CRRT workshop (Therapy overview I)

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CRRT Therapy Overview …

CRRT Therapy Overview
CRRT day 2013, Cairo, Egypt organized by Scribe. www.scribeofegypt.com

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  • 1. Dr. Michel Helmy Marketing Manager – Acute Therapies South East Europe, Middle East & Africa CRRT Workshop CRRT Therapy Overview I CRRTCRRT Therapy Overview ITherapy Overview I
  • 2. © 2012 – Michel Helmy 2 Continuous Renal Replacement Therapy Also known as “slow CContinuous RRenal RReplacement TTherapy”. DefinitionDefinition “Any extracorporeal blood purification therapy intended to substitute for impaired renal function over an extended period of time and applied for or aimed at being applied for 24 hours/day24 hours/day.” R. Bellomo, C Ronco and R. Mehta, Nomenclature for Continuous Renal Replacement Therapies, AJKD, Vol 28, November 1996
  • 3. © 2008, Gambro 3 Renal Replacement – Why? Removal of waste products (solutes) Removal of fluid Regulation electrolytes (solutes) Regulation acid-base balance (solutes)
  • 4. © 2012 – Michel Helmy 4 Removal of waste products (solutes) Removal of fluid Regulation Electrolytes (solutes) Regulation acid-base balance (solutes) Prevent further kidney damage Renal Recovery Hemodynamically safe Why Continuous Renal Replacement?
  • 5. © 2012 – Michel Helmy 5 Day of treatment 0 20 40 60 80 100 120 140 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BUN (mg %) CRRT IHD Comparison between HD and CRRT During iHD, serum levels of uremic toxins fall quickly but increase again quickly after the treatment. This saw- tooth urea profile cause significant changes in the serum osmolality –especially in the first treatment- and can result in a disequilibrium syndrome and additional fluid shift into the extra-vascular space. In CRRT, the serum urea levels fall more slowly but continuously and can be maintained at a constant low level so disequilibrium syndrome can be avoided.
  • 6. © 2012 – Michel Helmy Why Choose CRRT? • Slow, gentle and continuous • Well tolerated by hemodynamically unstable patient • Prevent further damage to kidney tissue • Promote healing and renal recovery • Regulates electrolytes, acid-base balance • Removes large amounts of fluid and waste products over time • Allow other supportive measures, i.e., nutrition CRRT closely mimics the native kidney. Bellomo, Ronco. Continous hemofiltration in the intensive care unit. Crit Care, 2000; 4(6)
  • 7. © 2012 – Michel Helmy 7 Therapy Indications WH0 ? … is our patientWH0 ?WH0 ? … is our patient
  • 8. © 2012 – Michel Helmy 8 Indications for CRRT in the ICU (General Principals) A E I O U Bruce A. Molitoris. Critical Care Nephrology 2005. 151-154 Each illness that will be mentioned fits in at least one of these 5 principles, but mostly more. Sometimes an illness will cover all of them. Acidosis (Diseases with metabolic acidosis due to acid-base imbalance) E.g. in ARF, ARDS, Sepsis Electrolytes Imbalance (diseases with Electrolyte imbalance) E.g. in ARF, ARDS, Sepsis, MOF Intoxications (water soluble toxins) E..g in Rhabdomyolysis Overload (Fluid management in diseases with volume overload) E.g. in CHF, ARDS, Burns Uraemia (ARF)
  • 9. © 2012 – Michel Helmy 9 Clinical Indications . Renal Indications • ARF with oliguria or anuria • Azotemia (a medical condition characterized by abnormal levels of urea, creatinine, various body waste compounds, and other nitrogen-rich compounds in the blood as a result of insufficient filtering of the blood by the kidneys) • Volume overload • Tumor lysis syndrome • Sepsis • Cerebral edema Non-renal Indications • Drug overdose • Metabolic disorders (Lactic acidosis) • Crush Injuries / Rhabdomyolosis (Myocyte “muscle” Necrosis) Disintegration of striated/skeletal muscle Muscular cell components, myoglobin, released into circulation Resulting in electrolyte imbalance, hypovolemia, met. acidosis, coagulopathies, myoglobinuric RF • Sepsis • ARDS • Fluid overload (e.g. 2ndry to CHF) • Bellomo, Ronco. Continous hemofiltration in the intensive care unit. Crit Care, 2000; 4(6) • Schetz. Kidney International. 1999; 56:72. 88 – 94 • Meyer, M. 2000 RRT; Critical Care Clin. 16 (1). 29
  • 10. © 2012 – Michel Helmy 10 Clinical Indications . Renal Replacement vs. Renal Support Renal Replacements • Life threatening indications: • Hyperkalemia (K>6.5 mmol/l) • Acidemia (pH<7.1) due to metabolic acidosis • Pulmonary edema • Uremic complications (e.g. pericarditis) • Solute control • Fluid removal • Regulation of acid-base • Regulation of electrolytes Renal Support • Nutrition • Fluid removal in CHF • Cytokine manipulation (sepsis) • Cancer chemotherapy • Respiratory acidosis in ARDS • Fluid management in MOF R.L. Metha. Blood Purification 2001; 19: 227-232
  • 11. © 2012 – Michel Helmy 11 • Non-obstructive oliguria (urine output <200 mL/12 h) or anuria • Severe acidaemia (pH <7.1)because of metabolic acidosis • Azotaemia (urea >30 mmol/L) • Hyperkalaemia (K+ >6.5 mmol/L or rapidly rising K+ ) • Suspected uremic organ involvement (pericarditis / encephalopathy / neuropathy / myopathy) • Progressive and uncontrolled severe dysnatremia (Na >180 or <115 mmol/L) • Uncontrolled hyperthermia • Clinically significant, diuretic-unresponsive organ edema (especially lungs) • Drug overdose with dialyzable toxin • Coagulopathy requiring the rapid administration of large amounts of blood products in patients with or at risk of pulmonary edema / ARDS The following is a proposed set of indications which can be used as triggers for initiating CRRT R.Bellomo, C.Ronco. Critical Care 2000 – 4: 339-345
  • 12. © 2012 – Michel Helmy 12 Indications generally used to start renal replacement therapy in standard clinical practice in patients with AKI Biochemical indications • Refractory hyperkalaemia > 6.5 mmol/l • serum urea > 30 mmol/l • Refractory metabolic acidosis pH ≤ 7.1 • Refractory electrolyte abnormalities: • hyponatraemia or hypernatraemia and hypercalcaemia • Tumor lysis syndrome with hyperuricaemia and hyperphosphataemia • Urea cycle defects, and organic acidurias resulting in hyperammonaemia, methymalonic acidaemia Clinical indications • Urine output < 0.3 ml/kg for 24 h or absolute anuria for 12 h • AKI with multiple organ failure • Refractory volume overload • End organ damage: pericarditis, encephalopathy, neuropathy, myopathy, uraemic bleeding • Create intravascular space for plasma and other blood product infusions and nutrition • Severe poisoning or drug overdose
  • 13. © 2012 – Michel Helmy 13 Role of CRRT in ARF Removal of toxins (urea, creatinine) Regulate electrolyte and water balance Regulate acid-base balance Prevent further damage to the kidney tissues Promote healing and renal recovery
  • 14. © 2012 – Michel Helmy Role of CRRT in CHF Maintain 24/7 fluid balance (All CRRT therapies) • Reduce ascites and peripheral edema • Relieve Pulmonary edema Normalize cardiac filling pressures Maintain 24/7 Electrolyte and acid/base balance (CVVHD, CVVHDF) • - Dialytic control of electrolytes • - Delivery of bicarbonate or lactate buffer Possibly prevent further renal damage or prolong renal Insufficiency Possibly reduce length of stay Refractory Congestive Heart Failure: Overview and Application of Extracorporeal Ultrafiltration, Paul Blake and Emil P. Paganini, Advances in RRT, Vol 3, No2 (April), 1996: pp 166-173
  • 15. © 2012 – Michel Helmy 15 Role of CRRT in Sepsis Removal of middle to large molecule septic mediators by convection and adsorption including TNF-α, IL-1, IL-6 and IL-8 through: Removal of excess fluid and waste products Maintenance of acid-base balance Improve cardiovascular hemodynamic → removal of cardiodepressants (caused by inflammatory mediators) Thermoregulation Bruce A. Molitoris. Critical Care Nephrology 2005. 28-34
  • 16. © 2012 – Michel Helmy 16 Role of CRRT for Rhabdomyolysis Maintain fluid, electrolyte, acid/base balance. Prevent further damage to kidney tissue Removal of small to middle protein molecules - 17,000 Dalton through convection • May cause nuisance BLD alarms Example of reduction of pigmentation In Ultra- Filtration fluid over 3 days of treatment
  • 17. © 2012 – Michel Helmy 17 Role of CRRT in Intoxications Removal of small molecules by Dialysis • Dialysate up to 4l/h • Optional replacement up to 500ml/h Duration: depends on clearance of toxic medication