaced the term ARF. AKI is described as an abrupt decrease in kidney function, which encloses both injury (structural damage) and impairment (loss of function). Classification of AKI involves (a) Pre-renal AKI, (b) Acute Post- renal obstructive nephropathy and (c) Intrinsic acute kidney disease. Of these, only intrinsic AKI represents true kidney disease, while pre-renal and post-renal AKI are the outcome of extra renal diseases leading to decreased glomerular filtration rate (GFR). (1)
Based on the Kidney Disease, Improving Global Outcomes (KDIGO) report, the prevalence of AKI in hospitalized patients ranges from 17 to 31%. AKI – related inpatient care is also associated with increased healthcare costs due to prolonged hospitalizations, additional investigations and the development of complications such as the need for renal replacement therapy (RRT), Sepsis, a commonly experienced scenario in an intensive care unit ( ICU ), often leads to multi organ dysfunction and the kidney is one of the organs frequently affected. Acute kidney injury (AKI) occurs in about 19% patients with moderate sepsis, 23% with severe sepsis and 51% with septic shock, when blood cultures are positive. (2) Among the SEPSIS AKI, UROSEPSIS AKI tops the list and outcome will be improved phenomenally when managed appropriately.
The comorbid conditions commonly associated with urosepsis are Diabetes, Hypertension and CKD.
Chronic Kidney Disease is defined as the appearance of kidney damage, exhibited by abnormal albumin excretion or declined kidney function, evaluated by measured or estimated glomerular filtration rate (GFR), that persists for more than three months (3) and CKD is staged by the level of eGFR and proteinuria(4&5), CKD population are more prone for AKI due to reduced renal reserve.
Sepsis - Life threatening organ dysfunction caused by a dysregulated host response to infection OR
SEQUENTIAL ORGAN FAILURE ASSESSMENT SCORE(SOFA) - 2 @ presentation
Sepsis AKI - AKI in the presence of sepsis without other significant contributing factors explaining AKI , Simultaneous presence of both Sepsis-3 and Kidney Disease: Improving Global Outcomes (KDIGO) criteria of AKI .
Severe sepsis - Sepsis with organ damage with lactate >4 mmol/l,
Septic shock - The patient of sepsis requiring vasoactive support.
MODS- Multi Organ Dysfunction Syndrome - Multiple organs deranged in the presence of sepsis.
SOFA score is used to indicate the outcome in terms of mortality in sepsis patients(6).
Double J stents have been used for more than 25 years and have become a major urological endoscopic armamentarium. They are used mainly for stabilization of the ureter after surgery and to provide drainage through a ureter that may be obstructed, leaking, dysfunctional or strictured. They are often used after extracorporeal shockwave stone surgery to minimize blockage from steinstrasse (multiple stone fragments that can clog and obstruct a ureter after lithotripsy), to bypass a larger ureteral calculus, or to help identify the ureter radiologically or surgically.(7)
The DJ stenting has been used for Emphysematous pyelonephritis to improve the drainage from kidneys to bladder. With appropriate medical management , glycemic control and use of drainage procedure(Percutaneous Nephrostomy)PCN/Double J stenting(DJ stenting))have improved the outcomes, but PCN is invasive and cumbersome procedure where as the DJ stent is noninvasive and can be kept endoscopically in local anesthesia for drainage. With this background we have done a prospective study, to show the outcome of DJ stenting, in pyelonephritis which progressed to SEPSIS, MODS and Septic shock even though there is no Emphysematous pyelonephritis(8).
The physiology behind this drainage procedure (DJ stenting) is correcting the obstruction and decreases the intra renal pressure by avoiding physiological uretero vesical sphincter mechanism, so that intra renal and intra vesical pressure equalizes, and intra renal pressure decreases and AKI declines as renal perfusion normalizes after DJ stenting.
The normal intra abdominal pressure is of 5mmHg, if it increases the intra renal perfusion pressure decreases which results in AKI. The normal intravesical pressure is <5cm of H2O whereas the normal intra renal pressure is of 0-20cm of H2O. When the intra renal pressure increases 21 to 41cm of H20 pyelo tubular reflux occurs,41 to 68 pyelo venous back flow occurs and fornix rupture occurs when intra renal pressure increases >81cm of H2O(9).
The increased Intra Renal Pressure(IRP) results in decreased perfusion to the kidney( MAP - IRP) results in AKI(10). The DJ stenting helped to decrease the Intra Renal pressure there by improving renal perfusion and improved the outcomes like improvement in mortality, need of RRT, and decline in progression to CKD.
REFERENCES
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10) Pauchard F, Ventimiglia E, Corrales M, Traxer O. A Practical Guide for Intra-Renal Temperature and Pressure Management during Rirs: What Is the Evidence Telling Us. J Clin Med. 2022 Jun 15;11(12):3429. doi: 10.3390/jcm11123429. PMID: 35743499; PMCID: PMC9224584.
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