Renal Replacement Therapy: modes and evidenceMohd Saif Khan
Renal replacement therapy is a supportive care often required in critically ill patients who develop acute renal failure and its complications. Complexity arises when such patients become hemodynamically unstable and pose special challenge to critical care clinicians in ICU to carefully choose dialytic modality to tackle volume and solute overload. This presentation is about short description of modalities of RRT and current evidence regarding initiation, dose and type of modality.
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!"
Continuous renal replacement therapy is a recently introduced modality for renal replacement therapy in hemodynamic unstable patients with AKI in ICU
THIS lecture was represented in Mansoura international hemodialysis course
Renal Replacement Therapy: modes and evidenceMohd Saif Khan
Renal replacement therapy is a supportive care often required in critically ill patients who develop acute renal failure and its complications. Complexity arises when such patients become hemodynamically unstable and pose special challenge to critical care clinicians in ICU to carefully choose dialytic modality to tackle volume and solute overload. This presentation is about short description of modalities of RRT and current evidence regarding initiation, dose and type of modality.
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!"
Continuous renal replacement therapy is a recently introduced modality for renal replacement therapy in hemodynamic unstable patients with AKI in ICU
THIS lecture was represented in Mansoura international hemodialysis course
Antibiotic dose modification is crucial on patients with CRRT with sepsis and MOF. This talk highlights the importance of achieving plasma therapeutic drug concentration in ICU patients to enhance their chances of survival while on CRRT
Historical background
The concept of incremental dialysis
The residual kidney function and its significance
Incremental hemodialysis
Observational studies on incremental HD
The candidates for incremental HD
The potential benefits and risks associated with incremental HD
Incremental peritoneal dialysis
The intact nephron hypothesis in reverse
Antibiotic dose modification is crucial on patients with CRRT with sepsis and MOF. This talk highlights the importance of achieving plasma therapeutic drug concentration in ICU patients to enhance their chances of survival while on CRRT
Historical background
The concept of incremental dialysis
The residual kidney function and its significance
Incremental hemodialysis
Observational studies on incremental HD
The candidates for incremental HD
The potential benefits and risks associated with incremental HD
Incremental peritoneal dialysis
The intact nephron hypothesis in reverse
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
1. DR Samir Sally, MD
Consultant Internal Medicine & Nephrology,
MUNC, Mansoura University, Egypt
2. ARF: History
• Ischuria Renalis: 1st description of ARF, by William
Heberden in 1802.
• Acute Bright’s disease: in William Osler’s
Textbook for Medicine (1909).
• War Nephritis: During the 1st World War.
• Crush Syndrome: During 2nd World War.
• Acute Renal Failure: First use of the term ARF
by Homer W. Smith in his textbook “The kidney-
structure and function in health and disease (1951).
3. ARF
• ARF: is defined as an abrupt or rapid decline in renal
filtration function (over hours to weeks) and usually
reversible.
• This is one of 35 definitions in the literature.
• No precise biochemical definition of ARF was
proposed.
• No consensus on the diagnostic criteria or
clinical definition of ARF.
4. AKI and RIFLE Criteria
• In 2004 the ADQI (Acute Dialysis Quality
Initiative) group published their consensus
definition for AKI, the Risk–Injury–Failure–
Loss–Endstage renal disease (RIFLE)
classification
5.
6. KDIGO 2012
• VOLUME 2 | ISSUE 1 | MARCH 2012
• http://www.kidney-international.org
• The first precise
biochemical,
clinical definition of
AKI with diagnostic
criteria
7. • AKI is defined as any of the following:
– Increase in SCr by ≥ 0.3mg/dl (≥ 26.5 umol/l)
within 48 hours; or
– Increase in SCr to ≥ 1.5 times baseline, which is
known or presumed to have occurred within the
prior 7 days; or
– Urine volume < 0.5ml/kg/h for 6 hours.
KDIGO 2012: AKI Definition
9. • 5–20% of critically ill patients experience an episode of AKI
during the course of their illness
• AKI requiring RRT: 4·9% of all admissions to intensive-care
units (ICU)
• Mortality in hospitalised patients ranging from 10%-80%:
– Patients who present with uncomplicated AKI, have a mortality rate of
up to 10%.
– Patients presenting with AKI and multiorgan failure have been
reported to have mortality rates of over 50%.
– If renal replacement therapy is required the mortality rate rises
further to as high as 80%.
AKI: Incidence
11. AKI: Management
• Evaluate for causes: Evaluate patients with AKI promptly to
determine the cause, with special attention to reversible causes.
• Stage the severity: Monitor patients with AKI with measurements
of SCr and urine output to stage the severity,
• Manage according to stage and cause: Manage patients
with AKI according to the stage and cause.
• Evaluate after 3 months: Evaluate patients 3 months after AKI
for resolution, new onset, or worsening of pre-existing CKD.
– If patients have CKD, manage these patients as detailed in the KDOQI CKD
Guideline
– If patients do not have CKD, consider them to be at increased risk for CKD and
care for them as detailed in the KDOQI CKD Guideline 3 for patients at
increased risk for CKD.
12. Stage 1 Stage 2 Stage 3
AKI: Management according to stages
13. 1. OLIGOANURIA: Non obstructive oliguria or anuria
2. METABOLIC ACIDOSIS: Severe metabolic acidosis
3. AZOTAEMIA: (blood urea >30mmol/l)
4. HYPERKALAEMIA (K>6.5)
5. UREMIC MANIFESTATIONS: pericarditis, encephalopathy
6. DYSNATRAEMIA: (Na>160 or <115)
7. HYPERTHERMIA
8. CEREBRAL OR PULMONARY OEDEMA: Clinically significant
9. COAGULOPATHY: requiring large amounts of blood products
in patients with pulmonary oedema
10. INTOXICATIONS: Dialysable drug overdose and toxins
AKI: Renal Replacement Therapy (RRT)
Indications
15. Advantages
• Hemodynamic stability
• Easy to use in ICU
• Continuous removal of toxins
• Easy control of fluid balance
• No treatment-induced
increase of intracranial
pressure
• Early use of TPN
• User-friendly machines
Disadvantages
• Slower clearance of
toxins
• Need for prolonged
anticoagulation
• Patient immobilization
• Hypothermia
• Increased costs
AKI: Renal Replacement Therapy (RRT)
Continuous RRT
16. Advantages over IHD in critically ill pts.
• Allows adequate volume of nutrition without compromising
fluid balance
• Decreased vasopressor requirements during fluid removal
• Increased hemodynamic stability
• Optimizes fluid balance in lung injury
• Continuous control of fluid balance
AKI: Renal Replacement Therapy (RRT)
Continuous RRT
17. AKI:RRT Modalities
KDIGO 2012 Recommendations
1. Use continuous and intermittent RRT as
complementary therapies in AKI patients.
2. We suggest using CRRT, rather than standard
intermittent RRT, for hemodynamically unstable
patients.
3. We suggest using CRRT, rather than intermittent
RRT, for AKI patients with acute brain injury or other
causes of increased intracranial pressure or
generalized brain edema.
19. • CRRT is indicated in
any patient who
meets criteria for
hemodialysis therapy
but cannot tolerate
intermittent dialysis
due to hemodynamic
instability
AKI: Renal Replacement Therapy (RRT)
CRRT Indications
22. • Pros
– Filters blood effectively
– Control fluid balance by
regulating
transmembrane
pressures
– No replacement fluid
therefore less pharmacy
cost
• Cons
– No replacement fluid
given so electrolyte
abnormalities can occur
– Low ultrafiltration rates
that keep electrolytes
balanced do not remove
urea effectively
AKI: Renal Replacement Therapy (RRT)
SCUF
26. • CVVHDF is probably the most common type of
CRRT used.
• It combines aspects of both CVVHD and CVVH.
• CVVHDF removes small and middle molecules.
AKI: Renal Replacement Therapy (RRT)
CVVHDF
28. Size of molecules cleared by CRRT Hemofilter
28
Molecular weights
Small Molecules
Diffusion is better than
convection
Middle Molecules
Convection better than
diffusion
Nothing above 50.000 is cleared
Mode of removal
Large Molecules
Convection or adsorbtion
30. Internal Jugular Vein
– Primary site of choice due to lower associated risk of
complication and simplicity of catheter insertion.
Femoral Vein
– Patient immobilized, the femoral vein is optimal and
constitutes the easiest site for insertion.
Subclavin Vein
– The least preferred site given its higher risk of
pneumo/hemothorax and its association with central
venous stenosis.
AKI: Renal Replacement Therapy (RRT)
CRRT: Vascular Access
31. The length of the catheter chosen will
depend upon the site used
– Size of the catheter is important in the pediatric
population.
The following are suggested guidelines for
the different sites:
–RIJ= 15 cm French
–LIJ= 20 cm French
–Femoral= 25 cm French
AKI: Renal Replacement Therapy (RRT)
CRRT: Vascular Access
33. • Clinicians tend to delay RRT when they
o Suspicion that patients may recover on their own.
o Concern for the well-known risks associated with
the RRT procedure:
oHypotension
oArrhythmia
oMembrane bioincompatibility
oComplications of vascular access
oAnticoagulant administration.
AKI: Renal Replacement Therapy (RRT)
CRRT: Time of Initiation
34. Timing of CRRT initiation:
Conclusion
Renal Indications
• Fluid overload unresponsive to
diuretic treatment
• Hyperkalaemia (>6.5 mmol/L or
rapidly rising level)
• Azotaemia (urea >36 mmol/L)
• Severe acidaemia (pH <7.1)
• Oliguria (urine output <200
mL/12 hours) or anuria (urine
output <50 mL/12 hours)
• Uraemic complication like
bleeding, pericarditis, or
encephalopathy
In critically ill and hemodynamically unstable pts. CRRT should be
initiated if one of the following
Non Renal Indications
• Drug overdose with dialysable toxin
• Patients requiring large amount of
fluids, parentral nutrition or blood
product but at risk of developing
pulmonary oedema or acute
respiratory distress syndrome
• Sepsis and systemic inflammation
• Cardiac failure
• Hyper or hypo-thermia with core
temperature >39.5ºC or <30ºC
35. • It is recommended that an improvement in the patient‟s
clinical condition and urine output would justify temporary
discontinuation of ongoing renal support to see if AKI is
recovering. UK Renal Association 5th Edition, 2011
• Bouman et al : Urine output returned to and was stable at >
60 ml/h.
• Uchino et al :
– Urine output of ≥ 450 ml/day without diuretic
– Urine output of ≥ 2400 ml/day with diuretic
AKI: Renal Replacement Therapy (RRT)
CRRT: Discontinuation
Bouman et al. Crit Care Med 2002;30:2205–2211.
Uchino et al. Crit Care Med 2008
38. Patients: 1124
Intensive Therapy (563): 35 ml/kg/hour
Less Intensive Therapy (561): 21 ml/kg/hour
Mortality at 60 days: 302/563 vs 298/561
P value: Non Significant
The VA/NIH Acute Renal Failure Trial Network:. N Engl J Med 2008, 359:7-20. 2008
39. Randomized to
CVVHDF with effluent 25ml/kg/h
CVVHDF with effluent 40ml/kg/h
• Primary endpoint = mortality at d 90
Multicenter (n=35) PRCT in Australia and New Zealand
n=1508
The RENAL Replacement Study Investigators. N Engl J Med 2009; 361: 1627-38 2009
40. AKI: Renal Replacement Therapy (RRT)
CRRT: Dose
0
10
20
30
40
50
60
70
80
Ronco et al
2000
Bouman et al
2002
Saudan et al
2006
ATN Trial
2008
Tolwani et al
2008
RENAL 2009
PercentSurvival
Studies
% Survival by CRRT Dose
High Dose
Low Dose
P Value: NS
42. Exercise on Dosing
Mr. Smith, 60 kg, ARF
Required dose: 35ml/kg BW/hr CVVHDF
– Pre: 30%
– Post:70%
– Pt., fluid removal: 100 ml/hr
– Dialysate: ?????
42
Calculation: 60kg x 35 ml/kg/h = 2100 ml/h
Flow rates
1000 ml Dialysate
1000 ml Replacement
700 ml Post-Replacement
300 ml Pre-Dilution (PBP)
43. Exercise on Dosing
Mrs. Jones, 100 kg, Polytrauma with Rhabdo
Required dose: 35ml/kg BW/hr
Mode: CVVHDF
– Pre-Replacement : 50% Post 50%
– Pt. fluid removal: 200 ml/hr
43
Calculation: 100kg x 35 ml/kg/h = 3500 ml/h
Flow rates:
1650ml Dialysate
1600ml Replacement
800 ml Post-Replacement
800 ml Pre-Replacemnt
44. Therapy Table (Example)
44
Acute Renal Failure Sepsis Rhabdomyolyse
Dose (ml/kg/BW/hr) 35 50 35
Blood flow (ml/min) 150-350 250-450 > 150
Patient 60 kg
Dialysate
Replacement Post
Replacement Pre = PBP
60 x 35 = 2100 ml
900 ml
400 ml
800 ml
60 x 50 = 3000 ml
1200 ml
600 ml
1200 ml
60 x 35 = 2100 ml
500 ml
550 ml
1050 ml
Patient 70 kg
Dialysate
Replacement Post
Replacement Pre = PBP
70 x 35 = 2450 ml
1000 ml
450 ml
1000 ml
70 x 50 = 3500 ml
1300 ml
700 ml
1400 ml
70 x 35 = 2450 ml
500 ml
650 ml
1300 ml
Patient 80 kg
Dialysate
Replacement Post
Replacement Pre = PBP
80 x 35 = 2800 ml
1000 ml
600 ml
1200 ml
80 x 50 = 4000 ml
1400 ml
900 ml
1800 ml
80 x 35 = 2800
500 ml
750 ml
1550 ml
Patient 90 kg
Dialysate
Replacement Post
Replacement Pre = PBP
90 x 35 = 3150 ml
1050 ml
700 ml
1400 ml
90 x 50 = 4500 ml
1500 ml
1000 ml
2000 ml
90 x 35 = 3150
500 ml
900 ml
1750 ml
47. • No anticoagulation is indicated in:
– Prolonged bleeding times
– Thrombocytopenia
– Liver failure
• The filter needs to be changed after about 8 h.
• When using CRRT without anticoagulation:
– Use a pre-dilution technique
– Increase the dialysate flow to 3 l/h
– Periodic saline flushes.
AKI: Renal Replacement Therapy (RRT)
CRRT: Anticoagulation
48. TYPICAL REGIMEN IN CRRT :
o Priming of the circuit ( 5000 IU / L )
o Initial Heparin Bolus : 5 - 8 IU / kg
o Infuse Heparin at : 5 to 12 IU / kg / hr
ACT on post filter : Adjust heparin rate to keep
ACT between 1.5 & 2.0 times
AKI: Renal Replacement Therapy (RRT)
CRRT: Anticoagulation
STANDARD HEPARIN
49. Advantages
• Easy to use
• Effective
• inexpensive
Disadvantages
• Occasional
Thrombocytopenia
• Hemorrhagic Risk
with Bleeding
patient
STANDARD HEPARIN
AKI: Renal Replacement Therapy (RRT)
CRRT: Anticoagulation
50. • Vascular access
– Vascular spasm(initial BFR too high)
– Movement of catheter against vessel wall
– Improper length of hemodialysis catheter inserted
• Fluid volume deficit
– Excessive fluid removal without appropriate fluid
replenishment
AKI: Renal Replacement Therapy (RRT)
CRRT: Complications
51. • Hypotension
– Intravascular volume depletion
– Underlying cardiac dysfunction
• Electrolyte imbalances
– High ultrafiltration rates (high clearance)
– Inadequate replenishment of electrolytes by
intravenous infusion,
– Inadequate replenishment of bicarbonate loss
during CRRT
AKI: Renal Replacement Therapy (RRT)
CRRT: Complications
52. • Acid/base imbalance
– Renal dysfunction
– Respiratory compromise
• Blood loss
– Ineffective anticoagulation therapy
– Clotting of hemofilter
– Inadvertent disconnection in the CRRT system
– Hemorrhage due to over-anticoagulation
– Blood filter leaks
AKI: Renal Replacement Therapy (RRT)
CRRT: Complications
53. • Air embolus
– Leaks or faulty connections in tubing
– Line separation.
• Cardiac arrest
– Hypotension/hypertension
– Hemolysis
– Air embolism
– Circulatory overload
– Arrhythmias
AKI: Renal Replacement Therapy (RRT)
CRRT: Complications
54. AKI: Renal Replacement Therapy (RRT)
CRRT: Conclusion
• The first precise, biochemical and clinical
definition of AKI: presented by KDIGO on March
2012 which allows clear diagnostic criteria and
management according stages.
• Incidence of AKI: is increasing particularly hospital
acquired AKI with mortality ranging from 10 – 80 %.
55. AKI: Renal Replacement Therapy (RRT)
CRRT: Conclusion
• KDIGO Plan of management of AKI
– Evaluate for cause
– Stage severity
– Mange according to cause and stage
– Evaluate after 3months for development of CKD or high
risk
• Dialyzable toxins and drugs should be familiar for
nephrologist
– Lithium, Methanol, Ethylene glycol, Salicylate,
Barbiturates, Metformin, Aminoglycosides, Metronidazole,
Carbapenems, Cephalosporins and most
56. AKI: Renal Replacement Therapy (RRT)
CRRT: Conclusion
• CRRT is the leading form of RRT: for AKI in intensive
care units wordwide.
• CRRT is suggested: for AKI patients with acute brain
injury or other causes of increased intracranial
pressure or generalized brain edema.
• CVVHDF: is probably the most common type of CRRT
used. It combines aspects of both CVVHD and CVVH,
and removes small and middle molecules
57. AKI: Renal Replacement Therapy (RRT)
CRRT: Conclusion
• Subclavian vascular access should be avoided.
• The length of the catheter chosen will depend upon
the site used.
• No significant benefit of initiating CRRT early vs late,
so it is recommende to initiate if renal or non renal
insications are present
58. AKI: Renal Replacement Therapy (RRT)
CRRT: Conclusion
• ATN trial, 2008 (1124 patients) and RENAL trial,
2009 (1508 patients): showed no significant
difference between intensive CRRT dose (35 ml/kg/h)
and less intensive CRRT dose (20 ml/kg/h).
• In hypercatabolic and multi-organ failure: the higher
CRRT dose is recommended.