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1. Renal Replacement Therapy in AKI
Mohammed Abdel Gawad
Nephrology Consultant - Alexandria - Egypt
MD Nephrology - Mansoura University
NephroTube Founder/Admin
drgawad@gmail.com
NephroTube Webinar
May 2020

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contact me
drgawad@gmail.com
For more Nephrology lectures visit
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4. Dialytic Management of AKI
When to Initiate?
Best Modality?
When to Stop?
What is the Dose?

5. Dialytic Management of AKI
When to Initiate?
Best Modality?
When to Stop?
What is the Dose?
What is the Evidence?

6. Dialytic Management of AKI
When to Initiate?
Best Modality?
When to Stop?
What is the Dose?
What is the Evidence?

7. When to initiate? Early vs Late
What is meant by EARLY?
What is meant by LATE?
Studies aimed at determining the optimal time for starting
RRT have evaluated various arbitrary cut-offs for:
• serum creatinine
• serum urea
• urine output
• time from ICU admission or duration of AKI

8. When to initiate? Early vs Late
What is meant by EARLY?
What is meant by LATE?
Studies aimed at determining the optimal time for starting
RRT have evaluated various arbitrary cut-offs for:
• serum creatinine
• serum urea
• urine output
• time from ICU admission or duration of AKI

10. Kidney International Supplements (2012) 2, 19–36

12. 1031 studies
Lancet. 2020 May 9;395:1506-1515

14. • Fluid overload (refractory to medical measures)
• Hyperkalemia (refractory to medical measures)
• Sever metabolic acidosis (refractory to medical
measures)
• Signs of uremia (such as pericarditis, neuropathy, or
an otherwise unexplained decline in mental status)
• Certain alcohol and drug intoxications
In the
absence of these
factors there is
generally a
tendency to avoid
dialysis as long as
possible

16. 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

19. NephSap AKI

20. NephSap AKI

21. NephSap AKI
Dialysis initiation is
most appropriate on
day five of this patient’s
hospitalization because
she now has metabolic,
volume, and laboratory
indications for initiation
of renal replacement
therapy (RRT).

22. NephSap AKI

23. NephSap AKI

24. Dialytic Management of AKI
When to Initiate?
Best Modality?
When to Stop?
What is the Dose?
What is the Evidence?

26. When to Stop?
Kidney International Supplements (2012) 2, 89–115
10

27. When to Stop?
Assessment of kidney function during RRT
• In IHD, the fluctuations of solute levels prevent
achieving a steady state.
• Changes in BUN and creatinine levels can also be
modified by nonrenal factors, such as volume status
and catabolic rate.
• In CRRT, continuous solute clearance of 25–35 ml/min
will stabilize serum markers after 48 hours. This
allows more reliable measurements of CrCl by the
native kidneys during CRRT.
Kidney International Supplements (2012) 2, 89–115

28. When to Stop?
Assessment of kidney function during RRT
Shealy CB, Campbell RC, Hey JC, et al. 24-hr creatinine clearance as a guide for
CRRT withdrawal: a retrospective study (abstr). Blood Purif 2003;21: 192.
Successful termination of CRRT, defined as the absence of
CRRT requirement for at least 14 days following cessation
10
CrCl

29. When to Stop?
Assessment of kidney function during RRT
CrCl RRT
<12 mL/min RRT was continued
12 to 20 mL/min Decision was left to the discretion of
providers
> 20 mL/min RRT was discontinued
Palevsky PM et al. N Engl J Med. 2008;359:7-20
10
ATN
CrCl

30. When to Stop?
Assessment of kidney function during RRT
Palevsky PM et al. N Engl J Med. 2008;359:7-20
When the UOP > 30 mL/hour
CrCl Assessment methodology
1 hr 3hr 6h
Urine
collection
Midpoint
serum Cr
9
CrCl

31. When to Stop?
Assessment of kidney function during RRT
Palevsky PM et al. N Engl J Med. 2008;359:7-20
When the UOP > 30 mL/hour
CrCl Assessment methodology
1 hr 3hr 6h
Urine
collection
serum Cr serum Cr
Average serum Cr
9
CrCl

32. When to Stop?
Assessment of kidney function during RRT
Uchino S, Bellomo R, Morimatsu H, et al. Crit Care Med 2009; 37: 2576–2582. 9
UOP

33. When to Stop?
Assessment of kidney function during RRT
Uchino S, Bellomo R, Morimatsu H, et al. Crit Care Med 2009; 37: 2576–2582. 9
UOP

36. 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
7

37. How to Stop?
The process of stopping RRT may consist
of:
• Simple discontinuation of RRT,
• or may include a change in the
modality, frequency, or duration of
RRT.
Kidney International Supplements (2012) 2, 89–115

38. Dialytic Management of AKI
When to Initiate?
Best Modality?
When to Stop?
What is the Dose?
What is the Evidence?

41. RRT Modalities
Marshall MR, Golper TA. Semin Dial. 2011;24:142-148.

43. Hemodialysis
Diffusion (mainly)
+ Convection (ultrafiltration)
removing water accumulated during
the interdialytic period
CRRT: CVVHD

44. Hemodialysis Hemofiltration
Diffusion (mainly)
+ Convection (ultrafiltration)
removing water accumulated during
the interdialytic period
Convection (ultrafiltration)
large amount of ultrafiltration
+ higher removal of larger, poorly
diffusible solutes
CRRT: CVVHD CRRT: CVVHF

45. Hemodiafiltration
Diffusion (HD)
+ High Convection (ultrafiltration) (HF)

46. Hemodiafiltration
Diffusion (HD)
+ High Convection (ultrafiltration) (HF)
CRRT: CVVHDF
If ultrapure dialysate
produced by the
dialysis machine as
replacement fluid
Online HDF
(OL HDF)

47. CRRT: SCUFHemofiltration, CRRT: CVVHF

48. Cochrane Database Syst Rev 2007: CD003773.

49. Hemodynamicaly stable patients

50. Analyzing 15 RCTs in 1550 AKI patients
Cochrane Database Syst Rev 2007: CD003773.
Hemodynamicaly stable patients

51. Cochrane Database Syst Rev 2007: CD003773.
Hemodynamicaly stable patients

52. Cochrane Database Syst Rev 2007: CD003773.
Hemodynamicaly stable patients

53. Cochrane Database Syst Rev 2007: CD003773.
Hemodynamicaly stable patients

54. Kidney International Supplements (2012) 2, 89–115
Hemodynamicaly stable patients

55. Hemodynamicaly unstable patients / ↑ ICP

56. Kidney International Supplements (2012) 2, 89–115
Hemodynamicaly unstable patients / ↑ ICP

57. Cochrane Database Syst Rev 2007: CD003773.
Hemodynamicaly unstable patients / ↑ ICP

58. Cochrane Database Syst Rev 2007: CD003773.
Hemodynamicaly unstable patients / ↑ ICP

59. • Controversy exists as to which is the optimal RRT modality for patients with
AKI.
• In current clinical practice, the choice of the initial modality for RRT is
primarily based on:
• the availability
• experience
• patient’s hemodynamic status.
• In the presence of hemodynamic instability in patients with AKI, CRRT is
preferable to standard IHD.
• SLED may also be tolerated in hemodynamically unstable patients with AKI
in settings where other forms of CRRT are not available, (but data on
comparative efficacy and harm are limited).
• Once hemodynamic stability is achieved, treatment may be switched to
standard IHD.

60. RRT Modalities
Kidney International Supplements (2012) 2, 89–115

63. NephSap AKI

64. NephSap AKI

65. NephSap AKI

66. NephSap AKI

68. Dialytic Management of AKI
When to Initiate?
Best Modality?
When to Stop?
What is the Dose?
What is the Evidence?

70. Kt/V urea has important limitations as a tool for
RRT dosing in AKI. AKI patients are metabolically
unstable, with variations in urea generation.
Ikizler TA, Sezer MT, Flakoll PJ, et al. Kidney Int 2004; 65: 725–732.

72. Effluent rate is the ultrafiltration rate for haemofiltration (CVVH), or
the sum of ultrafiltration rate and dialysis rate for CVVHDF

74. NephSap AKI

75. NephSap AKI

78. Vascular Access

82. Peritoneal Dialysis

85. To Summarize
1

86. To Summarize
• Hemodynamic stable = IRRT & CRRT no difference regarding
outcomes
• Hemodynamic unstable/↑ICP = CRRT is preferred
1

87. To Summarize
• Emergency indication = Start RRT immediately
• If No Emergency indication consider:
• broader clinical context
• laboratory trends rather than single values
0

88. To Summarize
• Late starting of RRT in AKI is suggested
0

89. To Summarize
• Stop CRRT when CrCl > 15-20ml/min (weak evidence)
• UOP is an important parameter when termination of CRRT is
considered
0

90. To Summarize
• CRRT Dose
= Delivered effluent volume of 20-25ml/kg/hr
= Prescribed effluent volume of 25-30ml/kg/hr
0

91. To Summarize
• No evidence that septic shock patients will benefit from higher
effluent volumes
• Plasma Adsorption may have an important role in management of
septic AKI patients
0

92. Thank You