Early vs late renal replacement therapy (RRT)
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A talk by Johan Mårtensson at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine. All available content from SSAI2017: https://scanfoam.org/ssai2017/ Delivered in collaboration between scanFOAM, SSAI & SFAI.
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This document provides information on defining and managing acute kidney injury (AKI). It discusses the Risk, Injury, Failure, Loss of function, End-Stage Renal disease (RIFLE) criteria and Kidney Disease Improving Global Outcomes (KDIGO) classification system for stratifying AKI. It also covers causes of AKI including pre-renal, intrinsic, and post-renal factors. The document outlines a 7 step AKI management bundle including confirming AKI, urgent senior review, assessing fluid status, urine dipstick testing, stopping nephrotoxic drugs, daily monitoring of labs and urine output, and considering ultrasound and urinary catheter placement.
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1. The document discusses acute renal failure in ICU patients, including epidemiology, pathophysiology, and treatment options like continuous renal replacement therapy (CRRT).
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Renal replacement therapy (RRT) replaces the normal blood filtering function of the kidneys. RRT is used in acute kidney injury (AKI) and chronic kidney disease (CKD). The main types of RRT are peritoneal dialysis (PD), hemodialysis (HD), sustained low efficiency dialysis (SLED), and continuous renal replacement therapy (CRRT). PD uses the peritoneal membrane for diffusion and convection, while HD uses a dialyzer and dialysate for diffusion. CRRT provides continuous RRT for hemodynamically unstable patients. Kidney transplantation is the best long-term treatment for end-stage renal disease.
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complications of HD case presentation
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CRRT options in the ICU
1. The document discusses acute renal failure in ICU patients, including epidemiology, pathophysiology, and treatment options like continuous renal replacement therapy (CRRT).
2. It presents two case studies of patients with acute renal failure and discusses initiating CRRT for them based on their clinical status and indications.
3. Key aspects of CRRT are reviewed, including modes of treatment, dosing, anticoagulation options like citrate, and the process for starting patients on CRRT at the hospital.
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The document discusses various complications that can occur during hemodialysis treatment including intradialytic hypotension, dialyzer reactions, disequilibrium syndrome, cramping, air embolism, hemolysis, cardiac arrhythmias, hemorrhage, pruritus, febrile reactions, hypokalemia, hyperkalemia, and dialysis pericarditis. It describes the etiology, diagnosis, and treatment approaches for each complication.
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* Pt weight: 60 kg
* Required dose: 35 ml/kg/hr
* Pt weight in kg: 60 kg
* Dose per kg: 35 ml/kg/hr
* Dose for pt: 60 kg x 35 ml/kg/hr = 2100 ml/hr
* Fluid removal: 100 ml/hr
* So required dialysate flow: 2100 - 100 = 2000 ml/hr
Therefore, the required dialysate flow is 2000 ml/hr.
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2) It reviews trials that found no survival benefit from higher CRRT doses above 35 ml/kg/hr.
3) It emphasizes that the prescribed CRRT dose may not be delivered due to interruptions, and recommends accounting for 10-15% downtime and prescribing 25-30 ml/kg/hr to achieve the recommended 20-25 ml/kg/hr delivered dose.
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1. Approximately 5% of critically ill patients with AKI will require RRT, with a mortality rate as high as 60%.
2. RRT options include intermittent HD, continuous therapies like CVVH/CVVHD/CVVHDF, and SLED.
3. The choice of RRT depends on the patient's cardiovascular status, resources available, and whether fluid removal or solute clearance is required. CRRT is preferred for hemodynamically unstable patients.
Rrt in icu dr said khamis zagazig april 2018 latest
The document provides an overview of renal replacement therapy (RRT) modalities for critically ill patients with acute kidney injury (AKI). It discusses the history and evolution of RRT, including intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT). The pros and cons of IHD and CRRT are presented. Key considerations for RRT include which modality to use, anticoagulation options, dialysate buffers, and membranes. Guidelines for determining therapy dose and duration and criteria for discontinuing RRT are summarized. Outcomes with IHD versus CRRT remain unclear due to limitations of existing studies. Overall, the document reviews best practices for delivering RRT to critically ill AK
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Crrt in aki
* Pt weight: 60 kg
* Required dose: 35 ml/kg/hr
* Pt weight in kg: 60 kg
* Dose per kg: 35 ml/kg/hr
* Dose for pt: 60 kg x 35 ml/kg/hr = 2100 ml/hr
* Fluid removal: 100 ml/hr
* So required dialysate flow: 2100 - 100 = 2000 ml/hr
Therefore, the required dialysate flow is 2000 ml/hr.
Basic ABG notes
This document provides an overview of arterial blood gas (ABG) analysis. It defines ABG and its components, including pH, PaO2, PaCO2, HCO3, and SaO2. Normal values for each component are listed. Acid-base imbalances, including respiratory acidosis, respiratory alkalosis, metabolic acidosis, and metabolic alkalosis are described. Causes, signs, symptoms, and management are covered for each imbalance. The document also explains how to interpret an ABG strip and assess compensated vs non-compensated acid-base disorders.
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This document discusses acute kidney injury (AKI), including its definition, classification systems, causes, biomarkers, treatment, and management. It provides a brief history of terms used to describe AKI and summarizes current classification systems. It also outlines causes of AKI, the advantages of various biomarkers for early detection, and general principles and indications for renal replacement therapy (RRT). Modalities of RRT including peritoneal dialysis, intermittent hemodialysis, slow low-efficiency dialysis, and continuous renal replacement therapy are compared.
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This document discusses SvO2 and ScvO2 monitoring. SvO2 measures oxygen saturation from blood in the pulmonary artery and requires a pulmonary artery catheter. It provides information about whole body oxygen utilization. A decreased SvO2 indicates increased tissue oxygen extraction, while an increased SvO2 demonstrates decreased extraction and adequate cardiac output to meet tissue needs. ScvO2 can be used as a surrogate for SvO2. Monitoring SvO2/ScvO2 can help guide resuscitation and understand if oxygen delivery meets demand, but risks are associated with pulmonary artery catheters and values must be interpreted in clinical context.
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Renal replacement therapy encompasses life-supporting treatments for renal failure such as hemodialysis, peritoneal dialysis, and continuous renal replacement therapy. Hemodialysis uses diffusion and filtration across a semi-permeable membrane to remove waste and fluid. Peritoneal dialysis infuses dialysate into the peritoneal cavity. Continuous renal replacement therapy provides 24-hour treatment through diffusion, convection, or a combination. These therapies aim to replace normal kidney functions of waste removal and fluid balance.
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The document discusses continuous renal replacement therapy (CRRT) modalities for acute kidney injury (AKI) patients in the intensive care unit (ICU). It provides details on different CRRT modalities including CVVH, CVVHD, and CVVHDF. CVVHDF is described as the safest combination as it utilizes both diffusion and convection. The document also discusses indications for specific CRRT therapies and notes that patient hemodynamic stability is the main determinant for choice of dialysis modality.
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This document discusses the use of ROTEM thromboelastometry in vascular surgery patients to help guide decisions around perioperative bleeding. It presents two case studies where ROTEM helped determine that bleeding was due to coagulopathy rather than surgical causes. In the first case, fibrinogen and prothrombin concentrate corrected the coagulopathy and stopped bleeding. In the second case, platelet transfusions addressed inadequate platelet function and resolved bleeding, avoiding unnecessary reoperation. The document advocates for using ROTEM to distinguish surgical from non-surgical bleeding and tailor treatment of coagulopathies over unneeded surgical exploration when bleeding arises from medical causes.
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This document discusses renal replacement therapy for acute kidney injury (AKI) in intensive care unit patients. It defines AKI and its prevalence in ICU patients. It describes the various modes of renal replacement therapy including intermittent hemodialysis, continuous renal replacement therapy and peritoneal dialysis. It discusses indications for starting renal replacement therapy and debates the optimal timing, modality and dosing of therapy. While several studies have examined these issues, the document concludes that the choice of renal replacement therapy should be individualized for each critically ill patient based on their condition and available resources.
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This document discusses a case scenario involving a 50-year-old male patient with diabetes and chronic kidney disease (CKD) who is admitted with urosepsis and acute kidney injury (AKI). Over the course of his hospital stay, the patient's kidney function declines and he requires renal replacement therapy. The document poses questions at various points in the case and provides answers regarding evaluating and managing the patient's AKI. It emphasizes identifying reversible causes, preventing progression through fluid management, and considering RRT for severe AKI.
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1) The document discusses continuous renal replacement therapies (CRRT) for acute kidney injury (AKI), including dosing guidelines.
2) It reviews trials that found no survival benefit from higher CRRT doses above 35 ml/kg/hr.
3) It emphasizes that the prescribed CRRT dose may not be delivered due to interruptions, and recommends accounting for 10-15% downtime and prescribing 25-30 ml/kg/hr to achieve the recommended 20-25 ml/kg/hr delivered dose.
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The document discusses renal replacement therapies in critical care, including various classification systems for acute kidney injury, the incidence and outcomes of AKI in ICU patients, and evidence around different renal replacement modalities. It notes that while there is no definitive evidence of superiority between therapies, higher therapy doses are associated with better outcomes. The document also explores using renal replacement therapies for blood purification beyond just solute clearance, such as for removing cytokines.
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Dr. Kumar presented on renal replacement therapy. The key points are:
1. Approximately 5% of critically ill patients with AKI will require RRT, with a mortality rate as high as 60%.
2. RRT options include intermittent HD, continuous therapies like CVVH/CVVHD/CVVHDF, and SLED.
3. The choice of RRT depends on the patient's cardiovascular status, resources available, and whether fluid removal or solute clearance is required. CRRT is preferred for hemodynamically unstable patients.
Rrt in icu dr said khamis zagazig april 2018 latest
The document provides an overview of renal replacement therapy (RRT) modalities for critically ill patients with acute kidney injury (AKI). It discusses the history and evolution of RRT, including intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT). The pros and cons of IHD and CRRT are presented. Key considerations for RRT include which modality to use, anticoagulation options, dialysate buffers, and membranes. Guidelines for determining therapy dose and duration and criteria for discontinuing RRT are summarized. Outcomes with IHD versus CRRT remain unclear due to limitations of existing studies. Overall, the document reviews best practices for delivering RRT to critically ill AK
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Invasive methods are well accepted, but there is increasing evidence that these methods are neither accurate nor effective in guiding therapy
An accurate and non-invasive measurement of CO is the best method of cardiovascular assessment
AKI IN ICU.pptx
AKI is common in ICU patients and is associated with high mortality. It is defined based on changes in serum creatinine and urine output. The RIFLE criteria is commonly used for classification. Causes include prerenal, intrinsic renal and post renal factors. Treatment involves identifying and treating the underlying cause, fluid resuscitation, and renal replacement therapy like intermittent hemodialysis or continuous renal replacement therapy as needed. Prevention strategies focus on ensuring adequate perfusion and minimizing nephrotoxins. Outcomes remain poor despite treatment.
Post resuscitation care
Therapeutic hypothermia, or induced hypothermia, involves deliberately cooling cardiac arrest patients to between 32-34°C for 12-24 hours after return of spontaneous circulation (ROSC) to reduce reperfusion injury to organs like the brain, heart, liver and kidneys from hypoperfusion and ischemia during the cardiac arrest. It aims to improve outcomes by reducing the effects of post-cardiac arrest syndrome, which involves a complex pathophysiological cascade following ischemia. Current research shows benefits of inducing therapeutic hypothermia before or during the cardiac arrest event. Key aspects of care involve induction of hypothermia within 6 hours, preferably 2 hours, of ROSC, maintenance of target temperature for 12-24 hours,
Adequacy of Hemodialysis
The patient is a 49-year-old woman with end-stage renal disease and diabetes who presented with altered mental status. She receives hemodialysis three times per week for a few years. Recently, she has been increasingly tired, weak, and unable to perform daily activities with poor appetite and nausea. On examination, she was pale and swollen with low hemoglobin. Tests found elevated creatinine, BUN, and electrolyte abnormalities. The most probable diagnosis is inadequate hemodialysis, as her symptoms and labs are consistent with worsening uremia due to insufficient solute clearance from her dialysis sessions. Kt/V is a measure of dialysis adequacy that accounts for urea clearance and patient
1 prismaflex crrt intro - seg 1 (2007)
The document outlines the objectives and key concepts of a training course on continuous renal replacement therapy (CRRT). It defines CRRT and discusses the basic principles of CRRT, including solute transport mechanisms, clinical indications, machine setup and safety features, and fluid balance principles. It also summarizes evidenced-based research showing improved patient survival with early CRRT initiation and adequate dose delivery.
Adel presentation crrt principles
This document discusses the principles and molecular transport mechanisms of continuous renal replacement therapy (CRRT), including ultrafiltration, diffusion, convection, and adsorption. Ultrafiltration works through a positive pressure gradient on the blood side and negative pressure on the fluid side of the hemofilter membrane. Diffusion moves molecules from a high to low concentration area until evenly distributed. Adsorption involves solutes clinging to the membrane, eventually clogging it. CRRT clearance depends on solute size, membrane pore size, and ultrafiltration rate, with small molecules cleared by diffusion and convection, and middle-large molecules primarily by convection. Membranes remove substances up to 50,000 Daltons.
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Rrt in icu dr said khamis zagazig april 2018 latest
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2) Diagnostic criteria include signs of infection along with dysregulated inflammatory response and organ dysfunction. Management goals within 3-6 hours include antibiotics, fluid resuscitation, lactate measurement, vasopressors for hypotension, and in some cases steroids and glucose control.
3) Common infection sites include the lungs, urinary tract, abdomen, and intravenous lines. Antibiotics should have appropriate spectrum and be given quickly based on likely pathogens. Other supportive therapies
02 Sperati Prevention And Management Of Acute Renal Failure
This document summarizes key aspects of acute renal failure (ARF), including epidemiology, causes, evaluation, diagnosis, management, and controversies in renal replacement therapy. It discusses common causes of ARF like prerenal azotemia, acute tubular necrosis, and rhabdomyolysis. Evaluation involves assessing urine output, electrolytes, fractional excretion of sodium, and distinguishing prerenal from intrinsic renal failure. Management is generally conservative and supportive, with renal replacement therapy as needed. Ongoing research aims to determine the optimal dose and modality of renal replacement therapy.
02 Sperati Prevention And Management Of Acute Renal Failure
This document provides an overview of acute renal failure (ARF), including its causes, diagnosis, and management. It discusses evaluating ARF through markers like fractional excretion of sodium and urea, and differentiating prerenal from intrinsic renal causes. Treatment involves supportive care and potentially renal replacement therapy, though the optimal modality and dose of therapy remain unclear from clinical trials.
Aki
This document provides an overview of acute kidney injury (AKI), including its classification, epidemiology, etiology, pathophysiology, patient assessment, and clinical presentation. It discusses the RIFLE, AKIN, and KDIGO classification systems for AKI and covers the major causes and mechanisms of pre-renal, intrinsic, and post-renal AKI. Patient assessment involves reviewing the medical history, medications, physical exam, and distinguishing signs of AKI from chronic kidney disease. Changes in urinary output can help indicate the underlying cause of AKI in hospitalized patients.
Tutorial national board 2010 Nephrology
The document discusses various topics related to nephrology including renal function, acute kidney injury, causes of polyuria, water balance, and fluid resuscitation. It provides definitions, classifications, diagnostic approaches, and management strategies for different kidney conditions.
Acute kidney injury
1) Acute kidney injury (AKI) is an abrupt decrease in kidney function over 7 days that results in a buildup of waste in the body. It can be caused by reduced blood flow to the kidneys or kidney damage.
2) AKI is common, affecting 1-25% of hospitalized patients depending on whether they are in the ICU or not. Mortality is high, reaching 50% for ICU patients with multiple organ failure.
3) AKI is staged based on changes in creatinine and urine output. Prevention focuses on identifying at-risk patients and avoiding insults like dehydration and nephrotoxic drugs. Treatment involves supportive care, reversing causes if possible, and
Update on Hepatorenal syndrome
This document discusses hepatorenal syndrome (HRS), an acute kidney injury that can occur in patients with cirrhosis and liver failure. It provides updates on diagnostic criteria and classifications of HRS subtypes. The pathophysiology of HRS involves increased blood flow to the gut, decreased central blood volume, and kidney vasoconstriction. Risk factors include advanced cirrhosis and bacterial translocation. Terlipressin with albumin is the standard treatment and can reverse HRS, though noradrenaline is also effective with fewer side effects. The timing of renal replacement therapy and role of liver transplantation in HRS are also reviewed.
Final aki for im 2014
<SUMMARY>
The document provides an overview of acute kidney injury (AKI), including definitions, classification, epidemiology, etiology, diagnosis, management, and prevention strategies. It defines AKI according to the KDIGO criteria and discusses the RIFLE and AKIN classification systems. Prerenal, intrinsic, and postrenal causes of AKI are outlined. Diagnosis involves establishing baseline kidney function, identifying potential causes, and evaluating volume status, laboratory tests, and imaging studies. Management focuses on treating the underlying cause, optimizing hemodynamics, and preventing complications. Prevention emphasizes recognizing risk factors and avoiding nephrotoxic exposures.
</SUMMARY>
Acute Pancreatitis
Acute pancreatitis is an inflammatory condition of the pancreas caused by the early activation of digestive enzymes within the pancreas. It can range from mild to severe, and in severe cases, it can lead to organ failure. The most common causes are gallstones, alcohol use, and viral infections. Symptoms include severe abdominal pain, nausea, vomiting, and fever. Laboratory tests show elevated levels of pancreatic enzymes in the blood. Severity is assessed using the Ranson score or APACHE II score. Treatment involves intravenous fluids, bowel rest, pain medications, and treating the underlying cause. Complications can include pancreatic pseudocysts, abscesses, and necrosis.
Renal Function Iin ICU
This document summarizes renal function in the ICU, including calculation of glomerular filtration rate (GFR) and creatinine clearance, fractional excretion of sodium, hepatorenal syndrome, rhabdomyolysis, and contrast-induced acute renal failure. It also presents several case studies involving evaluation of renal function and diagnosis of conditions such as acute tubular necrosis, SIADH, and normal renal function based on creatinine clearance calculations and urinary indices.
Early Vs Late Renal Replacement Therapy
IMPORTANCE: Optimal timing of initiation of renal replacement therapy (RRT) for severe acute kidney injury (AKI) but without life-threatening indications is still unknown.
OBJECTIVE: To determine whether early initiation of RRT in patients who are critically ill with AKI reduces 90-day all-cause mortality.
Liver disease in ICU – when to stop? by Julia Wendon
This document discusses criteria for admitting cirrhotic patients with acute on chronic liver failure (AoCLF) to critical care services and considerations for when to stop treatment. It notes several prognostic models and scores that can help assess patient prognosis and likelihood of benefitting from critical care interventions, including the SOFA and CLIF-SOFA scores. Organ failures are strongly associated with mortality, with scores of over 13 on these scales indicating over 80% mortality. The document outlines various factors that may prompt referral to critical care and interventions that can be provided to stabilize patients and allow for organ recovery. However, it notes treatment may not be beneficial in some cases depending on the number and severity of organ failures.
Similar to Early vs late renal replacement therapy (RRT) (20)
Gastrocon 2016 - Dr S.K Sinha's observation on Acute Pancreatitis
Gastrocon 2016 - Dr S.K Sinha's observation on Acute Pancreatitis
02 Sperati Prevention And Management Of Acute Renal Failure
02 Sperati Prevention And Management Of Acute Renal Failure
02 Sperati Prevention And Management Of Acute Renal Failure
02 Sperati Prevention And Management Of Acute Renal Failure
Liver disease in ICU – when to stop? by Julia Wendon
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"Market Research it too text-booky, I am in the market for a decade, I am living research book" this is what the founder I met on the event claimed, few of my colleagues rolled their eyes. Its true that one cannot over look the real life experience, but one cannot out beat structured gold mine of market research.
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The cyclothymia test is a pivotal tool in the diagnostic process. It helps clinicians assess the presence and severity of symptoms associated with cyclothymia.nursing management of patient with Empyema ppt
prepared by Prof. BLESSY THOMAS, SPN
Empyema is a disease of respiratory system It is defines as the accumulation of thick, purulent fluid within the pleural space, often with fibrin development.
Empyema is also called pyothorax or purulent pleuritis.
It’s a condition in which pus gathers in the area between the lungs and the inner surface of the chest wall. This area is known as the pleural space.
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Empyema usually develops after pneumonia, which is an infection of the lung tissue. it is mainly caused due in infectious micro-organisms. It can be treated with medications and other measures.
Electrocardiogram_20240614_173859_0000.pdf
Basics of Electrocardiogram
CONTENTS
●Conduction System of the Heart
●What is ECG or EKG?
●ECG Leads
●Normal waves of ECG.
●Dimensions of ECG.
● Abnormalities of ECG
CONDUCTION SYSTEM OF THE HEART
ECG:
●ECG is a graphic record of the electrical activity of the heart.
●Electrical activity precedes the mechanical activity of the heart.
●Electrical activity has two phases:
Depolarization- contraction of muscle
Repolarization- relaxation of muscle
ECG Leads:
●6 Chest leads
●6 Limb leads
1. Bipolar Limb Leads:
Lead 1- Between right arm(-ve) and left arm(+ve)
Lead 2- Between right arm(-ve) and left leg(+ve)
Lead 3- Between left arm(-ve)
and left leg(+ve)
2. Augmented unipolar Limb Leads:
AvR- Right arm
AvL- Left arm
AvF- Left leg
3.Chest Leads:
V1 : Over 4th intercostal
space near right sternal margin
V2: Over 4th intercostal space near left sternal margin
V3:In between V2 and V4
V4:Over left 5th intercostal space on the mid
clavicular line
V5:Over left 5th intercostal space on the anterior
axillary line
V6:Over left 5th intercostal space on the mid
axillary line.
Normal ECG:
Waves of ECG:
P Wave
•P Wave is a positive wave and the first wave in ECG.
•It is also called as atrial complex.
Cause: Atrial depolarisation
Duration: 0.1 sec
QRS Complex:
•QRS’ complex is also called the initial ventricular complex.
•‘Q’ wave is a small negative wave. It is continued as the tall ‘R’ wave, which is a positive wave.
‘R’ wave is followed by a small negative wave, the ‘S’ wave.
Cause:Ventricular depolarization and atrial repolarization
Duration: 0.08- 0.10 sec
T Wave:
•‘T’ wave is the final ventricular complex and is a positive wave.
Cause:Ventricular repolarization Duration: 0.2 sec
Intervals and Segments of ECG:
P-R Interval:
•‘P-R’ interval is the interval
between the onset of ‘P’wave and onset of ‘Q’ wave.
•‘P-R’ interval cause atrial depolarization and conduction of impulses through AV node.
Duration:0.18 (0.12 to 0.2) sec
Q-T Interval:
•‘Q-T’ interval is the interval between the onset of ‘Q’
wave and the end of ‘T’ wave.
•‘Q-T’ interval indicates the ventricular depolarization
and ventricular repolarization,
i.e. it signifies the
electrical activity in ventricles.
Duration:0.4-0.42sec
S-T Segment:
•‘S-T’ segment is the time interval between the end of ‘S’ wave and the onset of ‘T’ wave.
Duration: 0.08 sec
R-R Interval:
•‘R-R’ interval is the time interval between two consecutive ‘R’ waves.
•It signifies the duration of one cardiac cycle.
Duration: 0.8 sec
Dimension of ECG:
How to find heart rhytm of the heart?
Regular rhytm:
Irregular rhytm:
More than or less than 4
How to find heart rate using ECG?
If heart Rhytm is Regular :
Heart rate =
300/No.of large b/w 2 QRS complex
= 300/4
=75 beats/mins
How to find heart rate using ECG?
If heart Rhytm is irregular:
Heart rate = 10×No.of QRS complex in 6 sec 5large box = 1sec
5×6=30
10×7 = 70 Beats/min
Abnormalities of ECG:
Cardiac Arrythmias:
1.Tachycardia
Heart Rate more than 100 beats/min
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Early vs late renal replacement therapy (RRT)
- 1. Earlier vs Later Renal Replacement Therapy (RRT) Johan Mårtensson
- 2. Conflict of interest: None
- 3. Time for RRT? –Yes! Mr. Jones, 58 yr Day 4 in ICU Severe sepsis Fluid balance ++++ FiO2 0.7 S-creatinine 540 µmol/L Urea 40 mmol/L S-K+ 6.2 mmol/L Urine output 20 mL/hour (lasix infusion 40 mg/hr)
- 4. ”Late” RRT ”Conventional” or ”absolute” indications for RRT in AKI: • Refractory hyperkalemia (e.g. K+ >6) • Refractory acidemia & metabolic acidosis (e.g. pH <7.2) • Refractory pulmonary edema due to fluid overload • Uremic complications (e.g. bleeding, pericarditis) • Overdose/toxicity from a dialyzable drug/toxin
- 6. Contemporary AKI staging KDIGO stage Plasma creatinine Urine output 1 1.5-2 times baseline OR >26.5 µmol/l increase <0.5 ml/kg/h for 6-12 h 2 2.0-2.9 times baseline <0.5 ml/kg/h for ≥12 h 3 3.0 times baseline OR Increase to ≥354 µmol/l <0.3 ml/kg/h for ≥24 h OR Anuria for ≥12 h the Kidney Disease Improving Global Outcomes (KDIGO) guidelines
- 8. AKIKI setup 620 pts, 31 ICUs • KDIGO stage 3 AKI • Mechanical ventilation and/or catecholamine infusion • No absolute indication Early Group (n=311) Start RRT immediately Late Group (n=308) Start RRT if: Absolute indication OR Oliguria >72 hrs
- 9. AKIKI treatmentRandomisation 2 hours 57 h 0 20 40 60 80 100%receivingRRT Early Late 49% no RRT 51% RRT ≥1 absolute indication (82%) Oliguria >72 h (18%)
- 11. AKIKI secondary outcomes P=0.12 0 2 4 6 8 10 DependenceonRRTday60,% Early Late P=0.03 0 5 10 15 20 Catheter-relatedbloodstreaminfection,% Early Late
- 12. The ELAIN trial
- 13. ELAIN setup 231 pts (mainly post-surgical), single-center • KDIGO stage 2 AKI • Plasma Neutrophil gelatinase-associated lipocalin (NGAL) >150 ng/ml • Any of the following: • Severe sepsis • Vasoactive support • Fluid overload • Worsening SOFA score Early Group (n=112) RRT within 8 h from KDIGO 2 Late Group (n=119) RRT within 12 h from KDIGO 3 OR Absolute indication
- 14. ELAIN treatment Randomisation 6 hours 26 hours 0 20 40 60 80 100 %receivingRRT Early Late 9% no RRT 91% RRT -KDIGO 3 (84%) -Absolute indication (16%)
- 16. ELAIN renal recovery P=0.62 0 20 40 60 80 100 meanofrecovery90surv Early Late Survivors P=0.02 0 20 40 60 80 100 Renalrecoveryday90,% Early Late All patients
- 18. Other factors affecting decision making • Anticipation of worsening kidney function • Worsening nonrenal organ dysfunction • Expected high solute burden (e.g. tumor lysis syndrome) • Facilitate other supportive measures (nutrition, drugs, other fluids) • Perception of benefit
- 19. * * Treating clinician must confirm clinical equipoise
- 20. Take-home message • No strong evidence that ”early” RRT will improve outcomes • ”Early” RRT may expose some patients to unnecessary treatment • Timing based on patient characteristics, illness severity and trends in physiology/biochemistry