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Acute Kidney Injury Management
Volume Replacement
Mohammed Abdel Gawad
Nephrology Consultant - Alexandria - Egypt
MD Nephrology - Mansoura University
NephroTube Founder/Admin
drgawad@gmail.com
NephroTube Webinar
June 2020
To download the lecture with full animations
contact me
drgawad@gmail.com
For more Nephrology lectures visit
www.NephroTube.com
Talk Outline
• Crystalloids / Balanced crystalloids
• Hypotonic crystalloids
• Sodium bicarbonate
• Synthetic colloids
• Human albumin solutions
• How much fluid / Volume assessment
Talk Outline
• Crystalloids / Balanced crystalloids
• Hypotonic crystalloids
• Sodium bicarbonate
• Synthetic colloids
• Human albumin solutions
• How much fluid / Volume assessment
N Engl J Med 2004;350:2247-56.
n = 6997 Albumin Saline
N Engl J Med 2004;350:2247-56.
n = 6997 Albumin Saline
Outcome: Deaths
Cochrane Database Syst Rev. 2013 Feb 28;2:CD000567.
What is KDIGO missing?
N Engl J Med 2004;350:2247-56.
n = 6997
Crit Care Med. 2011 Feb;39(2):386-91
17 RCT, n=1977
Outcome: Deaths
p .047
Crit Care Med. 2013; 41: 580–637.
And this is what KDIGO missing
BMJ. 2006 Nov 18;333(7577):1044.
n = 6045 Albumin Saline
J Chin Med Assoc. 2009 May;72(5):243-50
Albumin ≤ 20 g/L Albumin > 20 g/L
A daily minimum of 25 g intravenous human albumin for
3 days during their first 7 days of admission
Albumin use
AKI in critically ill and septic patients
• Isotonic crystalloids for initial management for
expansion of intravascular volume in patients at risk
for AKI or with AKI.
• Albumin in severe sepsis and septic shock when
patients require substantial amounts of crystalloids.
• Albumin as a part of initial volume replacement may
have a role in low serum albumin patient (<2-2.5
g/dl).
NephSAP AKI 2017
NephSAP AKI 2017
Talk Outline
• Crystalloids / Balanced crystalloids
• Hypotonic crystalloids
• Sodium bicarbonate
• Synthetic colloids
• Human albumin solutions
• How much fluid / Volume assessment
Talk Outline
• Crystalloids / Balanced crystalloids
• Hypotonic crystalloids
• Sodium bicarbonate
• Synthetic colloids
• Human albumin solutions
• How much fluid / Volume assessment
2012 Oct;8(10):589-60104
July 16, 2019
05
Sodium bicarbonate administration in the setting of lactic
acidosis has consistently failed to significantly improve
hemodynamic status in humans
July 16, 2019
05
In the bicarbonate group the following increased:
All-cause mortality
Risk of hypocalcaemia
04
2012 Oct;8(10):589-60104
2012 Oct;8(10):589-60104
NephSAP Volume 18, Number 2, May 2019 QUESTIONS
NephSAP Volume 18, Number 2, May 2019 QUESTIONS
ICU patients with a pH less than 7.20, PaCO2 ≤45
mmHg, and serum bicarbonate ≤20 mmol/L
received 4.2% sodium bicarbonate (The bicarbonate
infusion was titrated to increase the arterial pH to
7.30):
• decreased rate of acute kidney injury requiring
renal replacement therapy
• improved mortality at 28 days
• lower rate of hyperkalemia,
• higher incidence of metabolic alkalosis,
hypernatremia, and hypocalcemia
Talk Outline
• Crystalloids / Balanced crystalloids
• Hypotonic crystalloids
• Sodium bicarbonate
• Synthetic colloids
• Human albumin solutions
• How much fluid / Volume assessment
NephSAP
NephSAP
Talk Outline
• Crystalloids / Balanced crystalloids
• Hypotonic crystalloids
• Sodium bicarbonate
• Synthetic colloids
• Human albumin solutions
• How much fluid / Volume assessment
Albumin use
AKI in critically ill and septic patients
• Isotonic crystalloids for initial management for
expansion of intravascular volume in patients at risk
for AKI or with AKI.
• Albumin in severe sepsis and septic shock when
patients require substantial amounts of crystalloids.
• Albumin as a part of initial volume replacement may
have a role in low serum albumin patient (<2-2.5
g/dl).
!!
Cells. 2015 Oct 7;4(4):622-30
Cells. 2015 Oct 7;4(4):622-30
All subsequent RCTs have not addressed that
these patients are meeting the criteria of
diuretic resistance!!
Journal of Critical Care 29 (2014) 253–259
Journal of Critical Care 29 (2014) 253–259
10
Nephrotic Edema
Underfill vs. Overfill
Comprehensive clinical nephrology. 5th edition. 2015
09
Nephrotic Edema
Underfill vs. Overfill
Front Pediatr. 2016 Jan 11;3:111
09
Nephrotic Edema
Underfill vs. Overfill
Front Pediatr. 2016 Jan 11;3:111
Distinction between these mechanisms prior to
the initiation of diuretic therapy is not made in
routine clinical practice
Distinction has no effect on therapy strategy
selection in routine clinical practice
09
Albumin use
Diuretic Resistance - Hypoalbuminemia
Suggestion
Albumin should be reserved for patients with
resistant edema or ascites with sever
hypoalbuminemia (plasma albumin <2.0 g/dL) whom
diuretic doses have been maximized with no response
Ann Pharmacother. 2003 May;37(5):695-700.
Individualization
09
Albumin use - Precautions
Administration of albumin prior to furosemide
could potentiate greater increases in diuresis (than
administering both at the same time)
Albumin exert maximal effect of intravascular
volume expansion within 30 to 60 min of
administration
Sci. 2001, 16, 448–454.
08
Which type of albumin?
Salt-poor albumin !!
J Am Soc Nephrol. 2001;12(5):1010.
BMC Nephrol. 2012 Jan;13:92.
08
www.NephroTube.com
Talk Outline
• Crystalloids / Balanced crystalloids
• Hypotonic crystalloids
• Sodium bicarbonate
• Synthetic colloids
• Human albumin solutions
• How much fluid / Volume assessment
Volume Assessment?
Inferior vena cava ultrasonography
2019. 3(1): 8-13
Volume overload
Collapsibility index: (IVC-exp diameter - IVC insp diameter) / (IVC-exp diameter) * 100
multiple vertical B-lines (arrows)
arising from the pleural line
2017 Jul;14(7):427-440
3 or more B lines in 2 or more
bilateral lung zones were
diagnostic for pulmonary edema
(sensitivity, 94%; specificity, 92%)
B-line score cutoff of 15 is
significantly correlated with
clinical congestion scores
Lung ultrasonography
Thank You

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Acute Kidney Injury Management Volume Replacement Techniques

  • 1. Acute Kidney Injury Management Volume Replacement Mohammed Abdel Gawad Nephrology Consultant - Alexandria - Egypt MD Nephrology - Mansoura University NephroTube Founder/Admin drgawad@gmail.com NephroTube Webinar June 2020
  • 2.
  • 3. To download the lecture with full animations contact me drgawad@gmail.com For more Nephrology lectures visit www.NephroTube.com
  • 4.
  • 5. Talk Outline • Crystalloids / Balanced crystalloids • Hypotonic crystalloids • Sodium bicarbonate • Synthetic colloids • Human albumin solutions • How much fluid / Volume assessment
  • 6. Talk Outline • Crystalloids / Balanced crystalloids • Hypotonic crystalloids • Sodium bicarbonate • Synthetic colloids • Human albumin solutions • How much fluid / Volume assessment
  • 7.
  • 8. N Engl J Med 2004;350:2247-56. n = 6997 Albumin Saline
  • 9. N Engl J Med 2004;350:2247-56. n = 6997 Albumin Saline
  • 10. Outcome: Deaths Cochrane Database Syst Rev. 2013 Feb 28;2:CD000567.
  • 11.
  • 12. What is KDIGO missing?
  • 13. N Engl J Med 2004;350:2247-56. n = 6997
  • 14. Crit Care Med. 2011 Feb;39(2):386-91 17 RCT, n=1977 Outcome: Deaths p .047
  • 15. Crit Care Med. 2013; 41: 580–637. And this is what KDIGO missing
  • 16. BMJ. 2006 Nov 18;333(7577):1044. n = 6045 Albumin Saline
  • 17. J Chin Med Assoc. 2009 May;72(5):243-50 Albumin ≤ 20 g/L Albumin > 20 g/L A daily minimum of 25 g intravenous human albumin for 3 days during their first 7 days of admission
  • 18. Albumin use AKI in critically ill and septic patients • Isotonic crystalloids for initial management for expansion of intravascular volume in patients at risk for AKI or with AKI. • Albumin in severe sepsis and septic shock when patients require substantial amounts of crystalloids. • Albumin as a part of initial volume replacement may have a role in low serum albumin patient (<2-2.5 g/dl).
  • 19.
  • 22.
  • 23.
  • 24. Talk Outline • Crystalloids / Balanced crystalloids • Hypotonic crystalloids • Sodium bicarbonate • Synthetic colloids • Human albumin solutions • How much fluid / Volume assessment
  • 25.
  • 26. Talk Outline • Crystalloids / Balanced crystalloids • Hypotonic crystalloids • Sodium bicarbonate • Synthetic colloids • Human albumin solutions • How much fluid / Volume assessment
  • 27.
  • 30. Sodium bicarbonate administration in the setting of lactic acidosis has consistently failed to significantly improve hemodynamic status in humans July 16, 2019 05
  • 31. In the bicarbonate group the following increased: All-cause mortality Risk of hypocalcaemia 04
  • 34. NephSAP Volume 18, Number 2, May 2019 QUESTIONS
  • 35. NephSAP Volume 18, Number 2, May 2019 QUESTIONS ICU patients with a pH less than 7.20, PaCO2 ≤45 mmHg, and serum bicarbonate ≤20 mmol/L received 4.2% sodium bicarbonate (The bicarbonate infusion was titrated to increase the arterial pH to 7.30): • decreased rate of acute kidney injury requiring renal replacement therapy • improved mortality at 28 days • lower rate of hyperkalemia, • higher incidence of metabolic alkalosis, hypernatremia, and hypocalcemia
  • 36. Talk Outline • Crystalloids / Balanced crystalloids • Hypotonic crystalloids • Sodium bicarbonate • Synthetic colloids • Human albumin solutions • How much fluid / Volume assessment
  • 37.
  • 40. Talk Outline • Crystalloids / Balanced crystalloids • Hypotonic crystalloids • Sodium bicarbonate • Synthetic colloids • Human albumin solutions • How much fluid / Volume assessment
  • 41. Albumin use AKI in critically ill and septic patients • Isotonic crystalloids for initial management for expansion of intravascular volume in patients at risk for AKI or with AKI. • Albumin in severe sepsis and septic shock when patients require substantial amounts of crystalloids. • Albumin as a part of initial volume replacement may have a role in low serum albumin patient (<2-2.5 g/dl).
  • 42.
  • 43.
  • 44. !!
  • 45.
  • 46.
  • 47.
  • 48.
  • 49. Cells. 2015 Oct 7;4(4):622-30
  • 50. Cells. 2015 Oct 7;4(4):622-30 All subsequent RCTs have not addressed that these patients are meeting the criteria of diuretic resistance!!
  • 51. Journal of Critical Care 29 (2014) 253–259
  • 52. Journal of Critical Care 29 (2014) 253–259 10
  • 53. Nephrotic Edema Underfill vs. Overfill Comprehensive clinical nephrology. 5th edition. 2015 09
  • 54. Nephrotic Edema Underfill vs. Overfill Front Pediatr. 2016 Jan 11;3:111 09
  • 55. Nephrotic Edema Underfill vs. Overfill Front Pediatr. 2016 Jan 11;3:111 Distinction between these mechanisms prior to the initiation of diuretic therapy is not made in routine clinical practice Distinction has no effect on therapy strategy selection in routine clinical practice 09
  • 56. Albumin use Diuretic Resistance - Hypoalbuminemia Suggestion Albumin should be reserved for patients with resistant edema or ascites with sever hypoalbuminemia (plasma albumin <2.0 g/dL) whom diuretic doses have been maximized with no response Ann Pharmacother. 2003 May;37(5):695-700. Individualization 09
  • 57. Albumin use - Precautions Administration of albumin prior to furosemide could potentiate greater increases in diuresis (than administering both at the same time) Albumin exert maximal effect of intravascular volume expansion within 30 to 60 min of administration Sci. 2001, 16, 448–454. 08
  • 58. Which type of albumin? Salt-poor albumin !! J Am Soc Nephrol. 2001;12(5):1010. BMC Nephrol. 2012 Jan;13:92. 08
  • 60.
  • 61. Talk Outline • Crystalloids / Balanced crystalloids • Hypotonic crystalloids • Sodium bicarbonate • Synthetic colloids • Human albumin solutions • How much fluid / Volume assessment
  • 62.
  • 63.
  • 64.
  • 66. Inferior vena cava ultrasonography 2019. 3(1): 8-13 Volume overload Collapsibility index: (IVC-exp diameter - IVC insp diameter) / (IVC-exp diameter) * 100
  • 67. multiple vertical B-lines (arrows) arising from the pleural line 2017 Jul;14(7):427-440 3 or more B lines in 2 or more bilateral lung zones were diagnostic for pulmonary edema (sensitivity, 94%; specificity, 92%) B-line score cutoff of 15 is significantly correlated with clinical congestion scores Lung ultrasonography

Editor's Notes

  1. Sodium bicarbonate produces CO2 after buffering plasma protons. This CO2 is then free to diffuse across cell membranes resulting in an intracellular hypercarbic acidemia, while bicarbonate is unable to cross cell membranes to buffer this effect. Nonbicarbonate Buffers. Bicarbonate buffering results in carbon dioxide production and a lowering of free proton concentration. Lower free protons favors disassociation of nonbicarbonate buffers which, in turn, are buffered again by bicarbonate resulting in increasing carbon dioxide production resulting in a cycle of increasing intracellular carbon dioxide so long as exogenous bicarbonate is administered. Acceleration of lactate generation — Acidemia may act as a "brake" on lactic acid generation by inhibiting glycolysis, largely mediated by a reduction in the activity of the enzyme, phosphofructokinase [17].