When to dialyse a patient and with what modality of dialysis will be topic of discussion.The recent advances and debates surrounding the topic will be discussed in detail

1. Dialysis in AKI
DR.K.SAMPATH KUMAR MD DNB DM FRCP
MEENAKSHI MISSION HOSPITAL
MADURAI

2. Why should we dialyse in AKI ?
K,Acidosis
PE, CCF,CNS
Bleed
Infection
Mortality

3. Management of AKI
• Treatment of acute kidney injury (AKI) is
principally supportive
•Goal: optimization of fluid status ,
•maintain metabolic,
• nutritional &
•electrolyte balance

4. When to start ?

5. Indications for Dialysis
Traditional and Recent
•BU.150
•s.Cr 5
•Hyperk>6
PEdema
Uencep
Tr Acidosis
Fluid
overload
Stage 2-3
AKI?
Mod

6. Intermittent Continuous
SCUF
PDCRRTPiRRTIHD
C-HD
C-HF
C-HDF
Automated
Manual

7. IHD – Most popularHD
Blood circuit
Dialysis circuit
Safety monitors
Complications
Hypotension
Bleeding
Access related
Monitor and dialysate
malfn
Infection

8. AKI patients in ICU
Hypercatabolic
AKI
Hypotensive
Myocardial depression
Inotropic support
Fluid overload
Leaky capillaries
Inflammatory milieu
Challenge
For
RRT
CRRT/PIRRT

9. Josée Bouchard1, Ravindra L. Mehta1, , ,
Kidney International (2009) 76, 422–427

10. Rate of fluid removal is the crucial
factor between HD and CRRT/SLED .
• In HD - over a 4 hours period if 4 Litres of fluid is to be
removed , it translates into a fluid removal of 16
ml/min.
• CRRT/SLED - fluid removal of as little as 3 ml/min will
translate into 4320 ml [ 3 ml x 1440 minutes= 4320
ml/day]- Well tolerated by patient

11. Seminars in Dialysis
Volume 22, Issue 2, pages 165-168, 20 APR 2009 DOI: 10.1111/j.1525-139X.2008.00548.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1525-139X.2008.00548.x/full#f3
Fall in serum osmolality predicts ICT

12. Seminars in Dialysis
Volume 22, Issue 2, pages 165-168, 20 APR 2009 DOI: 10.1111/j.1525-
139X.2008.00548.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1525-139X.2008.00548.x/full#f2
IC Pressure surge
HCO3 +H CO2 + H20

13. Should we dialyse early or can wait?
Earlier initiation of RRT may produce benefits by
avoiding hypervolemia, eliminating of toxins,
establishing acid-base homeostasis.
However, early initiation of RRT may unnecessarily
expose some patients to potential harm because some
patients will spontaneously recover renal function.
— Zarbock, et al

15. Original Article
Initiation Strategies for Renal-Replacement
Therapy in the Intensive Care Unit
Stéphane Gaudry, M.D., David Hajage, M.D., Fréderique Schortgen, M.D., Laurent
Martin-Lefevre, M.D., Bertrand Pons, M.D., Eric Boulet, M.D., Alexandre Boyer, M.D.,
Guillaume Chevrel, M.D., Nicolas Lerolle, M.D., Ph.D., Dorothée Carpentier, M.D.,
Nicolas de Prost, M.D., Ph.D., Alexandre Lautrette, M.D., Anne Bretagnol, M.D.,
Julien Mayaux, M.D., Saad Nseir, M.D., Ph.D., Bruno Megarbane, M.D., Ph.D.,
Marina Thirion, M.D., Jean-Marie Forel, M.D., Julien Maizel, M.D., Ph.D., Hodane
Yonis, M.D., Philippe Markowicz, M.D., Guillaume Thiery, M.D., Florence
Tubach, M.D., Ph.D., Jean-Damien Ricard, M.D., Ph.D., Didier Dreyfuss, M.D., for
the AKIKI Study Group
N Engl J Med
Volume 375(2):122-133
July 14, 2016
PFrench multi
centre study of
predominantly
Medical AKI
patients

16. No change in 60 day mortality

17. AKIKI – Delayed strategy – 50% did not
require Dialysis

18. ELAIN TRIAL- Mostly Post surgical AKI

20. No substitute for continued vigilance
and clinical decision making
When to start dialysis ?

21. Bicarb
Vs
Lactate
Heparin
Vs
Citrate

22. Access creation and Anticoagulation
central veins for cannulation
Choosing a catheter
Technical aspects of catheter insertion
Prevention of catheter infection
Anticoagulation – Heparin based
Anticoagulation – Non heparin based

23. USG – Compressibility of vein
Absence of thrombus
The ICU Book. Ed. By Marino.4th Edition

24. Handbook of Dialysis, Ed.Daugirdas. 5TH Edition

25. 2 Main routes of Catheter related
Blood stream Infection
Touch contamination
At the Hub , connectors
Extraluminal spread
From skin

26. Heparin dosing
• Loading 2000/5000u
• Wait for 3 min
• 500-1000u /h infusion
• v PTT>65s
• a PTT 45s
• No direct correlation
between bleed and
PTT prolongation
• Clotting episodes
unpredicatable
Heparin Free
• In those with High
bleeding risk
• Pre dilute
• Increase Dialysate flow
rate
• No saline flushes as is
done in MHD !
• ( microbubbles)
• FUN /BUN > 0.8

27. KDIGO

28. Components CVVH CVVHD CVVHDF
Blood Pump 100 ml/min 100 ml/min 100 ml/min
Dialysis fluid NIL 1000 L / h 1000 ml/h
Replacement
fluid
1000 ml/h NIL 1000 ml/h
Urea clearance
[ ml/min]
20 25 33
Effluent
volume
[ml/kg/h]
20 -25 20-25 20-25

29. CVVHDF
Continuous Veno-Venous Hemodiafiltration
Replacement
S
Access
Return
Effluent
Dialysate
 Fluid removal
 Solute removal
(small and larger solutes)
 Diffusion
 Convection

30. • Filtration Fraction (FF) = QUF / QP
• QUF = Ultrafiltration Rate
• QP = Plasma Flow Rate
• FF = 1500 / [150x60 x (1-0.30)] =
23%
• Risk of Filter clotting with FF >
25%
Replacement fluid- Where it
Is infused matters

31. Adsorption in CRRT membranes – Septic Shock states
High Mobility Group Box -1 Protein removal by OXIRIS
C Factors

32. Machine alarms, Disconnect time for diagnostic tests
Pre filter replacement - Less clearance by 15%

33. There can be slip between cup and the lip!
FUN/SUN < 0.6 = Risk of filter clotting

34. Beware of CRRT Downsides !
1
• Hypothermia – DIC, Cardiac arrest
• Warmer chamber incorporation
2
• Hypophosphatemia- Muscle weakness
• Phosphate replacement
3
• Heparin induced thrombocytopenia
• Heparin free CRRT , Fondaparinox

35. Lower antibiotic levels
May have nullified effects
Of high dose therapy
Kielstein JT, Burkhardt O: Curr Pharm Biotechnol.12:2015–2019, 2011

36. Antibiotic doses- Blind spot!
Each 10 L of Effluent Volume = 7
ml/min of GFR [ 7ml x 1440min =
10.08 L]
The loading dose stays the same for
all antibiotics in CRRT
Subsequent doses – Better not to
commit to memory!
Pickering JW, Frampton CM, Walker RJ, Shaw GM, Endre ZH.
Crit Care. 2012; 16(3):R107

37. • 2 Periods were studied- 2004-2007 [ 1] and 2008-2011[2]
• In period 1 only CRRT was carried out in hypotensive
patients
• In latter period PIRRT was carried out for 40% of such
patients
• Survival improved significantly in Period [2] due to
multiple factors

38. Mortality was less with SLED . Does it indicate that
SLED is better?

39. BP as a guide for modality
selection

40. MMHRC experience- 2015-16
AGE RANGE

42. Factors affecting survival of CRRT patients
0
10
20
30
40
50
60
70
80
Survival Hemodynamics APACHE S.Bicarb
survival Mortality
72 mm vs 62 mm Hg
23 vs 29
16 Vs 13
11
49
66

43. PD for AKI

44. Do you think PD is effective for AKI in ICU?
Perit Dial Int. 2012 May-Jun; 32(3): 351–355.

45. Why the disconnect between theory and
Practice?
• Good data on PD and AKI are in short supply, and the
existing studies have shown conflicting results.
• Accuracy of fluid removal rates and inadequate solute
clearances with PD
• Risk of peritonitis, especially among critically ill AKI
patients.
• Respiratory compromise when fluid is present in
abdomen.
• Training in PD catheter placement and exposure low.

46. Advantages Vs Limitations
Start
• Simple to arrange
• Less demanding
Natural
Access
• No vasc.access
• No Anticoagulant
Spl.
• Children
• CCF, Hypotension
• Life saver in Developing
Countries
No
• Laparotomy
• Ac.pulm.edema
• Hyperkalemia
No
• Hypercatabolic*
?
• Peritonitis *
• Clearances*
• Biocompatible
•More Physiologic

47. Technical issues of catheters
and Fluids

48. Advantages of Tenckhoff catheter over stiff
catheter
• Single
• Double cuff designs
Leakage is
less
• Larger diameter
• More side holes
Better flow
• Less peritonitis
• Stiff catheters – Infected early
Infection
• Can be in place for entire
duration of AKILongevity

55. Fluroscopy

61. 4/17/2015 PD SCIENTIA CMC VELLORE 61
Avoid injury to Inferior epigastric artery.
Doppler identification pre –op.

62. Cycler assisted PD in AKI

63. Cardio renal syndrome in ICU
TNF alpha
IL-1
IL-6
Improves
Fluid status
Cardiac Performance
Quality of Life
Hospitalization rates reduced
MM
0.5- 30kDa

64. Cardiac function improved
LVEF improved
PA systolic P decreased

65. PD preferable in Stroke with AKI?
Release from
Injured Neurons
Free O2 generation
Apoptosis
Osmotic damage
Ischemic penumbra
Extends
Excitotoxicity

66. Glutamate is removable by PD
MW- 147 Da
PD
Reduction in
Infarct size in
Animal study
Godino Mdel C, et al.
J Clin Invest 2013; 123:4359–63.

67. PD for AKI
• PD is easier to start , simple to monitor and lighter on
the purse for a patient and should be given due
consideration in AKI .
• Wider exposure of Nephrologists and Physicians to
practical issues of PD catheter insertion and PD
delivery are crucial in developing countries.
• Automated PD offers several advantages and may be
non inferior to CRRT in many ICU and field settings.

68. Success of dialysis in AKI depends on ……
Patient Physician
Gadgets Nursing
Star Power

69. Thank you