The document provides an overview of renal replacement therapy (RRT) modalities for critically ill patients with acute kidney injury (AKI). It discusses the history and evolution of RRT, including intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT). The pros and cons of IHD and CRRT are presented. Key considerations for RRT include which modality to use, anticoagulation options, dialysate buffers, and membranes. Guidelines for determining therapy dose and duration and criteria for discontinuing RRT are summarized. Outcomes with IHD versus CRRT remain unclear due to limitations of existing studies. Overall, the document reviews best practices for delivering RRT to critically ill AK
This document provides an overview of renal replacement therapies used in critical care settings. It discusses some of the key questions around when and how to use these therapies for acute kidney injury (AKI) patients. While there is no definitive evidence that answers all the questions, the literature suggests starting renal replacement therapy early according to RIFLE criteria and aiming for a minimum dose of 35 ml/kg/hr. Choice of therapy mode (intermittent vs continuous) may not be as important as ensuring adequate dosing. Further research is still needed to fully understand how to optimize outcomes for AKI patients requiring renal replacement therapy.
This document provides an overview of principles of haemodialysis. It describes the components of haemodialysis including the blood circuit, dialysate circuit and dialyzer. It explains how diffusion and convection work to remove solutes and fluid across the dialyzer membrane. High water purity standards are required for patient safety. Haemodiafiltration combines diffusive and convective clearances and may provide benefits over standard haemodialysis.
This document discusses different modalities for treating acute kidney injury (AKI) in critically ill patients, including continuous renal replacement therapy (CRRT) and intermittent hemodialysis. It provides pros and cons of each modality and factors to consider in determining the optimal treatment for an individual patient. While CRRT allows for more gradual fluid removal and hemodynamic stability, clearance is better with intermittent therapies. The document concludes that hemodynamic stability is the main determinant of treatment choice and clearance is optimized through combination of diffusion and convection methods.
This document discusses different types of continuous renal replacement therapy (CRRT), including CVVH, CVVHD, and CVVHDF. CRRT is indicated for critically ill patients with renal failure and hemodynamic instability or those who need continuous removal of volume or toxins. The procedures, anticoagulation methods, and order examples for each modality are provided. Standard heparin, low molecular weight heparin, and regional citrate anticoagulation are compared. CVVH uses hemofiltration, CVVHD uses hemodialysis, and CVVHDF uses a combination of hemofiltration and hemodialysis for renal replacement in critically ill patients.
This document discusses the prescription of peritoneal dialysis, including the choice of modality (CAPD vs APD), clearance targets, and measurement of clearance through Kt/V and creatinine clearance. It also covers factors that determine clearance like residual renal function, body size, and transport characteristics. For CAPD and APD, prescription factors include exchange frequency and volume, and dwell times. Nutritional monitoring for PD patients includes nPNA, serum albumin, subjective global assessment, and lean body mass. Treatment of malnutrition may include dietitian support, supplements, promotility agents, steroids, and amino acids.
The document discusses continuous renal replacement therapy (CRRT), including its indications, prescription, adverse effects, and comparison to intermittent hemodialysis. CRRT is indicated for hemodynamically unstable patients with acute kidney injury and is used to slowly clear waste and correct fluid/electrolyte imbalances. The prescription details parameters like blood and dialysate flow rates, fluid removal/addition amounts, and anticoagulation. Adverse effects include electrolyte disturbances and bleeding risks. CRRT is more portable and suitable for urgent cases than intermittent hemodialysis.
This document provides an overview of renal replacement therapies used in critical care settings. It discusses some of the key questions around when and how to use these therapies for acute kidney injury (AKI) patients. While there is no definitive evidence that answers all the questions, the literature suggests starting renal replacement therapy early according to RIFLE criteria and aiming for a minimum dose of 35 ml/kg/hr. Choice of therapy mode (intermittent vs continuous) may not be as important as ensuring adequate dosing. Further research is still needed to fully understand how to optimize outcomes for AKI patients requiring renal replacement therapy.
This document provides an overview of principles of haemodialysis. It describes the components of haemodialysis including the blood circuit, dialysate circuit and dialyzer. It explains how diffusion and convection work to remove solutes and fluid across the dialyzer membrane. High water purity standards are required for patient safety. Haemodiafiltration combines diffusive and convective clearances and may provide benefits over standard haemodialysis.
This document discusses different modalities for treating acute kidney injury (AKI) in critically ill patients, including continuous renal replacement therapy (CRRT) and intermittent hemodialysis. It provides pros and cons of each modality and factors to consider in determining the optimal treatment for an individual patient. While CRRT allows for more gradual fluid removal and hemodynamic stability, clearance is better with intermittent therapies. The document concludes that hemodynamic stability is the main determinant of treatment choice and clearance is optimized through combination of diffusion and convection methods.
This document discusses different types of continuous renal replacement therapy (CRRT), including CVVH, CVVHD, and CVVHDF. CRRT is indicated for critically ill patients with renal failure and hemodynamic instability or those who need continuous removal of volume or toxins. The procedures, anticoagulation methods, and order examples for each modality are provided. Standard heparin, low molecular weight heparin, and regional citrate anticoagulation are compared. CVVH uses hemofiltration, CVVHD uses hemodialysis, and CVVHDF uses a combination of hemofiltration and hemodialysis for renal replacement in critically ill patients.
This document discusses the prescription of peritoneal dialysis, including the choice of modality (CAPD vs APD), clearance targets, and measurement of clearance through Kt/V and creatinine clearance. It also covers factors that determine clearance like residual renal function, body size, and transport characteristics. For CAPD and APD, prescription factors include exchange frequency and volume, and dwell times. Nutritional monitoring for PD patients includes nPNA, serum albumin, subjective global assessment, and lean body mass. Treatment of malnutrition may include dietitian support, supplements, promotility agents, steroids, and amino acids.
The document discusses continuous renal replacement therapy (CRRT), including its indications, prescription, adverse effects, and comparison to intermittent hemodialysis. CRRT is indicated for hemodynamically unstable patients with acute kidney injury and is used to slowly clear waste and correct fluid/electrolyte imbalances. The prescription details parameters like blood and dialysate flow rates, fluid removal/addition amounts, and anticoagulation. Adverse effects include electrolyte disturbances and bleeding risks. CRRT is more portable and suitable for urgent cases than intermittent hemodialysis.
Renal Replacement Therapy: modes and evidenceMohd Saif Khan
This document discusses various modes of renal replacement therapy (RRT) for acute kidney injury (AKI) patients, including their principles, advantages, disadvantages, and evidence regarding optimal dosing. It summarizes that while early RRT initiation and higher RRT doses were associated with better outcomes in some studies, large randomized controlled trials found no significant differences in mortality between early versus late initiation or higher versus lower RRT doses. The optimal RRT modality and timing remains unclear based on current evidence.
Renal replacement therapy encompasses life-supporting treatments for renal failure such as hemodialysis, peritoneal dialysis, and continuous renal replacement therapy. Hemodialysis uses diffusion and filtration across a semi-permeable membrane to remove waste and fluid. Peritoneal dialysis infuses dialysate into the peritoneal cavity. Continuous renal replacement therapy provides 24-hour treatment through diffusion, convection, or a combination. These therapies aim to replace normal kidney functions of waste removal and fluid balance.
This document discusses renal replacement therapies for acute kidney injury in critical care. It begins by outlining some open questions about optimal therapy use. It then reviews classification systems for AKI severity and evidence that increased severity is associated with higher mortality. The document discusses evidence for relationships between higher therapy dose and better outcomes for intermittent hemodialysis and continuous venovenous hemofiltration. While no definitive evidence establishes the superiority of any one therapy, higher therapy doses are generally associated with better patient outcomes. The document outlines various renal replacement therapy options and their pros and cons.
Renal Replacement therapy (Dialytic Management) in AKI - Dr.GawadNephroTube - Dr.Gawad
- Recorded videos of this lecture:
English Language version of this lecture is available at:
https://youtu.be/NN9vyWjIPbE
Arabic Language version of this lecture is available at:
https://youtu.be/i-Qlf31Vd-Y
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This document discusses renal replacement therapy for acute kidney injury (AKI) in intensive care unit patients. It defines AKI and its prevalence in ICU patients. It describes the various modes of renal replacement therapy including intermittent hemodialysis, continuous renal replacement therapy and peritoneal dialysis. It discusses indications for starting renal replacement therapy and debates the optimal timing, modality and dosing of therapy. While several studies have examined these issues, the document concludes that the choice of renal replacement therapy should be individualized for each critically ill patient based on their condition and available resources.
1. Anticoagulation is required for hemodialysis due to the activation of coagulation pathways from turbulent blood flow through the dialysis circuit.
2. Standard-risk patients are typically treated with unfractionated heparin or low molecular weight heparin to prevent clotting during the procedure.
3. High bleeding risk patients and those with heparin-induced thrombocytopenia are treated using a "no-heparin" method to avoid systemic anticoagulation.
CRRT and AKI
- Continuous renal replacement therapy (CRRT) is a treatment for acute kidney injury (AKI) that can remove fluid and waste products from patients who are hemodynamically unstable.
- CRRT was developed in the 1970s-1980s and uses an extracorporeal blood pump and catheter to continuously filter blood outside the body.
- The choice of CRRT or intermittent dialysis depends on the patient's condition and stability, with CRRT often preferred for unstable patients with fluid overload or brain injury.
- Proper nursing management before, during, and after CRRT is crucial and includes assessments, monitoring, preventing mechanical issues, and managing antico
A very simple yet comprehensive presentation to understand the concept of CRRT and its implementation in Intensive Care Unit. Intended for the very beginners in ICU. After going through the presentation you will be able to say "Now I know it!"
The Dose of Renal Replacement Therapy.pptxvipin kauts
1) The document discusses continuous renal replacement therapies (CRRT) for acute kidney injury (AKI), including dosing guidelines.
2) It reviews trials that found no survival benefit from higher CRRT doses above 35 ml/kg/hr.
3) It emphasizes that the prescribed CRRT dose may not be delivered due to interruptions, and recommends accounting for 10-15% downtime and prescribing 25-30 ml/kg/hr to achieve the recommended 20-25 ml/kg/hr delivered dose.
The document discusses guidelines for reusing dialyzers, including labeling dialyzers with patient names, testing dialyzers after each use, and monitoring patients for reactions. It outlines requirements for reprocessing dialyzers, including using ultrapure water and specific cleaning/disinfecting agents like sodium hypochlorite, hydrogen peroxide, formaldehyde, glutaraldehyde, and peracetic acid. It also covers reprocessing blood tubings and testing their performance.
This document provides an introduction, history, and indications for continuous renal replacement therapy (CRRT). It summarizes that CRRT was developed as an alternative to intermittent hemodialysis for critically ill patients. CRRT allows for slow, continuous removal of waste and fluid over many hours compared to brief, intermittent hemodialysis sessions. The document reviews the components of CRRT systems and indications for its use in critically ill patients with conditions like fluid overload, acidosis, hyperkalemia, or multi-organ dysfunction.
This document discusses guidelines for hemodialysis prescription. It provides details on various aspects of the dialysis prescription including modality, frequency, duration, dose, dialysate composition and temperature. It emphasizes the importance of achieving adequate dialysis as defined by fluid removal, normalized electrolytes and minerals, adequate dialysis dose and absence of symptoms. The criteria for optimal dialysis are more stringent and include normalization of blood pressure and minerals without medications, absence of symptoms during and between treatments, no interference with daily life and near-normal life expectancy.
This document discusses various protocols for anticoagulation during hemodialysis. It begins by noting that patients on hemodialysis are at risk of both bleeding and thrombosis. It then outlines several protocols for anticoagulation including unfractionated heparin (UFH) administered via constant infusion or intermittent bolus, and low molecular weight heparin (LMWH). LMWH has benefits over UFH like longer half-life and more predictable effects, but is also more expensive. The document also discusses heparin-free dialysis, regional citrate anticoagulation, and other alternatives to standard heparin protocols. Selection of the optimal anticoagulation method requires consideration of individual patient
This document discusses continuous renal replacement therapy (CRRT). It defines CRRT as an extracorporeal blood purification therapy intended to substitute impaired renal function over an extended period of 24 hours. It describes the requirements, indications, principles, and modalities of CRRT including vascular access, semi-permeable membranes, transport mechanisms, dialysate, replacement fluids, and different types of CRRT like CVVH, CVVHD, and CVVHDF. It also discusses dosing of CRRT, anticoagulation methods, and some complications.
This document discusses extracorporeal therapies and renal replacement therapy (RRT). It describes different types of RRT including intermittent hemodialysis, continuous dialysis, and their principles and setup. It covers non-renal uses of RRT such as for sepsis, acute respiratory distress syndrome, congestive heart failure, and more. It also describes hemoperfusion, which uses activated charcoal or resin to adsorb molecules from blood, and issues around preventing clotting during the process.
Intra dialytic hypotension ,,, prof Alaa SabryFarragBahbah
This document describes a case of intradialytic hypotension in a 65-year-old man on hemodialysis. During one of his dialysis treatments, he developed hypotension with symptoms of feeling poorly and diaphoresis. His dry weight was increased in response, but he experienced another episode of hypotension several days later. The document then discusses intradialytic hypotension in general, including definitions, mechanisms, complications, and approaches to assessing volume status in hemodialysis patients.
This document discusses incremental dialysis, which is an approach to adjusting dialysis dose based on a patient's residual kidney function (RKF). The key points are:
1) Patients starting dialysis often have some remaining RKF, and incorporating this into their dialysis prescription through an incremental approach may help preserve RKF longer.
2) Observational studies have found associations between preserving higher levels of RKF and benefits like improved survival, volume control, and lower inflammation.
3) The optimal approach is to start dialysis at the correct time and adjust the dose incrementally as RKF declines, individualizing treatment for each patient. Some studies found twice-weekly hemodialysis may better preserve RKF
1) The document discusses different modalities for providing dialytic support for acute kidney injury (AKI) patients, including intermittent and continuous renal replacement therapies.
2) It compares the pros and cons of different modalities and notes there is no clear evidence of differences in mortality or renal recovery between intermittent and continuous therapies.
3) Guidelines recommend considering patient hemodynamic stability and using continuous renal replacement therapy for unstable patients or those with brain injury, and emphasize starting renal replacement therapy based on clinical criteria rather than a single laboratory value.
Dr. Osama El-Shahat discusses various aspects of acute kidney injury (AKI) management including staging, modalities of renal replacement therapy, and general principles. The document covers (1) staging systems like RIFLE and AKIN to classify AKI severity, (2) modalities like intermittent hemodialysis, slow continuous ultrafiltration, and continuous renal replacement therapy, and (3) general guidelines around initiating renal replacement therapy, vascular access, solutions, anticoagulation, and dose of therapy. The overall message is that managing AKI requires an individualized approach and more high-quality research is still needed.
Renal Replacement Therapy: modes and evidenceMohd Saif Khan
This document discusses various modes of renal replacement therapy (RRT) for acute kidney injury (AKI) patients, including their principles, advantages, disadvantages, and evidence regarding optimal dosing. It summarizes that while early RRT initiation and higher RRT doses were associated with better outcomes in some studies, large randomized controlled trials found no significant differences in mortality between early versus late initiation or higher versus lower RRT doses. The optimal RRT modality and timing remains unclear based on current evidence.
Renal replacement therapy encompasses life-supporting treatments for renal failure such as hemodialysis, peritoneal dialysis, and continuous renal replacement therapy. Hemodialysis uses diffusion and filtration across a semi-permeable membrane to remove waste and fluid. Peritoneal dialysis infuses dialysate into the peritoneal cavity. Continuous renal replacement therapy provides 24-hour treatment through diffusion, convection, or a combination. These therapies aim to replace normal kidney functions of waste removal and fluid balance.
This document discusses renal replacement therapies for acute kidney injury in critical care. It begins by outlining some open questions about optimal therapy use. It then reviews classification systems for AKI severity and evidence that increased severity is associated with higher mortality. The document discusses evidence for relationships between higher therapy dose and better outcomes for intermittent hemodialysis and continuous venovenous hemofiltration. While no definitive evidence establishes the superiority of any one therapy, higher therapy doses are generally associated with better patient outcomes. The document outlines various renal replacement therapy options and their pros and cons.
Renal Replacement therapy (Dialytic Management) in AKI - Dr.GawadNephroTube - Dr.Gawad
- Recorded videos of this lecture:
English Language version of this lecture is available at:
https://youtu.be/NN9vyWjIPbE
Arabic Language version of this lecture is available at:
https://youtu.be/i-Qlf31Vd-Y
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
This document discusses renal replacement therapy for acute kidney injury (AKI) in intensive care unit patients. It defines AKI and its prevalence in ICU patients. It describes the various modes of renal replacement therapy including intermittent hemodialysis, continuous renal replacement therapy and peritoneal dialysis. It discusses indications for starting renal replacement therapy and debates the optimal timing, modality and dosing of therapy. While several studies have examined these issues, the document concludes that the choice of renal replacement therapy should be individualized for each critically ill patient based on their condition and available resources.
1. Anticoagulation is required for hemodialysis due to the activation of coagulation pathways from turbulent blood flow through the dialysis circuit.
2. Standard-risk patients are typically treated with unfractionated heparin or low molecular weight heparin to prevent clotting during the procedure.
3. High bleeding risk patients and those with heparin-induced thrombocytopenia are treated using a "no-heparin" method to avoid systemic anticoagulation.
CRRT and AKI
- Continuous renal replacement therapy (CRRT) is a treatment for acute kidney injury (AKI) that can remove fluid and waste products from patients who are hemodynamically unstable.
- CRRT was developed in the 1970s-1980s and uses an extracorporeal blood pump and catheter to continuously filter blood outside the body.
- The choice of CRRT or intermittent dialysis depends on the patient's condition and stability, with CRRT often preferred for unstable patients with fluid overload or brain injury.
- Proper nursing management before, during, and after CRRT is crucial and includes assessments, monitoring, preventing mechanical issues, and managing antico
A very simple yet comprehensive presentation to understand the concept of CRRT and its implementation in Intensive Care Unit. Intended for the very beginners in ICU. After going through the presentation you will be able to say "Now I know it!"
The Dose of Renal Replacement Therapy.pptxvipin kauts
1) The document discusses continuous renal replacement therapies (CRRT) for acute kidney injury (AKI), including dosing guidelines.
2) It reviews trials that found no survival benefit from higher CRRT doses above 35 ml/kg/hr.
3) It emphasizes that the prescribed CRRT dose may not be delivered due to interruptions, and recommends accounting for 10-15% downtime and prescribing 25-30 ml/kg/hr to achieve the recommended 20-25 ml/kg/hr delivered dose.
The document discusses guidelines for reusing dialyzers, including labeling dialyzers with patient names, testing dialyzers after each use, and monitoring patients for reactions. It outlines requirements for reprocessing dialyzers, including using ultrapure water and specific cleaning/disinfecting agents like sodium hypochlorite, hydrogen peroxide, formaldehyde, glutaraldehyde, and peracetic acid. It also covers reprocessing blood tubings and testing their performance.
This document provides an introduction, history, and indications for continuous renal replacement therapy (CRRT). It summarizes that CRRT was developed as an alternative to intermittent hemodialysis for critically ill patients. CRRT allows for slow, continuous removal of waste and fluid over many hours compared to brief, intermittent hemodialysis sessions. The document reviews the components of CRRT systems and indications for its use in critically ill patients with conditions like fluid overload, acidosis, hyperkalemia, or multi-organ dysfunction.
This document discusses guidelines for hemodialysis prescription. It provides details on various aspects of the dialysis prescription including modality, frequency, duration, dose, dialysate composition and temperature. It emphasizes the importance of achieving adequate dialysis as defined by fluid removal, normalized electrolytes and minerals, adequate dialysis dose and absence of symptoms. The criteria for optimal dialysis are more stringent and include normalization of blood pressure and minerals without medications, absence of symptoms during and between treatments, no interference with daily life and near-normal life expectancy.
This document discusses various protocols for anticoagulation during hemodialysis. It begins by noting that patients on hemodialysis are at risk of both bleeding and thrombosis. It then outlines several protocols for anticoagulation including unfractionated heparin (UFH) administered via constant infusion or intermittent bolus, and low molecular weight heparin (LMWH). LMWH has benefits over UFH like longer half-life and more predictable effects, but is also more expensive. The document also discusses heparin-free dialysis, regional citrate anticoagulation, and other alternatives to standard heparin protocols. Selection of the optimal anticoagulation method requires consideration of individual patient
This document discusses continuous renal replacement therapy (CRRT). It defines CRRT as an extracorporeal blood purification therapy intended to substitute impaired renal function over an extended period of 24 hours. It describes the requirements, indications, principles, and modalities of CRRT including vascular access, semi-permeable membranes, transport mechanisms, dialysate, replacement fluids, and different types of CRRT like CVVH, CVVHD, and CVVHDF. It also discusses dosing of CRRT, anticoagulation methods, and some complications.
This document discusses extracorporeal therapies and renal replacement therapy (RRT). It describes different types of RRT including intermittent hemodialysis, continuous dialysis, and their principles and setup. It covers non-renal uses of RRT such as for sepsis, acute respiratory distress syndrome, congestive heart failure, and more. It also describes hemoperfusion, which uses activated charcoal or resin to adsorb molecules from blood, and issues around preventing clotting during the process.
Intra dialytic hypotension ,,, prof Alaa SabryFarragBahbah
This document describes a case of intradialytic hypotension in a 65-year-old man on hemodialysis. During one of his dialysis treatments, he developed hypotension with symptoms of feeling poorly and diaphoresis. His dry weight was increased in response, but he experienced another episode of hypotension several days later. The document then discusses intradialytic hypotension in general, including definitions, mechanisms, complications, and approaches to assessing volume status in hemodialysis patients.
This document discusses incremental dialysis, which is an approach to adjusting dialysis dose based on a patient's residual kidney function (RKF). The key points are:
1) Patients starting dialysis often have some remaining RKF, and incorporating this into their dialysis prescription through an incremental approach may help preserve RKF longer.
2) Observational studies have found associations between preserving higher levels of RKF and benefits like improved survival, volume control, and lower inflammation.
3) The optimal approach is to start dialysis at the correct time and adjust the dose incrementally as RKF declines, individualizing treatment for each patient. Some studies found twice-weekly hemodialysis may better preserve RKF
1) The document discusses different modalities for providing dialytic support for acute kidney injury (AKI) patients, including intermittent and continuous renal replacement therapies.
2) It compares the pros and cons of different modalities and notes there is no clear evidence of differences in mortality or renal recovery between intermittent and continuous therapies.
3) Guidelines recommend considering patient hemodynamic stability and using continuous renal replacement therapy for unstable patients or those with brain injury, and emphasize starting renal replacement therapy based on clinical criteria rather than a single laboratory value.
Dr. Osama El-Shahat discusses various aspects of acute kidney injury (AKI) management including staging, modalities of renal replacement therapy, and general principles. The document covers (1) staging systems like RIFLE and AKIN to classify AKI severity, (2) modalities like intermittent hemodialysis, slow continuous ultrafiltration, and continuous renal replacement therapy, and (3) general guidelines around initiating renal replacement therapy, vascular access, solutions, anticoagulation, and dose of therapy. The overall message is that managing AKI requires an individualized approach and more high-quality research is still needed.
This document discusses dialytic support for patients with acute kidney injury (AKI). It begins by outlining classifications and definitions of AKI severity. It then addresses many open questions regarding renal replacement therapy (RRT) for AKI, such as when to start, what modality to use, and when to stop. The document reviews various RRT modalities and considerations for their use. It provides guidelines on determining when to initiate RRT based on lab values and clinical criteria. Overall, the document aims to help clinicians navigate the many decisions that must be made in providing RRT for AKI patients.
Dr. Osama El-Shahat is a consultant nephrologist and head of the nephrology department at New Mansoura General Hospital. He is also an educational ambassador for the International Society of Nephrology. The document discusses the stage-based management of acute kidney injury (AKI) including monitoring for stage 1 risk, conservative therapy for stage 2 injury, and considering renal replacement therapy for stage 3 failure. It provides recommendations at each stage to monitor patients, discontinue nephrotoxic agents, and consider ICU admission or invasive diagnostic workup as needed.
Stage-based management of acute kidney injury (AKI) involves monitoring for progression from risk to injury to failure. For stage 1 (risk), monitoring to prevent progression is recommended. For stage 2 (injury), conservative therapy is recommended due to high risk of mortality/morbidity. For stage 3 (failure), renal replacement therapy (RRT) should be considered due to highest risk of death. Continuous renal replacement therapy (CRRT) is preferred for hemodynamically unstable patients and allows for slow correction while maintaining hemodynamic stability. Higher CRRT doses of 35 ml/kg/hr may improve survival compared to lower doses, though optimal dosing remains controversial.
This document discusses the pros and cons of different modalities of continuous renal replacement therapy (CRRT) for acute kidney injury (AKI). It outlines various CRRT machines and modalities like CVVH, CVVHDF, and how they differ in mechanisms of diffusion, convection, and clearance rates. The modalities are compared to intermittent hemodialysis (IHD) and factors like hemodynamic stability, efficiency, and logistics are evaluated. Quality indicators for CRRT delivery and recent literature on optimizing multidisciplinary CRRT teams to potentially improve outcomes in AKI patients are also summarized.
The document discusses renal replacement therapy options for patients with end-stage renal disease, including hemodialysis, peritoneal dialysis, and kidney transplantation. It provides details on each treatment modality and emphasizes the importance of early referral to a nephrologist to allow time for vascular access placement, transplant evaluation, and patient education. The best vascular access for hemodialysis is an arteriovenous fistula due to its lower risk of infection and greater longevity. All statements regarding kidney transplantation timing and criteria are correct. Screening for malignancies is important in transplant recipients due to higher cancer risks with immunosuppression.
CRRT (continuous renal replacement therapy) involves using an extracorporeal circuit connected to the patient via catheters to slowly remove fluid and toxins over 24 hours, mimicking the function of the kidneys. It was developed for critically ill patients who cannot tolerate the fluid shifts of intermittent hemodialysis. CRRT uses a semipermeable membrane to filter fluids and small molecules from the blood based on hydrostatic pressure gradients. It provides more hemodynamic stability than intermittent hemodialysis and allows for better nutrition support by preventing fluid overload. CRRT is indicated for patients who cannot tolerate intermittent dialysis due to hemodynamic instability from their critical illness.
The document discusses continuous renal replacement therapy (CRRT) in critical care units. It begins with definitions and history of renal replacement therapy. It then covers principles, techniques, applications, results and complications of CRRT. The techniques discussed include continuous venovenous hemofiltration (CVVH), hemodialysis (CVVHD) and hemodiafiltration (CVVHDF). Advantages include hemodynamic stability, precise volume control and removal of toxins and cytokines. Complications can include bleeding, infection and electrolyte imbalances. CRRT remains the preferred technique for critically ill patients with acute kidney injury in many intensive care settings.
This document discusses renal replacement therapy (RRT) for acute kidney injury (AKI). It addresses when to start RRT, what modality to use, and how RRT can be delivered. The key points are:
1) There is no clear threshold for when to start RRT, and decisions should consider clinical context and trends in labs rather than single thresholds. Early initiation may improve outcomes.
2) Continuous RRT (CRRT) is preferred for hemodynamically unstable patients and may aid recovery of renal function compared to intermittent RRT.
3) Delivery of RRT involves considerations of vascular access, membranes, solutions, anticoagulation, and dose, with the goal of individualizing treatment
This document discusses recommendations for renal replacement therapy (RRT) in acute kidney injury (AKI) patients. It recommends considering peritoneal dialysis as a suitable continuous RRT modality. For hemodynamically unstable patients, continuous RRT such as CVVH is preferred over intermittent RRT. Bicarbonate-based solutions are suggested over lactate-based solutions for patients with liver failure or lactic acidemia. High flux, biocompatible membranes and regional citrate anticoagulation are presented as preferred options. The optimal dose of RRT is unclear from clinical trials.
This document discusses uremic toxins and their classification, effects, and approaches for removal. It begins by classifying uremic toxins into small water-soluble compounds like urea and guanidines, and protein-bound toxins like indoxyl sulfate and p-cresol. Protein-bound toxins are associated with cardiovascular and other diseases. Therapeutic strategies discussed include reducing protein intake, manipulating gut flora, increasing dialytic removal through high flux dialysis or HDF, adsorption techniques, and kidney transplantation.
Continuous rrt and its role in critically ill patients [autosaved]Harsh shaH
The document discusses renal replacement therapy (RRT) for acute kidney injury (AKI) in critically ill patients. It describes that early initiation of RRT may improve outcomes compared to late initiation. Continuous RRT is preferred for hemodynamically unstable patients as it allows for slower fluid and solute removal. The optimal RRT approach depends on the individual patient's clinical status and needs.
This document discusses continuous renal replacement therapies (CRRT) and associated techniques. It begins by defining CRRT and listing some common modalities, such as continuous venovenous hemofiltration (CVVH). It then reviews the history of CRRT and important developments. Key organizations that have influenced CRRT standards and definitions are mentioned, such as the Acute Dialysis Quality Initiative (ADQI). Practical aspects of CRRT administration and equipment are outlined, including machines, filters, tubing sets, vascular access, and replacement fluids.
This document discusses various aspects of renal replacement therapy for acute kidney injury. It begins by outlining the stage-based management of AKI, with increasing intervention and monitoring recommended as the stage progresses from risk to injury to failure. The document then addresses indications for starting renal replacement therapy, appropriate modalities including intermittent hemodialysis, slow continuous ultrafiltration, and continuous renal replacement therapy. Key factors like vascular access, solutions, membranes, anticoagulation, and dose are discussed. The overall conclusions are that while data from high-quality randomized controlled trials are still lacking, earlier initiation of renal replacement therapy may aid recovery, and continuous modalities are generally preferred over intermittent hemodialysis for unstable patients. Individualization of
CRRT describes a group of renal replacement therapies that provide continuous renal replacement over an extended period of time, typically 24 hours per day. There are several CRRT modalities including CVVH, CVVHD, and CVVHDF that utilize different molecular transport mechanisms like diffusion, convection, and ultrafiltration. CRRT is commonly used to treat acute kidney injury as it closely mimics the native kidney and is better tolerated by hemodynamically unstable patients. Studies have shown that earlier initiation of CRRT and achieving an adequate dose of effluent flow rate or solute clearance may improve survival rates in patients with acute renal failure.
Salon b 13 kasim 15.45 17.00 yusuf savran-ingtyfngnc
This document discusses 6 case reports of patients with acute renal injury who were treated with continuous renal replacement therapy (CRRT). It provides details on each patient's condition and treatment. It then reviews the different CRRT modalities, initiatives for treatment, dosing considerations, and conclusions from studies on optimal dose. The key factors in choosing CRRT over intermittent hemodialysis are hemodynamic instability, fluid removal needs, and clearing inflammatory mediators. Studies show a minimum dose of 35 ml/kg/hr improves survival compared to 20 ml/kg/hr, but higher doses do not necessarily result in further benefit. Early initiation of treatment and individualized dosing are recommended.
Dr. Kumar presented on renal replacement therapy. The key points are:
1. Approximately 5% of critically ill patients with AKI will require RRT, with a mortality rate as high as 60%.
2. RRT options include intermittent HD, continuous therapies like CVVH/CVVHD/CVVHDF, and SLED.
3. The choice of RRT depends on the patient's cardiovascular status, resources available, and whether fluid removal or solute clearance is required. CRRT is preferred for hemodynamically unstable patients.
Renal replacement therapy AND HD P1.pptxOnkarKole3
1. Renal replacement therapy (RRT) began in the 1860s with the coining of the term "dialysis" and early attempts at peritoneal dialysis and hemodialysis. 2. There are three main types of RRT - hemodialysis, peritoneal dialysis, and renal transplantation. 3. Hemodialysis involves circulating blood outside the body across a semi-permeable membrane to remove waste and excess water and electrolytes. 4. Proper vascular access via an arteriovenous fistula or graft and anticoagulation are essential to safe and effective hemodialysis.
Similar to Rrt in icu dr said khamis zagazig april 2018 latest (20)
The document provides historical background on the development of peritoneal dialysis (PD) and outlines its use in acute kidney injury (AKI). It discusses:
1. The first experiments using the peritoneal cavity for uremia removal in the 1920s.
2. The development of intermittent PD in the 1960s and continuous ambulatory PD in the 1970s.
3. Evidence that high doses of continuous PD can provide appropriate metabolic control in AKI, with survival and renal recovery rates similar to other renal replacement therapies.
4. Indications for acute PD include hemodynamic instability and bleeding risks, while contraindications include recent abdominal surgery and severe peritonitis.
This document summarizes a presentation on therapeutic plasma exchange (PEX) given by Kamal Mohamed Okasha. It provides an overview of the PEX procedure and potential indications for PEX, including Goodpasture's Syndrome, thrombotic thrombocytopenic purpura, cryoglobulinemia, multiple myeloma, and ANCA disease. It discusses complications of PEX and guidelines for efficacy based on recent studies. In particular, it examines the use of PEX for Goodpasture's Syndrome, noting that PEX aims to remove circulating anti-GBM antibodies and that studies have found improved outcomes, including renal function and survival, for patients receiving PEX treatment.
Hussein drug therapy in aki 3 osama alshahat 2 pptxFarragBahbah
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Membranous nephropathy 22 october 2019, prof. hussein sheashaaFarragBahbah
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1. The epidemiology, presentation, and trends of DKD.
2. The pathology and biomarkers of DKD.
3. The management of DKD, including the use of RAAS blockers, anti-hyperglycemic drugs like SGLT2 inhibitors and GLP1 RAs, and renal replacement therapies.
4. It concludes with a discussion of taking a holistic approach to DKD and lessons that can be learned from basic research on autophagy.
The document discusses several cases of glomerular disease:
1) A 27-year-old male with nephrotic syndrome and a kidney biopsy showing IgG and C3 deposits along the glomerular basement membrane consistent with membranous nephropathy.
2) A 78-year-old female admitted with nephrotic syndrome after a history of NSAID use, with a biopsy showing focal segmental glomerulosclerosis.
3) A 26-year-old male with nephrotic syndrome and renal impairment, whose biopsy demonstrated membranoproliferative glomerulonephritis with C3 deposition and subendothelial electron dense deposits. Follow up showed elevated
A 30-year-old man presented with lower limb swelling, shortness of breath, and decreased urine output for 2 weeks. He had a history of drug abuse including heroin, tramadol, and marijuana. Initial labs showed severe kidney dysfunction with a creatinine of 7.5 mg/dl. A renal biopsy was performed which showed acute tubular injury, focal interstitial nephritis with eosinophil infiltrate, and mesangial proliferative glomerulonephritis. He was started on hemodialysis and steroids. After treatment, his kidney function improved and he was discharged with a creatinine of 1.5 mg/dl.
A 19-year-old male gym player presented with decreased urine output, fatigue, loss of appetite, joint pain, nausea, and vomiting for one week. Lab results showed impaired renal function. He has a history of artheralgia treated with long-acting penicillin. Investigations showed positive ANA and anti-ds DNA. A renal biopsy was done which revealed lupus nephritis class 4, indicating an active inflammation. The treatment plan includes high dose steroids, immunosuppressants, and supplements.
This document discusses tubulointerstitial nephritis (TIN), a pattern of renal injury characterized by inflammation and edema of the renal tubules and interstitium. TIN is most commonly caused by drugs (71% of cases) and infections (15% of cases). On biopsy, TIN shows lymphocytic infiltration of the tubules and interstitium with tubular atrophy and normal glomeruli and vessels. Treatment involves withdrawing the offending agent and supportive care. Corticosteroids may aid recovery but their effectiveness is debated. Prognosis depends on factors like duration of the insult and degree of fibrosis - complete recovery is more likely if treatment begins early.
Fasting ramadan nephrology prospective prof. osama el shahateFarragBahbah
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Ramadan fasting & kidney disease may 2019FarragBahbah
Ramadan fasting is a unique metabolic model that consists of alternating periods of fasting and feasting rather than continuous fasting. During the fast, the body breaks down fat stores and releases fatty acids into the bloodstream to be used for energy. This process can help eliminate toxins from the fatty acids. Fasting has also been shown to help reduce inflammation and support the immune system. However, fasting also carries risks and may not be appropriate for certain groups like pregnant women, those with medical conditions, or people on medication. Proper hydration and electrolyte replacement is important when fasting to avoid health issues.
- Short-term catheters should only be used for acute dialysis or limited hospital use. Non-cuffed femoral catheters are only for bed-bound patients.
- Long-term catheters should be used with a plan for permanent access and prefer those capable of high flow rates. Choice depends on local experience and goals.
- Long-term catheters should avoid the same side as a maturing arteriovenous access, if possible.
This document summarizes the medical history and treatment of a 55-year-old male patient with end-stage renal disease on hemodialysis for 17 years and secondary hyperparathyroidism. Medical treatment with cinacalcet and calcitriol was unsuccessful in lowering his high calcium, phosphorus, and PTH levels. Consultations with ENT and cardiology found no issues. The doctor decided that parathyroidectomy was the best option to treat his tertiary hyperparathyroidism that was not responding to medical treatment.
A 53-year-old male has been undergoing regular hemodialysis for end-stage renal disease (ESRD) for the past 6 years. He has a history of secondary hyperparathyroidism with elevated parathyroid hormone (PTH) levels over 2000. Medical treatment with vitamin D analogs and cinacalcet failed to control his PTH levels. Due to the failure of medical management and severe hyperparathyroidism, the patient is scheduled to undergo parathyroidectomy, which is the recommended treatment in cases of ESRD with tertiary hyperparathyroidism that do not respond to oral medications.
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
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In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
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DECLARATION OF HELSINKI - History and principlesanaghabharat01
This SlideShare presentation provides a comprehensive overview of the Declaration of Helsinki, a foundational document outlining ethical guidelines for conducting medical research involving human subjects.
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Travel Clinic Cardiff offers comprehensive travel health services, including vaccinations, travel advice, and preventive care for international travelers. Our expert team ensures you are well-prepared and protected for your journey, providing personalized consultations tailored to your destination. Conveniently located in Cardiff, we help you travel with confidence and peace of mind. Visit us: www.nxhealthcare.co.uk
Demystifying Fallopian Tube Blockage- Grading the Differences and Implication...
Rrt in icu dr said khamis zagazig april 2018 latest
1. Renal Replacement Therapy In
Critically Ill Patients
Said Khamis MD (MSc., Nephro., KUL Belgium)
Professor Of Medicine & Nephrology
Chief of Nephrology Unit
Menoufia University Hospitals (Egypt)
2. Introduction
In the past, the interaction between nephrology and
intensive care was minimal Today,
there is
continuous
interaction
with
several
moments of
high
interaction
due to
common
patients
and
complex
syndromes
Contrib Nephrol. Basel, Karger, 2010 (166):1–3
3. Introduction (Contd)
Classification of blood purification in critical care (BPCC) technology
PMX =
polymyxin-
B immobilized
fiber;
PMMA =
polymethylmeth
acrylate;
PAN =
polyacrylonitrile;
PEPA =
polyether
polymer alloy
Contrib Nephrol. Basel, Karger, 2010(166):11–20
4.
5.
6. Agenda
• History of Acute RRT: Modalities
• Introduction
• Acute RRT: Modalities
– CRRT versus IHD
– Hybrid RRT (SLED)
– CRRT versus SLED
– Using what?
– How much therapy?
– When To Stop/Switch?
• Conclusions
7.
8.
9.
10.
11. Evolution of Renal Replacement Therapy
Abel, 1913
First dialysis
of animal
Kolff, 1945
First dialysis
in human
Teschan, 1950s
Daily dialysis in
Korean war
Since 1960s
Chronic, intermittent hemodialysis (IHD)
( 24hrs q.w. 10-16hrs b.i.w.
- 4-6hrs t.i.w. )
Daily dialysis?
Kramer, 1977
First CRRT
(CAVH)
1994
Automated
CRRT
CRRT
or
SLEDD?
Contrib Nephrol. 2004; 145: 1-9
12. Where are we ?
• What therapy should we use?
• When should we start it?
• What are we trying to achieve?
• How much therapy is enough?
• When do we stop/switch?
• Can we improve outcomes?
13. Introduction
• Acute kidney injury (AKI) is
– Frequent complication of hospitalization (1–25% )
– Associated with substantial morbidity, mortality & health
care expenditures (MR: 20-60%)
• Although understanding of the epidemiology of AKI has
improved, there are:
– No proven therapies that reverse the course of established AKI
• Renal replacement therapy (RRT):
– Key component of the supportive care given to patients with
severe AKI (in 4% of ICU pts.)
Nephron Clin Pract 2009;112:c222–c229
14. Introduction (cont.)
-AKI with need for RRT in the ICU is a complex & devastating condition,
with a reported mortality rate as high as 50–80%.
-Among RRT-requiring patients who survive the critical phase of their
illness, the majority will be free of RRT at the time of hospital
discharge
Hyman A & Mendelssohn DC (2002) Am J Nephrol 22: 29–34
W. Van Biesen, N. Lameire .Intensive Care Medicine 2003, pp 663-675
15. Introduction (cont.)
• Thus, the idea that by inventing ‘the perfect RRT-machine’,
no more patients with ICU-related AKI will die, will remain
an illusion. Furthermore, AKI mostly recovers if the patient
survives.
• RRT in AKI should thus be seen as a bridging therapy that allows the
patient to survive while the native kidneys recover.
• The main objective of RRT should, thus, be to avoid
additional harm to the patient as much as possible while
clearing the uremic waste products & maintaining the
‘milieu interieur’ as closely possible to normal.
W. Van Biesen & N. Lameire Intensive Care Medicine 2003, pp 663-675
16. Moore et al., Management of Acute Kidney Injury: AJKD Core Curriculum 2018
17.
18.
19.
20. Whatever the criteria used to define ‘early’
versus ‘late’ RRT,
It is apparent that what may be ‘early’ for one
patient
could be ‘late’ for another patient depending on
the patient’s comorbidity and clinical course
Macedo E, Mehta R. Semin Dial 2011; 24: 132–137
21. Proposed Indications for RRT
• Oliguria < 200ml/12 hours
• Anuria < 50 ml/12 hours
• Hyperkalaemia > 6.5 mmol/L
• Severe acidaemia pH < 7.0
• Uraemia > 30 mmol/L
• Uraemic complications
• Dysnatraemias > 155 or < 120 mmol/L
• Hyper/(hypo)thermia
• Drug overdose with dialysable drug
Lameire, N et al. Lancet 2005; 365: 417-430
23. The Ideal Renal Replacement Therapy
• Allows control of intra/extravascular volume
• Corrects acid-base disturbances
• Corrects uraemia & effectively clears “toxins”
• Promotes renal recovery
• Improves survival
• Is free of complications
• Clears drugs effectively (?)
24. Initial Choice of RRT for AKI
• IHD
Hemodynamically stable
Severe hyperkalemia
• CRRT
Hemodynamically unstable
Can not tolerate fluid removal
Intracranial bleed
• PD ?!!
27. Acute RRT: Modalities (1)
• Although institutional policies may determine the
local availability of these modalities,
– CRRT & SLED tend to be used in patients with
greater hemodynamic instability
• There is likely substantial inter-center variability with respect to
how each of these forms of RRT is utilized & prescribed.
• IHD
– Typically administered with conventional dialysis
machine with session length ranging from 3 to 5 h
either daily or every other day.
Vanholder et al. Critical Care 2011, 15:204
28. Intermittent Therapies - PRO
(Relatively) Inexpensive
Flexible timing allows for mobility/transport
Rapid correction of fluid overload
Rapid removal of dialyzable drugs
Rapid correction of acidosis & electrolyte abnormality
Minimises anticoagulant exposure
30. Acute RRT: Modalities (2)
• CRRT
– Is applied with an intended ttt. time of 24 h & generally
requires dedicated machines that operate at comparatively
lower blood & dialysate pump speeds
• CRRT involves either
– Dialysis (diffusion-based solute removal) or
– Filtration (convection-based solute and water removal) Rx that operate in a
continuous mode
– CRRT is generally better tolerated than conventional therapy,
since many of the complications of IHD are related to the
rapid rate of solute and fluid loss
Vanholder et al. Critical Care 2011, 15:204
38. Continuous Therapies - PRO
Haemodynamic stability => ??? better renal recovery
Stable and predictable volume control
Stable and predictable control of chemistry
Stable intracranial pressure
Disease modification by cytokine removal (CVVH)?
Kidney Blood Press Res2003;26:123-127
Journal of the American Society of Nephrology, 2001
39. Continuous Therapies - CON
Anticoagulation requirements
Higher potential for filter clotting
Expense – fluids etc.
Immobility & Transport issues
Increased bleeding risk
High heparin exposure
Kidney Blood Press Res2003;26:123-127
Journal of the American Society of Nephrology, 2001
40. PD vs CRRT
– Patients with severe falciparum malaria
(48 patients) and sepsis (22 patients)
– Assignment: 34 to hemofiltration and 36 to PD.
– PD: 70 liters/ day of dialyzate was used
– CVVH: 25 liters of replacement fluid was used
Replacement fluid was lactate based with glucose of 2g/L
Dialyzate was Acetate based with glucose of 15g/L
– Results: PD has
Lower rate of resolution of acidosis
Slower rate of decline in plasma Creatinine
Markedly increased risk of death
42. • 5.4.1: We suggest initiating RRT in patients with AKI via an
uncuffed nontunneled dialysis catheter, rather than a
tunneled catheter. (2D)
• 5.4.2: When choosing a vein for insertion of a dialysis
catheter in patients with AKI, consider these preferences
(Not Graded):
First choice: right jugular vein;
Second choice: femoral vein;
Third choice: left jugular vein;
Last choice: subclavian vein with preference for the dominant side.
Vascular access
KDIGO® AKI Guideline March 2012
43.
44. Bicarbonate versus lactatebased fluid replacement in CVVH
Prospective, randomized study
• Results :
• Serum lactate concentration was
significantly higher and the
bicarbonate was lower in patients
treated with lactatebased
solutions
• Increased incidence of CVS
events in pts ttt with lactate
solution
– Hypotension
– Increased dose of inotropic
support
Barenbrock et al; Kidney Int (2000)
Solutions for CRRT
0%
10%
20%
30%
40%
50%
60%
70%
Bicarbonate Lactate
cardiovascular
complications
hypotensive episodes
45. 5.7.3: We suggest using bicarbonate, rather than
lactate, as a buffer in dialysate and
replacement fluid for RRT in patients with AKI and
liver failure and/or lactic acidemia. (2B)
Dialysis Interventions for Treatment of AKI
KDIGO® AKI Guideline March 2012
46. The Membrane
• High Flux membrane , synthetic , biocompatable , acting by
providing both methods of detoxications:
a) Diffusion : for low molecular weight toxins.
b) Convection : for large molecules.
5.5.1: We suggest to use dialyzers with a biocompatible
membrane for IHD and CRRT in patients with AKI. (2C)
KDIGO® AKI Guideline March 2012
48. 5.3.2.1: For anticoagulation in intermittent RRT, we
recommend using either unfractionated or low-
molecular weight heparin, rather than other
anticoagulants. (1C)
5.3.2.2: For anticoagulation in CRRT, we suggest using
regional citrate anticoagulation rather than heparin
in patients who do not have contraindications for
citrate. (2B)
KDIGO® AKI Guideline March 2012
54. Discontinuation of RRT
• The decision to discontinue RRT in patients with AKI is made based
on 1 of 3 clinical scenarios:
• intrinsic kidney function has adequately improved to meet demands,
• the disorder that prompted renal support has improved,
• or continued RRT is no longer consistent with goals of care.
• There is no definitive prospective evidence to guide clinicians, but
urine output appears to be predictive of successful RRT
discontinuation successful RRT discontinuation.
• Moore et al., Management of Acute Kidney Injury: AJKD Core Curriculum 2018
55. • In one study of patients on CRRT, 24-hour urine output > 400 mL/d in
patients not using diuretics or >2,300 mL/d in patients using diuretics
had >80% chance of successful RRT discontinuation.
• Other studies have suggested that quantitation of timed urinary
creatinine & urea excretion (either as total excretion per 24-hour period or
calculation of creatinine and urea clearance) may be helpful.
• Prospective studies are needed to help guide clinicians on when to
attempt RRT discontinuation.
Moore et al., Management of Acute Kidney Injury: AJKD Core Curriculum 2018
57. Uchino S, Bellomo R, Morimatsu H, et al. Crit Care Med 2009; 37: 2576–2582.
58. Uchino S, Bellomo R, Morimatsu H, et al. Crit Care Med 2009; 37: 2576–2582.
59. When to Stop?
Kidney International Supplements (2012) 2, 89–115
It is also important to acknowledge that there may be
patients with a futile prognosis in whom RRT would not
be appropriate and where withholding RRT constitutes
good end-of-life care
Lassnigg A, Schmidlin D, Mouhieddine M et al. J Am Soc Nephrol 2004; 15:1597–1605
60. The never ending debate!
CRRT
Vs
Intermittent HD
Intuitively: CRRT>IHD
Data: CRRT=IHD
61.
62.
63. CRRT versus IHD (1)
• The presumption of greater hemodynamic stability
with CRRT also remains controversial
– Three RCTs suggested no advantage with CRRT Vs IHD,
while others demonstrated more favorable hemodynamics
with CRRT
– Even if CRRT confers a hemodynamic benefit, It is unclear
whether this translates into improvements in the patient-
relevant outcomes of survival & renal recovery
Vanholder et al. Critical Care 2011, 15:204
64. CRRT versus IHD (2)
IHD CVVH
Diffusion
Low-flux membrane
High dialysate flow
A few hours per day
Technically demanding
Less labor intensive
Convection
High-flux membrane
Low dialysate flow
Theory continuously
Technically less demanding
Labor intensive
Journal of the American Society of Nephrology, 2001
IHD CVVH
Advantages
Short duration
Cheap
Less labor-intensive
Hemodynamic stability
Better removal of cytokines
Disadvantages
Rapid hemodynamic change
Technically sophisticated
Continuous anticoagulation
Patient immobility
Intensive nursing requirement
Increased expense
65. CRRT versus IHD (3)
• Despite the widespread use of CRRT in critically ill
patients with AKI, there are few data supporting its
benefits over conventional (IHD)
• Despite greater volume control, CVVHD did not lead to improvement in
survival, preservation of urine output, or renal recovery compared with IHD
in patients with AKI
• Currently the choice of IHD or CRRT is largely based on
the availability of CRRT, preference of the health care
provider & not on evidence-based indications
• Augustine et al. Am J Kidney Dis. 2004; 44: 6
• Lameire N et al. (2005) Lancet 365: 417–430
• Uehlinger et al. (2005). Nephrol Dial Transplant 20: 1630–1637
• Fliser and Kielstein Nature Clinical Practice Nephrology (2006) 2, 32-39
66. Outcome with IRRT vs CRRT (1)
• Trial quality low: many
non-randomized
• Therapy dosing variable
• Illness severity variable
or details missing
• Small numbers
• Uncontrolled technique,
membrane
• Definitive trial would
require 660 patients in
each arm!
• Unvalidated instrument
for sensitivity analysis
Kellum, J et al. Intensive Care Med 2002; 28: 29-37
“there is insufficient evidence to establish whether CRRT is associated with
improved survival in critically ill patients with ARF when compared with IRRT”
67. Outcome with IRRT vs CRRT (2)
Tonelli, M et al. Am J Kidney Dis 2002; 40: 875-885
• No mortality difference between therapies
• No renal recovery difference between
therapies
• Unselected patient populations
• Majority of studies were unpublished
This meta-analysis of six RCTs
included > 600 patients treated in four
countries It found no significant
difference in mortality rate for
critically ill patients with ARF treated
with IHD compared to CRRT
68.
69. • It is disappointing that CRRT has been a
therapeutic option in critical care medicine for
25 years without comprehensive evaluation of
its definitive benefits
• ‘‘The difficulty lies, not in new ideas, but
in escaping old ones ”
• John Maynard Keynes (1933)
• “Which therapy is more user friendly, safer and helpful
to the overall management of critically ill patients ?”
• Hybrid therapies will become the dominant RRT for
AKI over the next 5 to 10 years
70. Acute RRT: Modalities (3)
• SLED ('Hybrid‘ renal replacement therapies)
– Sometimes referred to as extended dialysis, is
considered a ‘hybrid’ of IHD and CRRT
• Administered using conventional dialysis
technology but typical sessions run for 8–12 h
using blood & dialysis flows that are intermediate
to those prescribed in IHD and CRRT
Davenport A .,Saudi J Kidney Dis Transplant 2008;19(4):529-536
Vanholder et al. Critical Care 2011, 15:204
73. Sustained Low Efficiency Daily Dialysis SLEDD
• CRRT and its increasing use by intensivists has put a
great deal of pressure on nephrologists to adapt &
compete
• Hybrid strategies seek a middle ground between CRRT
and standard HD
• Makes it possible for IHD to return to the ICU in a more
competitive manner
Lonnemann G et al. (2000) . Nephrol Dial Transplant 15: 1189–1193
• Marshall MR et al. (2001) . Kidney Int 60: 777–785
74. Is SLEDD the answer?
• Hybrid therapy with flexibility of duration and intensity
• SLEDD vs CRRT
• Major advantages: flexibility, reduced costs, low or
absent anticoagulation
• Similar adequacy and hemodynamics
– One small study (16 pts) showed slightly higher acidosis and lower BP
(Baldwin 2007)
– VA trial (Palevsky NEJM 2008) suggests similar outcomes as CRRT and
IRRT.
Vanholder et al. Critical Care 2011,15:204
81. Accelerated Venovenous Hemofiltration
• A strategy has recently been described whereby
– CRRT machinery was applied over a contracted treatment time of 9 h,
using increased blood and effluent flow rates
• Termed accelerated venovenous hemofiltration, this
modality retains many of the feasibility advantages of SLED,
– but dedicated commercial solutions were still required
• A retrospective case series demonstrated
– adequate solute removal, acceptable hemodynamic tolerability and
the ability to avoid systemic anticoagulation
Gashti et al.,Am JKidney Dis 2008; 51: 804–810.
82. Sustained low-efficiency dialysis in the ICU: Cost,
anticoagulation, and solute removal
Daily and weekly cost of SLED and CRRT
Berbece A N and Richardson R M A, KI (2006) 70, 963-968
SLED($) CRRT citrate ($) CRRT heparin ($)
Supply cost/day 69.75 402.8 334.95
HD RN cost/day 168.75a 37.5 37.5
Total cost /day 238.5 440.3 372.45
Total cost / week 1431 3089 2607
83. CRRT versus SLED
• In addition to the absence of a survival advantage,
CRRT is more costly than IHD & is associated with a
number of obstacles such as
– Continuous patient immobilization,
– The requirement for anticoagulation and
– The need for specialized machines and premixed commercial solutions
• This has stimulated a search for a strategy that
– Incorporates the putative hemodynamic benefits of CRRT without the
associated logistic and resource constraints
• SLED meets many of these criteria
Nephron Clin Pract 2009;112:c222–c229
84. CRRT versus SLED
• SLED
– Observational data from single centers suggest
that SLED is a feasible way of providing RRT that is
• Adequate, hemodynamically well tolerated, potentially
anticoagulation-free and possibly cost-effective
– However, only a few small RCTs have compared
SLED and CRRT
Nephron Clin Pract 2009;112:c222–c229
85. CRRT versus SLED
• Kielstein et al.,(Am J Kidney Dis 2004; 43: 342–349) randomized 39
critically ill patients with AKI to receive
– Either 24 h of CVVH or 12h of SLED
• Using invasive monitoring, these authors found
– No significant differences in all measured hemodynamic parameters
(MABP, SVR, CO) with comparable removal of creatinine and urea
– Berbece and Richardson (KI. 2006., 70, 963–968.)
compared SLED (23 patients, 165 treatments) with CRRT (11 patients, 209
days), they concluded that SLED may be routinely performed
without anticoagulation; it provides solute removal equivalent
to CRRT at significantly lower cost.
91. HD treatment in ICU depend
• Treatment behavior
• Availability of treatment methods
• Organization of the unit
• Knowledge & experience of nurses
• Existence of nephrological unit in the hospital
• Cost
• Individual doctor must therefore know the
advantages & disadvantage of different ttt options.
Kidney Blood Press Res2003;26:123-127
94. Evaluating AKI :
Comparison with AMI
Period Acute Myocardial
infarction
Acute Kidney Injury
1960’s LDH S Cr
1970’s CPK, Myoglobin S Cr
1980’s CPKMB S Cr
1990’s Troponin T S Cr
2000’s Troponin I S Cr
Multiple therapies
50% reduction in
mortality
Supportive therapy
High mortality, largely
unchanged
97. RRT for Acute Kidney Injury
• There is some evidence for a relationship
between higher therapy dose and better
outcome, at least up to a point
• This is true for IHD* and for CVVH**
• There is no definitive evidence for superiority
of one therapy over another, and wide
practice variation exists***
• Accepted indications for RTT vary
• No definitive evidence on timing of RRT
*Schiffl, H et al. NEJM 2002; 346: 305-310 ** Ronco, C et al. Lancet 2000; 355: 26-30
*** Uchino, S. Curr Opin Crit Care 2006; 12: 538-543
98. Conclusions - 1
• Despite the conceptual advantages of CRRT, multiple RCTs
have shown no evidence of improved patient outcomes with
this modality, as compared to conventional IHD
• The logistic challenges associated with CRRT and the relatively high
costs of this modality may stimulate the increased use of SLED
• However, well-designed RCTs are still needed to better
characterize the reported benefits of SLED prior to its
widespread adoption
99. Conclusions - 2
• The current balance of evidence suggests that among hemodynamically
unstable patients, CRRT need not be administered at doses >20
ml/kg/h, & in more stable patients, alternate day IHD is acceptable.
• SLEDD is a hybrid therapy combining most of the advantages of both
CRRT & IHD. All these options should not be considered as
competitors, but rather as alternatives that may be switched in the same
patient depending on his/her condition. Vanholder et al. Critical Care 2011, 15:204
• From the practical point of view, among these modalities, SLEDD
seems to offer the highest flexibility to tailor ttt according to the
individual needs of the patient.
100. Conclusions - 3
• In a country like Egypt where often there are
economical constraints, the judicious use of SLED
will help us optimize the need for CRRT.
SLEDD
“The Poor Man’s
CRRT”
T. El Baz, MD, Professor of Medicine ,Division
of Nephrology, Al Azhar Univ
101.
102.
103. The best evidence in the past,
may be the worst today,
may be the best in the future again,
however patients are the same !!!!
Welcome to MEDICINE
104. GENIUS 90 Therapy System
-Hybrid therapies encompass a group of Rxs, which are
essentially based on extending the duration & slowing down
the rate of diffusion of IHD
-Most regimens use standard IHD machines with slower blood
& dialysate flow rates.
- In addition, there is a batch IHD machine (Genius, Fresenius
Bad Homberg, Germany) in which the blood & dialysate flows
are linked by a single pump, so that the flow rates are of
similar magnitude.
Davenport A .,Saudi J Kidney Dis Transplant 2008;19(4):529-536
105. Key messages
• Mortality and hemodynamic stability did not differ
in AKI patients treated either with SLED or CVVH
• SLED treatment was associated with a lower quantity
of blood transfusions given, a shorter ICU stay,
shorter duration of mechanical ventilation and faster
recovery of renal function
• SLED was accompanied with reduced nursing time
spent for RRT and lower costs for providing RRT
106. GENIUS 90 Therapy System
-This system enables the safe & efficient implementation
of subsequent therapy procedures in the ch. dialysis
center or in the ICU: (IHD),(SLEDD)(SCUF).
-The heart of GENIUS 90 is a thermally-insulated glass tank
with a capacity of 90 litres.
-This glass tank is filled with ready-to-use dialysis
fluid, which can be varied individually before each ttt
& complies with the highest hygienic requirements.
107. This characteristic as well as the high mobility
permits highly efficient Rx at any desired
location.
-This is independent of the availability of the otherwise
necessary installations at the dialysis unit for water, waste
water & the central supply of concentrate.
-During the ttt, blood & dialysis fluid are
pumped to the dialyser through the peristaltic
pump.
-The used dialysis fluid is then returned to the bottom of
the glass tank through a glass distributor tube and forms a
layer below the fresh dialysis fluid.
-The latter remains separated from the used
dialysis fluid throughout the entire ttt because
of such physical effects as density & temp.
differences