CRRT options in the ICU


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  • CRRT options in the ICU

    1. 1. It’s April…Your Patient has Acute Renal Failure…Now What? Critical Care Grand Rounds Jennifer Hancock, MD, FRCPC, CCM Jan 15, 2009
    2. 2. Objectives <ul><li>Discuss the epidemiology of renal failure in the ICU according to the RIFLE criteria </li></ul><ul><li>Review the pathophysiology ATN </li></ul><ul><li>Discuss the practical aspects of CRRT including the different modes, timing, dosing and anticoagulation </li></ul><ul><li>Discuss future applications of RRT in the ICU setting </li></ul>
    3. 3. Case 1 <ul><li>70 kg 80yr  post-op emergency AAA </li></ul><ul><li>Supra-renal x-clamp 60mins, massive transfusion </li></ul><ul><li>Post-op: </li></ul><ul><ul><li>FiO 2 100%, Sats 88%, CXR volume O/L </li></ul></ul><ul><ul><li>BP 100/60 on levo 0.2 ug/kg/min, CVP 18 </li></ul></ul><ul><ul><li>Aneuric despite a lasix trial </li></ul></ul><ul><ul><li>pH 7.12/28/55/10 K 5.3 </li></ul></ul><ul><li>Decision is made to start dialysis </li></ul>
    4. 4. Case 2 <ul><li>45 year old male admitted with septic shock and MOF secondary to pneumonia. Treated with antibiotics, resuscitation, steroids, pressors and APC </li></ul><ul><li>By ICU Day 3: </li></ul><ul><ul><li>Intubated FiO2 60% sats 90% </li></ul></ul><ul><ul><li>CVP 14, levo 0.15ug/kg/min </li></ul></ul><ul><ul><li>pH 7.34, HCO3 18, K 4.3, Cr 325 </li></ul></ul><ul><ul><li>No uremic complications </li></ul></ul><ul><ul><li>Urine O/P ~10cc/hr, </li></ul></ul><ul><ul><li>Running balance +13L </li></ul></ul>
    5. 5. Both patients have ARF presumed secondary to ATN… Now what????
    6. 6. Why Worry About Acute Renal Failure? <ul><li>Common problem </li></ul><ul><ul><li>Reported incidence of 5-25% </li></ul></ul><ul><li>Serious problem </li></ul><ul><ul><li>Mortality ranges from 30-90% </li></ul></ul><ul><ul><li>Approaches 100% if 3 organ systems fail simultaneously </li></ul></ul><ul><ul><ul><ul><ul><li> </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li> Crit Care Med 2006;34:1913-1917 </li></ul></ul></ul></ul></ul>
    7. 7. Acute Dialysis Quality Initiative: RIFLE Criteria GFR Criteria U/O Criteria Cr  1.5X N GFR  >25% Cr  2X N GFR  >50% Cr  3XN or >354 GFR  >75% <0.5 cc/kg/hr X 6hr <0.5 cc/kg/hr X 12hr <0.3cc/kg/hr X 24hr Persistent loss > 4wks ESRD >3/12 R isk I njury F ailure L oss E SKD Crit Care Med 2004;8:204-212
    8. 8. Validation of the RIFLE Criteria <ul><li>Incidence of ARF: </li></ul><ul><li>Risk: 9-10% </li></ul><ul><li>Injury: 4.5-5% </li></ul><ul><li>Failure: 3.7-3.4% </li></ul><ul><li>Mortality Rates: </li></ul><ul><li>Risk: 15-22% </li></ul><ul><li>Injury: 29-41% </li></ul><ul><li>Failure: 41-51% </li></ul>Australian study of 21,000 patients Crit Care Med 2006;34:1913-1917
    9. 9. Acute Renal Failure in the ICU <ul><li>International multi-centered prospective study of 29269 patients </li></ul><ul><ul><li>5.7% developed ARF </li></ul></ul><ul><ul><li>52% ICU mortality, 60% Hospital mortality </li></ul></ul><ul><ul><li>13.8% of survivors needed RRT at discharge </li></ul></ul>
    10. 10. What Has Happened to the Kidneys? <ul><li> MAP sensed by receptors </li></ul><ul><li> sympathetic tone, Renin/ATII, ADH </li></ul><ul><li>Renal vasoconstriction =  renal flow & GFR =  pO2 of the medulla </li></ul><ul><li>?differences in sepsis </li></ul><ul><ul><li>RBF may  and tone  in sepsis </li></ul></ul><ul><ul><li>Inflammatory mediators </li></ul></ul><ul><ul><li>Microthrombi </li></ul></ul>NEJM 1995:332;647 Crit Care Med 2008:36;S198
    11. 11. So What…How Do We Help? <ul><li>Diuretics </li></ul><ul><ul><li> pO 2 in medulla from 16 to 35 mmHg </li></ul></ul><ul><ul><li> urine O/P “flush out tubules” </li></ul></ul><ul><ul><li>Multiple studies show no benefit and potentially harm </li></ul></ul><ul><li>Fenoldapam/Dopamine </li></ul><ul><ul><li>No Benefit </li></ul></ul><ul><li>Dialysis </li></ul><ul><ul><li>IHD </li></ul></ul><ul><ul><li>CRRT </li></ul></ul><ul><ul><li>SLEDD </li></ul></ul>
    12. 12. Acute Dialysis Options: What do we know? <ul><li>No difference in mortality outcomes regardless of mode of dialysis </li></ul><ul><li>Some patients do not tolerate IHD </li></ul><ul><ul><li>Symptomatic  BP occurs in 15-50% of IHD Am J Nephrol 1990;10(3):177-80 </li></ul></ul><ul><li>CRRT </li></ul><ul><ul><li>Enhanced hemodynamic stability </li></ul></ul><ul><ul><li>Increased net salt and water removal </li></ul></ul><ul><ul><li>Potentially improved renal recovery </li></ul></ul><ul><ul><li>Better preservation of cerebral perfusion </li></ul></ul>
    13. 13. Timing of RRT <ul><li>Conventional indications </li></ul><ul><li>Observational studies suggest that “earlier initiation” may improve outcomes </li></ul><ul><li>Volume overload </li></ul><ul><ul><li>i </li></ul></ul><ul><ul><li>Surgical patients: </li></ul></ul><ul><ul><ul><li>Restricting fluids  anastomotic leaks, sepsis, bleeding, return to OR, dehiscence </li></ul></ul></ul>J Card Surg 2004:17 Clin J Am Soc Nephrol 2006;915  lung function  vent free days  ICU stay NEJM 2006:354;2564 Ann Surg 2003:238;641
    14. 14. QEII CRRT Orders <ul><li>Filters </li></ul><ul><li>Mode of dialysis </li></ul><ul><li>Calculating dose </li></ul><ul><li>Anticoagulation </li></ul><ul><li>Replacement Solutions </li></ul>
    15. 15. CRRT Filters <ul><li>ST100 is an AN69 membrane </li></ul><ul><ul><li>Increased risk of anaphylactoid reactions in patients taking an ACE inhibitor </li></ul></ul><ul><li>HF1000 is a PAES membrane </li></ul>
    16. 16. CRRT Mode <ul><li>CVVHD </li></ul><ul><ul><li>Continuous Venovenous Hemodialysis </li></ul></ul><ul><li>CVVH </li></ul><ul><ul><li>Continuous Venovenous Hemofiltration </li></ul></ul><ul><li>CVVHDF </li></ul><ul><ul><li>Continuous Venovenous Hemodiafiltration </li></ul></ul><ul><li>SCUF </li></ul><ul><ul><li>Slow Continuous Ultrafiltration </li></ul></ul>
    17. 17. CVVHD - Hemodialysis <ul><li>Diffusion of solutes passively down a concentration gradient </li></ul><ul><ul><li>Na, Urea, Creatinine move from blood to dialysate </li></ul></ul><ul><ul><li>HCO 3 , Ca move from dialysate to blood </li></ul></ul>Blood from patient Blood to patient Dialysate flow
    18. 18. CVVH - Hemofiltration <ul><li>The hydrostatic pressure gradient induces convection of water across the membrane. The frictional forces between the solutes and water results in transport of small and middle weight molecules. </li></ul>Blood from patient Blood to patient High Pressure Low Pressure Replacement Fluid
    19. 19. CVVHDF - HemoDiafiltration <ul><li>A combination of both CVVH and CVVHD </li></ul>Blood from patient Blood to patient Dialysate flow High Pressure Low Pressure Replacement Fluid High Concentration Low Concentration
    20. 20. CRRT Practice Patterns Crit Care Resus 2008: 10; 225
    21. 21. Dosing in All Causes of ARF <ul><li>ATN Study </li></ul><ul><ul><li>Intensive therapy (CVVHDF 35 ml/kg/hr) vs. less intensive therapy (CVVHDF 20 ml/kg/hr) </li></ul></ul><ul><ul><li>>50 % of patients ARF related to sepsis </li></ul></ul><ul><ul><li>Average APACHE II 26 </li></ul></ul>NEJM 2008:359;E1
    22. 22. Determining Dose in CVVHDF <ul><li>Dialysis Dosing = Effluent Rate </li></ul><ul><li>Effluent Rate = Dialysate flow + Replacement Rate </li></ul><ul><li>For a 70 kg person at 20ml/kg/hr </li></ul><ul><ul><li>= 1400 ml/hr </li></ul></ul><ul><ul><li>= 700 ml/hr dialysate flow & 700 ml/hr replacement rate </li></ul></ul>
    23. 23. Dialysis Dosing at the QEII
    24. 24. Sepsis, Dosing & Hemofiltration <ul><li>High volume hemofiltration is aimed at non-selectively removing both pro and anti-inflammatory mediators </li></ul><ul><ul><li>Prospective study of 15 septic patients receiving HVHF (85 ml/kg/hr X 6 hr) then 35 ml/kg/hr </li></ul></ul><ul><ul><li>Mortality 48% vs. predicted mortality of 72% APACHEII and 69% SAPS </li></ul></ul>Semin Dial 2006:19;69
    25. 25. Sepsis, Dosing & Hemofiltration <ul><li>Pilot study of 20 septic patients </li></ul><ul><ul><li>Randomized to HVHF (65 ml/kg/hr) or LVHF (35ml/kg/hr) </li></ul></ul><ul><ul><ul><li>HVHF  norepi dose and  urine O/P </li></ul></ul></ul><ul><ul><ul><li>No mortality difference </li></ul></ul></ul><ul><li>IVOIRE study </li></ul><ul><ul><li>Randomized multi-centered European study </li></ul></ul><ul><ul><li>Septic patients to HVHF (70 ml/kg/hr) vs. LVHF (35 ml/kg/hr) </li></ul></ul><ul><ul><li>Recruitment due to end Dec 2008 </li></ul></ul>Intensive Care Med 2008: 34; 1646
    26. 26. Anticoagulation <ul><li>Clotting and the CRRT circuit </li></ul><ul><ul><li>Multifactorial: </li></ul></ul><ul><ul><ul><li>Patients with hypercoaguable states </li></ul></ul></ul><ul><ul><ul><li>Procoagulation effect of the circuit </li></ul></ul></ul><ul><ul><ul><li>Low blood flow rates </li></ul></ul></ul><ul><ul><ul><li>High convective transfer with CVVH or CVVHDF </li></ul></ul></ul><ul><ul><ul><li>Time responding to machine alarms </li></ul></ul></ul><ul><ul><li>Effects: </li></ul></ul><ul><ul><ul><li>Less effective dialysis </li></ul></ul></ul><ul><ul><ul><li>Loss of blood in the circuit </li></ul></ul></ul><ul><ul><ul><li>Increased costs </li></ul></ul></ul>
    27. 27. Types of Anticoagulation <ul><li>Systemic </li></ul><ul><ul><li>Heparin </li></ul></ul><ul><ul><ul><li> Antithrombin III activity  s Xa and IIa activity </li></ul></ul></ul><ul><ul><ul><li>Problem if high bleeding risk </li></ul></ul></ul><ul><ul><ul><li>Risk of HITT </li></ul></ul></ul><ul><ul><li>Reports of use of APC and argactaban </li></ul></ul><ul><li>Regional </li></ul><ul><ul><li>Citrate </li></ul></ul><ul><ul><li>Prostacyclin </li></ul></ul>
    28. 28. Prostacyclin <ul><li>Prostacyclin and prostaglandin E1 inhibits platelet activation </li></ul><ul><li>Short acting </li></ul><ul><li>Systemic hypotension, H/A, flushing </li></ul><ul><li>Filter life without any additional heparin only ~15 hours </li></ul><ul><li>Very expensive! </li></ul>Crit Care 2007:11;218
    29. 29. Regional Citrate <ul><li>Citrate chelates Ca </li></ul><ul><li>iCa < 0.35 inhibits coagulation </li></ul><ul><li>Citrate clearance </li></ul><ul><ul><li>Partially diffusion and convection </li></ul></ul><ul><ul><li>Partially enters circulation </li></ul></ul><ul><li>1 citrate metabolized by the liver and skeletal muscle to 3 HCO 3 </li></ul>
    30. 30. Citrate Anticoagulation Filter Effluent Waste Citrate Ca Replacement Fluid
    31. 31. Citrate Anticoagulation <ul><li>Pros </li></ul><ul><ul><li>No systemic anticoagulation </li></ul></ul><ul><ul><li>Can be used with suspected HITT patients </li></ul></ul><ul><ul><li>Possibly longer filter life </li></ul></ul><ul><ul><ul><li>Heparin ~48hr </li></ul></ul></ul><ul><ul><ul><li>Citrate ~72 hr </li></ul></ul></ul><ul><li>Cons </li></ul><ul><ul><li>More complicated system </li></ul></ul><ul><ul><ul><li>Citrate and calcium infusions </li></ul></ul></ul><ul><ul><li>Needs close monitoring </li></ul></ul><ul><ul><ul><li>Especially in liver patients! </li></ul></ul></ul><ul><ul><ul><li>Hypo/hyper calcemia </li></ul></ul></ul><ul><ul><ul><li>Metabolic Alkalosis </li></ul></ul></ul><ul><ul><ul><li>Metabolic Acidosis </li></ul></ul></ul>Crit Care 2007:11;218
    32. 32. Citrate Toxicity & the Citrate Ratio <ul><li>Citrate accumulation may occur if: </li></ul><ul><ul><li>Unintentional citrate over infusion </li></ul></ul><ul><ul><li>Decreasing liver function </li></ul></ul><ul><ul><li>Decreasing function of the filter </li></ul></ul><ul><li>Results in: </li></ul><ul><ul><li>Hypocalcemia </li></ul></ul><ul><ul><li>Metabolic Acidosis </li></ul></ul><ul><li>Citrate Ratio: [Total Ca2+]/[ iCa2+] </li></ul><ul><ul><li>Measured q12h </li></ul></ul><ul><ul><li>Ratio > 2.5 stop citrate anticoagulation! </li></ul></ul>
    33. 33. Anticoagulation at the QEII <ul><li>Two options: </li></ul><ul><ul><li>Citrate anticoagulation </li></ul></ul><ul><ul><ul><li>Citrate infusion pre-printed orders </li></ul></ul></ul><ul><ul><ul><ul><li>Post filter iCa 0.25-0.35 mmol/L </li></ul></ul></ul></ul><ul><ul><ul><li>Calcium infusion pre-printed orders </li></ul></ul></ul><ul><ul><ul><ul><li>Systemic iCa 1.0-1.35 mmol/L </li></ul></ul></ul></ul><ul><ul><li>No anticoagulation </li></ul></ul><ul><ul><ul><li>Use if patient on systemic anticoagulation for other reasons </li></ul></ul></ul><ul><ul><ul><li>Severe liver disease </li></ul></ul></ul>
    34. 34. Replacement Solutions <ul><li>Prismocal </li></ul><ul><ul><li>Calcium 0 mmol/L </li></ul></ul><ul><ul><li>Mg 0.5 mmol/L </li></ul></ul><ul><ul><li>Cl 106 mmol/L </li></ul></ul><ul><ul><li>Na 140 mmol/L </li></ul></ul><ul><ul><li>Lactate 3 mmol/L </li></ul></ul><ul><ul><li>Bicarb 32 mmol/L </li></ul></ul>
    35. 35. QEII Citrate Orders
    36. 36. No Anticoagulation Orders
    37. 37. Starting someone on CRRT at the QEII <ul><li>Joint process between both the Division of Critical Care and the Division of Nephrology </li></ul><ul><li>ICU must contact nephrology before starting any patient on CRRT </li></ul><ul><ul><li>This may be in the form of a phone consultation </li></ul></ul><ul><li>Lines to be inserted by ICU </li></ul><ul><li>Orders can be written by either ICU or Nephrology </li></ul>
    38. 38. Starting someone on CRRT at the QEII <ul><li>Indications </li></ul><ul><ul><li>Hemodynamically unstable (defined as already requiring vasopressors or inotropes to maintain blood pressure) </li></ul></ul><ul><ul><li>The patient became hemodynamically unstable (requiring vasopressors of inotropes to maintain blood pressure) during a previous IHD or SLEDD run </li></ul></ul><ul><li>In the initial implementation stages of CRRT at the QEII only 1 patient per unit will be on CRRT at a time, even if there is another patient hemodynamically unstable who requires dialysis. </li></ul>
    39. 39. Starting someone on CRRT at the the QEII <ul><li>Also during the implementation stages, CRRT will be the preferred mode of dialysis provided to unstable patients (over SLEDD) </li></ul><ul><li>Patients would not be a candidate for CRRT regardless of their hemodynamic status if: </li></ul><ul><ul><li>The patient has taken an overdose that requires dialysis </li></ul></ul><ul><ul><li>The patient is presenting with acute hyperkalemia refractory to medical management </li></ul></ul>
    40. 40. Putting it Together <ul><li>Case 1 </li></ul><ul><ul><li>70 kg 80 yr female </li></ul></ul><ul><ul><li>Volume overload </li></ul></ul><ul><ul><li>Poor oxygenation </li></ul></ul><ul><ul><li>MA - HCO3 10 </li></ul></ul><ul><ul><li>K - 5.5 </li></ul></ul><ul><ul><li>No reason to avoid citrate </li></ul></ul>
    41. 43. Remember: Dose = Replacement + Dialysate Dose = 70kg x 20ml/kg/hr =1.4 L/hr 1/2 given as replacement and dialysate
    42. 46. Putting it together…. <ul><li>Case 2 </li></ul><ul><li>85 kg 45 year old male with sepsis induced acute renal failure on APC </li></ul><ul><ul><li>No conventional indications for dialysis </li></ul></ul><ul><ul><ul><li>Sats ok on 60% </li></ul></ul></ul><ul><ul><ul><li>Metabolically stable </li></ul></ul></ul><ul><ul><ul><li>No uremic changes </li></ul></ul></ul><ul><ul><li>However 12.5L +ve cumulative balance, no renal recovery and acute lung injury </li></ul></ul><ul><ul><li>Temp: 39.2 </li></ul></ul>
    43. 49. Remember: Dose = Replacement + Dialysate Dose = 85kg x 20ml/kg/hr =1.7 L/hr 1/2 given as replacement and dialysate
    44. 51. Drugs and Dialysis <ul><li>Not Straight Forward! </li></ul><ul><ul><li>CVVH clearance </li></ul></ul><ul><ul><li>CVVHD clearance </li></ul></ul><ul><li>Will need much input from pharmacy </li></ul><ul><li>Loading doses shouldn’t be altered…it’s the maintenance that will need adjustment </li></ul>Sieving Coefficient Protein Binding Membrane Type Ultrafiltration Rate Molecular Size
    45. 52. Future Directions <ul><li>Plasma Exchange </li></ul><ul><li>High Volume CVVH in septic patients?? </li></ul><ul><ul><li>Waiting results of the IVOIRE study </li></ul></ul><ul><li>Liver dialysis? </li></ul><ul><ul><li>Molecular Adsorbents Recirculating System (MARS) </li></ul></ul><ul><ul><li>Albumen dialysis </li></ul></ul><ul><ul><li>Small studies suggest improved encephalopathy </li></ul></ul>