recent protocol for timing for dialysis in renal disease

1. Recent protocol for timing for
dialysis in renal Disease
Dr Lalit Agarwal
Woodlands Hospital
kolkata

2. Types of Renal disease
•Acute kidney Injury (AKI)
or acute rise in creatinine
•Chronic kidney Disease (CKD)
or chronic rise in creatinine
• AKI on CKD
•Kidney Failure or CKD Stage 5

3. Definition of AKI - KDIGO
• Increase in S.cr by ≥ 0.3 mg/dl within 48 hrs or
• Increase in S.cr to ≥ 1.5 times of baseline,
which is known or presumed to have occurred
within prior 7 days or
• Urine volume < 0.5 ml/kg/hr for 6 hours.
ADQI(RIFLE) -- AKIN-- KDIGO GROUP

4. Staging of AKI(KDIGO)
Stage Serum Creatinine Urine output
1 1.5-1.9 times baseline within 1 wk or
≥ 0.3 mg/dl increase within 48 hrs
<0.5ml/kg/h for
6-12 hrs
2 2.0-2.9 times baseline <0.5ml/kg/h for
≥ 12 hrs
3 3.0 times baseline or
increase in serum creat to ≥ 4.0 mg/dl or
initiation of RRT or
in patients < 18 yrs, decrease in eGFR to
<35ml/min per 1.73 m²
<0.3ml/kg/h for
≥ 24 hrs or
Anuria for ≥ 12
hrs

5. RRT in AKI
• Management of AKI is supportive.
• RRT is done with severe kidney injury
• initiation of RRT is a matter of clinical judgment and
circumstances.
• Initiation of RRT in AKI prevents uremia and
immediate death from adverse complications of
renal failure ( hyperkalemia, Acidosis, fluid overload
etc )
• The optimal timing of initiation, type of modality
and dosing of dialysis strategy for patients with AKI
may affect clinical outcome/ survival

6. RRT IN AKI
• Multiple modalities available IHD, CRRTs (diffusion
and convection- inflammatory cytokines), Hybrid
therapies /PIRRTs such as SLED and EDD, PD.
• Dose of dialysis :More dialysis or less dialysis ??
Intensive dialysis does not decrease mortality or
accelerate recovery or alter rate of non renal organ
failure c/w usual care
-IHD 3x/wk with Kt/V >= 1.2/treatment
-CRRT delivered effluent flow rate >= 20 ml/kg/hr
• Despite all , mortality remains high exceeding 40 -50
% in severely ill patients.

7. • RRT is basically not intended for removal of
inflammatory mediators/ solutes (adjunct).
Newer Technology to develop EC septic
mediators removal devices with/ without
RRT. Although septic mediators are reduced
by crrt,clinical benefit not seen consistently

8. Urgent (life threatening) indications
for RRT IN AKI
• Refractory fluid overload
• Severe hyperkalemia ( K > 6.5)
• Signs of uremia (pericarditis, encephalopathy)
• Severe metabolic acidosis (pH <7.1)
• Certain alcohol and drug (dialysable)
intoxications

9. Timing of Elective initiation
(not life threatening)
• Practically electively initiate RRT before
development of severe electrolyte (K>/=6) &
acid/base disturbance (pH<7.2) and volume
overload (no diuresis/increasing O2
requirement)with unresponsiveness to
medical management and no signs of kidney
function improving

10. Early initiation is controversial
• Do not initiate dialysis in the absence of
clinically significant uremic symptoms or BUN
<110 to 120 mg/dl or specific electrolyte and
acid base disturbance or volume overload.
• RCT has compared strategies of early vs
delayed initiation of RRT in the absence of
obvious indications have yielded conflicting
results

11. Early versus late initiation of RRT in patients with AKI -
a systematic review & meta-analysis of RCTs.
Bhatt GC, Das RR BMC Nephrol. 2017;18(1):78.
• This meta-analysis of 10 RCT showed no benefit of
early initiation on 30, 60, 90 days mortality
• No difference on the risk of dialysis dependence,
length of ICU or hospital stay or recovery of renal
function
Problems in this meta-analysis
• Strength of this study is low because of variable
definitions of early vs late initiation, high bias for
allocation concealment.

12. Initiation Strategies for RRT in the ICU
AKIKI Study Group
N Engl J Med. 2016;375(2):122.
• 620 pts multicentre RCT with severe AKI as per
KDIGO criteria +/- ventilation/vasopressor
• Exclusion: who needed urgent dialysis
• Early within 6 hrs of onset of severe AKI and
delayed initiation (as in urgent indication group)
• Results no obvious benefit of early RRT strategy
• Mortality at 60 days no difference, 49%
spontaneous recovery in delayed group, catheter
related infections and hypophosphatemia
common in early strategy group.

13. • Earlier-start vs usual-start dialysis in patients
with community-acquired AKI: a RCT. Jamale
TE et al, Am J Kidney Dis. 2013
Dec;62(6):1116-21.
• Comparison of std. and accelerated initiation
of RRT in AKI. Wald R et al. Canadian Critical
Care Trials Group. Kidney Int. 2015
Oct;88(4):897-904.
• no benefit associated with early initiation,
• To interpret with caution as both trials were
underpowered to detect mortality differences

14. Effect of Early vs Delayed Initiation of RRT( continous HDF) on
Mortality in Critically ill Patients With AKI: The ELAIN RCT.
Zarbock A, JAMA. 2016;315(20):2190
• 231 critical ill (severe sepsis + vaspressors + refractory volume
overload)
• Early RRT (pts with moderate AKI - KDIGO stage 2 within 8
hours)
• Delayed RRT within 12 hrs after KDIGO stage 3 or developed
urgent indication of dialysis or no initiation in (11 pts)
• Early RRT reduced 90 day mortality (HR 0.66,95% CI 0.45-0.97),
more pts recovered renal function(OR 0.55, 95% CI 0.32-0.93) ,
duration of RRT and hospital stay shorter.
It is difficult to understand such a widespread improvements
in outcome by just a small difference in timing of initiation of
dialysis. Almost all patients received RRT

15. Ongoing RCT
• Initiaion of dialysis early vs delayed in ICU(
Ideal –ICU)
• Standard versus accelerated initiation of RRT
in AKI ( starrt – AKI ) are undergoing and may
give conclusive answers.

16. CKD is reduced kidney function
and/or kidney damage
• Chronic kidney disease
– Kidney function
• Glomerular filtration rate (GFR)< 60mL/min/1.73m2 for ≥ 3
months with or without kidney damage
– Kidney damage
• ≥ 3 months with or without decreased GFR, manifested by
either
– Pathological abnormalities
– Markers of kidney damage, e.g., albuminuria
– Urine albumin-to-creatinine ratio (UACR)> 30mg/g
This definition does not account for age related GFR decline

17. Old Classification of CKD as Defined by Kidney Disease Outcomes
Quality Initiative (NKF/KDOQI) Modified and Endorsed by KDIGO
Note: GFR is given in mL/min/1.732 m²
National Kidney Foundation. KDOQI Clinical Practice Guidelines for Chronic Kidney Disease:
Evaluation, Classification, and Stratification. Am J Kidney Dis 2002;39(suppl 1):S1-S266
Stage Description Classification
by Severity
Classification
by Treatment
1 Kidney damage with
normal or increased GFR
GFR ≥ 90
2 Kidney damage with
mild decrease in GFR
GFR of 60-89 T if kidney
transplant
3 Moderate decrease in GFR GFR of 30-59 recipient
4 Severe decrease in GFR GFR of 15-29 nephro refer
5 Kidney failure GFR < 15 D if dialysis
KDIGO, Kidney Disease:
Increasing Global
Outcomes

18. Management includes steps to reduce progression of CKD
and reduce cardiovascular disease risk

19. Guidelines planned/common and
urgent dialysis initiations.
• KDIGO guidelines 2012
• Canadian society guidelines 2014
• European guidelines
• KDOQI guidelines 2015 UPDATE

20. Non specific Symptoms and Signs of Uremia
superimposed on low GFR
• Symptoms
• Fatigue
• Lethargy
• Confusion
• Anorexia
• Nausea
• Alterations in senses of smell
and taste
• Cramps
• Restless legs
• Sleep disturbances
• Pruritus
• Signs
• Seizures/change in seizure
threshold
• Amenorrhea
• Reduced core body
temperature
• Protein-energy wasting
• Insulin resistance
• Heightened catabolism
• Serositis (pleuritis, pericarditis)
• Hiccups
• Platelet dysfunction
• Somnolence

21. Elective dialysis initiation in CKD 5
is not based on specific level of eGFR
• Patients with CKD 5 with signs and symptoms
of uremia (excluding patients with absolute
indications to start dialysis):
• Initiate dialysis after excluding other possible
reversible causes of uremic signs/symptoms
(mimickers) and the uremic signs and
symptoms (say volume overload and metabolic
abnormalities) are refractory to medical
therapy.

22. Common/elective indications
• Declining nutritional status
• Persistent or difficult to treat volume overload
• Fatigue and malaise
• Mild cognitive impairment
• Refractory acidosis, hyperkalemia, and
hyperphosphatemia

23. Absolute indications to start chronic
dialysis in CKD 5
• Uremic pericarditis/pleuritis
• Uremic encephalopathy

24. A randomized, controlled trial of early versus late
initiation of dialysis (IDEAL Study)
Cooper BA et al , Engl J Med. 2010;363(7):609.
• 828 patients
• Late start dialysis 7.2 ml /min by MDRD
• Early start dialysis 9ml/min by MDRD
• Found no difference in survival and adverse
events between early and late initiation of
dialysis.

25. Thank you