Continuous renal replacement therapy in AKI
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Transcript of Continuous renal replacement therapy in AKI
Continuous Renal Replacement Therapy in Acute Kidney Injury:
Pros and Cons
MD, PhD. Head of Extracorporeal Hemocorrection Unit, National Scientific Medical Research Center, Astana, Kazakhstan
Продленная заместительная почечная терапия при острой почечной недостаточности:
за и против
Dr Abduzhappar Gaipov
Acute Kidney Injury (AKI): definition
AKI is defined as any of the following:
• Increase in SCr by ≥0.3 mg/dl (≥ 26.5 µmol/l) within 48 hours; or
• Increase in SCr to ≥1.5 times baseline, which is known or presumed to have occurred within the prior 7 days; or
• Urine volume <0.5 ml/kg/h for 6 hours.
2012 KDIGO
AKI classification systems: RIFLE
Staging of AKI (KDIGO 2012)
Kidney International Supplements (2012) 2, 19–36
Conceptual model for AKI
Kidney International Supplements (2012) 2, 19–36
Evalution of current AKI
Increased frequency of adverse prognostic forms of AKI:
• Inhospital mortality increased ≥2 times, associated with sepsis, cardiopulmonary distress and multiple organ dysfunctions
• Increased group of “AKI on CKD“
• Increased frequency of non-oligouric AKI (50 - 70% of the AKI)
• Increased number of “catabolic” form of AKI
High mortality in the ICU
• Depending on definition of AKI, up to 50-60% of patients in the ICU
• Up to 70% of these will require RRT
• Independent risk factor for mortality, 50 - 60% mortality in critically ill
Curr Opin Nephrol Hypertens. 2007 Mar;16(2):64-70 Current Anaesthesia and Critical Care 2005; 16:321-329
AKI after cardiac surgery (n=813)
• According to the RIFLE criteria, 19.3% of patients had renal impairment after cardiac surgery.
• a 90-day mortality rate according to RIFLE:
Risk – 8,0%;
Injury – 21,4%;
Failure – 32,5%.
Kuitunen A et al. Ann Thorac Surg 2006; 81:542-546
AKI - treatment
• Treatment of AKI is principally supportive -- renal replacement therapy (RRT) indicated in patients with severe AKI.
• Goal: optimization of fluid & electrolyte balance
• Paranteral nutrition during the oligouria
• Multiple modalities of RRT:
– Intermittent hemodialysis (IHD),
– continuous renal replacement therapies (CRRTs)
– hybrid therapies, ie sustained low-efficiency dialysis (SLED)
Molecuar mechanisms of RRT
Water soluble molecules
“small”
“middle”
“large”
High Flux
Low Flux
Kuf <10 mL/h/mmHg
Kuf >20 mL/h/mmHg
30000-50000 Daltons
< 500 - 600 Daltons
Convection
Water soluble molecules Dialysers Mechanisms
Diffusion
Convection Diffusion Diffusion
Convection
Hemodialysis Hemofiltration Hemodiafiltration
Modalities of RRT
SCUF – Slow Continuous Ultrafiltration Медленная продолжительная ультрафильтрация
CVVH – Continuous Venovenous Hemofiltration Продолжительная вено-венозная гемофильтрация
CVVHDF – Continuous Venovenous Hemodiafiltration Продолжительная вено-венозная гемодиафильтрация
SLED – Slow low efficiency dialysis Медленный низкой эффективности диализ
EDD – Extended daily dialysis Длительный ежедневный диализ
IHD – Intermittent hemodialysis Интермиттируюший гемодиализ
IUF – Isolated ultrafiltration Изолированная ультрафильтрация
Intermittent
Continuous
Hybrid
Sürekli Venovenöz hemofiltrasyon (CVVH)
CVVH clearance (K) KHF = Qf x S Qf = Ultrafiltration rate S = Sieving coefficient S = Cef/Cb Cef = Concentration in Effluent Cb = Concentration in blood
Sürekli venovenöz Hemodiyafiltrasyon (CVVHDF)
CVVHDF clearance (K) KHDF = (Qf x S) + (Qd x Sd) Qf = Ultrafiltration rate S = Sieving coefficient S = Cef/Cb Cef = Concentration in Effluent Cb = Concentration in blood Qd = Dialysate rate Sd = Dialysate saturation
Pre-dilüsyon ve Post dilüsyon
Replasman sıvısı, filtreye girmeden verilir ise predilüsyon, filtreden sonra verilir ise postdilüsyon denilir
Devices for renal replacement therapy
CRRT machines Pump #
HD, UF
HD, UF, HDF-Online, SLED, EDD
CVVH: pre or post dilution
CVVH: pre , post and mixt dilution CVVHDF: pre or post dilution
CVVH: pre , post and mix dilution CVVHDF: pre, post and mixt dilution, Citrate protocole
iHD machines Pump # Possible modalities
Absolute and relative indications to initiate RRT in AKI
Gibney et al, Clin J Am Soc Nephrol 2008
CLINICAL PRACTICE GUIDELINES – AKI Initiation of RRT
UK Renal Association, 5th Edition, 2011
2012 KDIGO
CLINICAL PRACTICE GUIDELINES – AKI Which modality of RRT?
UK Renal Association, 5th Edition, 2011
2012 KDIGO
The choice of modalities of RRT
Optimal modality of renal replacement therapy in acute renal failure according to the clinical status of the patient. IIUF: intermittent isolated ultrafiltration; CEPD: continuous equilibrium peritoneal dialysis; TPE: therapeutic plasma exchange.
The choice of modalities of RRT in Septic patients
Comprehensive Clinical Nephrology: Fourth Edition
iHD vs CVVH: Kinetics of BUN in RRTs
Ronco C et al
Nephrol Dial Transplant 13[Suppl 6]:76-85
iHD vs CVVH:
Kinetics of HCO3 in RRTs
Ronco C et al
Nephrol Dial Transplant 13[Suppl 6]:76-85
iHD vsCVVH :
Effect on the hydration of brain tissue
Данные компьютерной томографии головного мозга
CRRT vs IHD
Prowle, J. R. & Bellomo, R. Nat. Rev. Nephrol. 6, 521–529 (2010)
Intermittent versus continuous renal replacement therapy for acute renal failure in adults
Copyright © 2008 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
15 RCTs with 1550 patients comparing CRRT with IRRT.
MEDLINE,
EMBASE,
Cochrane Central Register of Controlled Trials (CENTRAL)
У гемодинамически стабильных пациентов, вид заместительной почечной терапии не влиял на важные исходы лечения пациентов, и поэтому преимущество CRRT над IRRT у таких больных не обосновано по имеющимся данным. Пациенты, получившие лечения CRRT имели лучшие гемодинамикие параметры как СрАД.
PROS AND CONS OF DIFFERENT MODALITIES
COMPARE AND CONTRAST DIFFERENT MODALITIES
IHD SLEDD CRRT
Name Intermittent hemodialysis Slow (or sustained) low efficiency
daily dialysis Continuous renal replacement therapy
Mechanism and
molecules removed Dialysis – mostly low MWt
Small + middle molecules
with SLEDD/F Small + middle molecules with
CVVHDF
Use Ambulatory ESRD
Hyperkalemia
Critically ill
Hyperkalemia Critically ill
Non-ambulatory
Blood flow 300-400 mL/min 200-300 mL/min 100-200 mL/min
Dialysate flow 500-800 mL/min 1-2L/h 2-3 L/h
Efficiency High Moderate Low
Hemodynamic
stability Poor
(hypotension common) Good Good
Duration 3-4 h 3x/week 6-12 h daily Continuous (24h/filter)
Access Fistula or vascath
(must be good!) Fistula or vascath
(must be good!) Vascath only
Anticoagulation Not needed Usually not needed
(if filter clots lose 150 mL blood) Important
(if filter clots lose 150 mL blood) Dialysis
Dysequilibrium
Syndrome (DDS)
Insufficient time for equilibration between
compartments can cause cerebral edema N/A N/A
Drugs and
toxicology
Risk of rebound if high VD
Better for low VD (e.g. toxic alcohols)
Unclear effects on drug
pharmacokinetics Slower removal
Logistics Need tap water supply,
need hygienic effluent
removal, Technically difficult
High start up costs, low familiarity,
low running costs,
Hypophosphatemia
High workload, clearance limited by
interruptions, costly sterile dialysate
bags, immobility
Rev colomb anestesiol. 2013;41(2):88–96
Kidney International (2006) 70, 963–968.
Kitchlu et al. BMC Nephrology (2015) 16:127
Quality indicator of CRRT and measures
Indicators Measures
Dose prescription High vs. low dose
Dose delivery Percentage of prescribed dose delivered
Anticoagulation selection Heparin vs. citrate vs. none
Anticoagulation monitoring PTT monitoring, citrate monitoring
Anticoagulation complications Bleeding, hypocalcaemia, incidence of HIT
Treatment interruption Number of interruptions and duration of interruptions; time to establish new circuit
Catheter-related issues Infections, bleeding, obstruction/thrombosis
Circuit-related issues Filter clotting, pressure alarming
Rewa et al. Systematic Reviews (2015) 4:102
CRRT: What is new in 2015 ?
Stucker et al. Critical Care (2015) 19:91
J Crit Care. 2015 Jun 26.
Conclusion: A well-trained CRRT team could be beneficial for mortality improvement of AKI patients requiring CRRT.
CLINICAL PRACTICE GUIDELINES - AKI Treatment facilities & referral to renal services
• Guideline 5.1- Renal services should work together with other specialties to develop guidelines for the management of AKI. These should include clear guidelines with respect to when to request a renal referral. (1A)
• Guideline 5.2 – Specialist renal advice should be given with consultant renal physician input. (1B)
• Guideline 5.5 – Renal physicians and intensivists should work together to provide care for patients with AKI on the intensive care unit (ICU). Nephrology trainees should be trained to care for acutely ill patients with AKI. (2C)
UK Renal Association, 5th Edition, 2011
Thank you for attention