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Rrt in icu dr said khamis zagazig april 2018 latest
1. Renal Replacement Therapy In
Critically Ill Patients
Said Khamis MD (MSc., Nephro., KUL Belgium)
Professor Of Medicine & Nephrology
Chief of Nephrology Unit
Menoufia University Hospitals (Egypt)
2. Introduction
In the past, the interaction between nephrology and
intensive care was minimal Today,
there is
continuous
interaction
with
several
moments of
high
interaction
due to
common
patients
and
complex
syndromes
Contrib Nephrol. Basel, Karger, 2010 (166):1–3
3. Introduction (Contd)
Classification of blood purification in critical care (BPCC) technology
PMX =
polymyxin-
B immobilized
fiber;
PMMA =
polymethylmeth
acrylate;
PAN =
polyacrylonitrile;
PEPA =
polyether
polymer alloy
Contrib Nephrol. Basel, Karger, 2010(166):11–20
4.
5.
6. Agenda
• History of Acute RRT: Modalities
• Introduction
• Acute RRT: Modalities
– CRRT versus IHD
– Hybrid RRT (SLED)
– CRRT versus SLED
– Using what?
– How much therapy?
– When To Stop/Switch?
• Conclusions
7.
8.
9.
10.
11. Evolution of Renal Replacement Therapy
Abel, 1913
First dialysis
of animal
Kolff, 1945
First dialysis
in human
Teschan, 1950s
Daily dialysis in
Korean war
Since 1960s
Chronic, intermittent hemodialysis (IHD)
( 24hrs q.w. 10-16hrs b.i.w.
- 4-6hrs t.i.w. )
Daily dialysis?
Kramer, 1977
First CRRT
(CAVH)
1994
Automated
CRRT
CRRT
or
SLEDD?
Contrib Nephrol. 2004; 145: 1-9
12. Where are we ?
• What therapy should we use?
• When should we start it?
• What are we trying to achieve?
• How much therapy is enough?
• When do we stop/switch?
• Can we improve outcomes?
13. Introduction
• Acute kidney injury (AKI) is
– Frequent complication of hospitalization (1–25% )
– Associated with substantial morbidity, mortality & health
care expenditures (MR: 20-60%)
• Although understanding of the epidemiology of AKI has
improved, there are:
– No proven therapies that reverse the course of established AKI
• Renal replacement therapy (RRT):
– Key component of the supportive care given to patients with
severe AKI (in 4% of ICU pts.)
Nephron Clin Pract 2009;112:c222–c229
14. Introduction (cont.)
-AKI with need for RRT in the ICU is a complex & devastating condition,
with a reported mortality rate as high as 50–80%.
-Among RRT-requiring patients who survive the critical phase of their
illness, the majority will be free of RRT at the time of hospital
discharge
Hyman A & Mendelssohn DC (2002) Am J Nephrol 22: 29–34
W. Van Biesen, N. Lameire .Intensive Care Medicine 2003, pp 663-675
15. Introduction (cont.)
• Thus, the idea that by inventing ‘the perfect RRT-machine’,
no more patients with ICU-related AKI will die, will remain
an illusion. Furthermore, AKI mostly recovers if the patient
survives.
• RRT in AKI should thus be seen as a bridging therapy that allows the
patient to survive while the native kidneys recover.
• The main objective of RRT should, thus, be to avoid
additional harm to the patient as much as possible while
clearing the uremic waste products & maintaining the
‘milieu interieur’ as closely possible to normal.
W. Van Biesen & N. Lameire Intensive Care Medicine 2003, pp 663-675
16. Moore et al., Management of Acute Kidney Injury: AJKD Core Curriculum 2018
17.
18.
19.
20. 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
21. Proposed Indications for RRT
• Oliguria < 200ml/12 hours
• Anuria < 50 ml/12 hours
• Hyperkalaemia > 6.5 mmol/L
• Severe acidaemia pH < 7.0
• Uraemia > 30 mmol/L
• Uraemic complications
• Dysnatraemias > 155 or < 120 mmol/L
• Hyper/(hypo)thermia
• Drug overdose with dialysable drug
Lameire, N et al. Lancet 2005; 365: 417-430
23. The Ideal Renal Replacement Therapy
• Allows control of intra/extravascular volume
• Corrects acid-base disturbances
• Corrects uraemia & effectively clears “toxins”
• Promotes renal recovery
• Improves survival
• Is free of complications
• Clears drugs effectively (?)
24. Initial Choice of RRT for AKI
• IHD
Hemodynamically stable
Severe hyperkalemia
• CRRT
Hemodynamically unstable
Can not tolerate fluid removal
Intracranial bleed
• PD ?!!
27. Acute RRT: Modalities (1)
• Although institutional policies may determine the
local availability of these modalities,
– CRRT & SLED tend to be used in patients with
greater hemodynamic instability
• There is likely substantial inter-center variability with respect to
how each of these forms of RRT is utilized & prescribed.
• IHD
– Typically administered with conventional dialysis
machine with session length ranging from 3 to 5 h
either daily or every other day.
Vanholder et al. Critical Care 2011, 15:204
28. Intermittent Therapies - PRO
(Relatively) Inexpensive
Flexible timing allows for mobility/transport
Rapid correction of fluid overload
Rapid removal of dialyzable drugs
Rapid correction of acidosis & electrolyte abnormality
Minimises anticoagulant exposure
30. Acute RRT: Modalities (2)
• CRRT
– Is applied with an intended ttt. time of 24 h & generally
requires dedicated machines that operate at comparatively
lower blood & dialysate pump speeds
• CRRT involves either
– Dialysis (diffusion-based solute removal) or
– Filtration (convection-based solute and water removal) Rx that operate in a
continuous mode
– CRRT is generally better tolerated than conventional therapy,
since many of the complications of IHD are related to the
rapid rate of solute and fluid loss
Vanholder et al. Critical Care 2011, 15:204
38. Continuous Therapies - PRO
Haemodynamic stability => ??? better renal recovery
Stable and predictable volume control
Stable and predictable control of chemistry
Stable intracranial pressure
Disease modification by cytokine removal (CVVH)?
Kidney Blood Press Res2003;26:123-127
Journal of the American Society of Nephrology, 2001
39. Continuous Therapies - CON
Anticoagulation requirements
Higher potential for filter clotting
Expense – fluids etc.
Immobility & Transport issues
Increased bleeding risk
High heparin exposure
Kidney Blood Press Res2003;26:123-127
Journal of the American Society of Nephrology, 2001
40. PD vs CRRT
– Patients with severe falciparum malaria
(48 patients) and sepsis (22 patients)
– Assignment: 34 to hemofiltration and 36 to PD.
– PD: 70 liters/ day of dialyzate was used
– CVVH: 25 liters of replacement fluid was used
Replacement fluid was lactate based with glucose of 2g/L
Dialyzate was Acetate based with glucose of 15g/L
– Results: PD has
Lower rate of resolution of acidosis
Slower rate of decline in plasma Creatinine
Markedly increased risk of death
42. • 5.4.1: We suggest initiating RRT in patients with AKI via an
uncuffed nontunneled dialysis catheter, rather than a
tunneled catheter. (2D)
• 5.4.2: When choosing a vein for insertion of a dialysis
catheter in patients with AKI, consider these preferences
(Not Graded):
First choice: right jugular vein;
Second choice: femoral vein;
Third choice: left jugular vein;
Last choice: subclavian vein with preference for the dominant side.
Vascular access
KDIGO® AKI Guideline March 2012
43.
44. Bicarbonate versus lactatebased fluid replacement in CVVH
Prospective, randomized study
• Results :
• Serum lactate concentration was
significantly higher and the
bicarbonate was lower in patients
treated with lactatebased
solutions
• Increased incidence of CVS
events in pts ttt with lactate
solution
– Hypotension
– Increased dose of inotropic
support
Barenbrock et al; Kidney Int (2000)
Solutions for CRRT
0%
10%
20%
30%
40%
50%
60%
70%
Bicarbonate Lactate
cardiovascular
complications
hypotensive episodes
45. 5.7.3: We suggest using bicarbonate, rather than
lactate, as a buffer in dialysate and
replacement fluid for RRT in patients with AKI and
liver failure and/or lactic acidemia. (2B)
Dialysis Interventions for Treatment of AKI
KDIGO® AKI Guideline March 2012
46. The Membrane
• High Flux membrane , synthetic , biocompatable , acting by
providing both methods of detoxications:
a) Diffusion : for low molecular weight toxins.
b) Convection : for large molecules.
5.5.1: We suggest to use dialyzers with a biocompatible
membrane for IHD and CRRT in patients with AKI. (2C)
KDIGO® AKI Guideline March 2012
48. 5.3.2.1: For anticoagulation in intermittent RRT, we
recommend using either unfractionated or low-
molecular weight heparin, rather than other
anticoagulants. (1C)
5.3.2.2: For anticoagulation in CRRT, we suggest using
regional citrate anticoagulation rather than heparin
in patients who do not have contraindications for
citrate. (2B)
KDIGO® AKI Guideline March 2012
54. Discontinuation of RRT
• The decision to discontinue RRT in patients with AKI is made based
on 1 of 3 clinical scenarios:
• intrinsic kidney function has adequately improved to meet demands,
• the disorder that prompted renal support has improved,
• or continued RRT is no longer consistent with goals of care.
• There is no definitive prospective evidence to guide clinicians, but
urine output appears to be predictive of successful RRT
discontinuation successful RRT discontinuation.
• Moore et al., Management of Acute Kidney Injury: AJKD Core Curriculum 2018
55. • In one study of patients on CRRT, 24-hour urine output > 400 mL/d in
patients not using diuretics or >2,300 mL/d in patients using diuretics
had >80% chance of successful RRT discontinuation.
• Other studies have suggested that quantitation of timed urinary
creatinine & urea excretion (either as total excretion per 24-hour period or
calculation of creatinine and urea clearance) may be helpful.
• Prospective studies are needed to help guide clinicians on when to
attempt RRT discontinuation.
Moore et al., Management of Acute Kidney Injury: AJKD Core Curriculum 2018
57. Uchino S, Bellomo R, Morimatsu H, et al. Crit Care Med 2009; 37: 2576–2582.
58. Uchino S, Bellomo R, Morimatsu H, et al. Crit Care Med 2009; 37: 2576–2582.
59. 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
60. The never ending debate!
CRRT
Vs
Intermittent HD
Intuitively: CRRT>IHD
Data: CRRT=IHD
61.
62.
63. CRRT versus IHD (1)
• The presumption of greater hemodynamic stability
with CRRT also remains controversial
– Three RCTs suggested no advantage with CRRT Vs IHD,
while others demonstrated more favorable hemodynamics
with CRRT
– Even if CRRT confers a hemodynamic benefit, It is unclear
whether this translates into improvements in the patient-
relevant outcomes of survival & renal recovery
Vanholder et al. Critical Care 2011, 15:204
64. CRRT versus IHD (2)
IHD CVVH
Diffusion
Low-flux membrane
High dialysate flow
A few hours per day
Technically demanding
Less labor intensive
Convection
High-flux membrane
Low dialysate flow
Theory continuously
Technically less demanding
Labor intensive
Journal of the American Society of Nephrology, 2001
IHD CVVH
Advantages
Short duration
Cheap
Less labor-intensive
Hemodynamic stability
Better removal of cytokines
Disadvantages
Rapid hemodynamic change
Technically sophisticated
Continuous anticoagulation
Patient immobility
Intensive nursing requirement
Increased expense
65. CRRT versus IHD (3)
• Despite the widespread use of CRRT in critically ill
patients with AKI, there are few data supporting its
benefits over conventional (IHD)
• Despite greater volume control, CVVHD did not lead to improvement in
survival, preservation of urine output, or renal recovery compared with IHD
in patients with AKI
• Currently the choice of IHD or CRRT is largely based on
the availability of CRRT, preference of the health care
provider & not on evidence-based indications
• Augustine et al. Am J Kidney Dis. 2004; 44: 6
• Lameire N et al. (2005) Lancet 365: 417–430
• Uehlinger et al. (2005). Nephrol Dial Transplant 20: 1630–1637
• Fliser and Kielstein Nature Clinical Practice Nephrology (2006) 2, 32-39
66. Outcome with IRRT vs CRRT (1)
• Trial quality low: many
non-randomized
• Therapy dosing variable
• Illness severity variable
or details missing
• Small numbers
• Uncontrolled technique,
membrane
• Definitive trial would
require 660 patients in
each arm!
• Unvalidated instrument
for sensitivity analysis
Kellum, J et al. Intensive Care Med 2002; 28: 29-37
“there is insufficient evidence to establish whether CRRT is associated with
improved survival in critically ill patients with ARF when compared with IRRT”
67. Outcome with IRRT vs CRRT (2)
Tonelli, M et al. Am J Kidney Dis 2002; 40: 875-885
• No mortality difference between therapies
• No renal recovery difference between
therapies
• Unselected patient populations
• Majority of studies were unpublished
This meta-analysis of six RCTs
included > 600 patients treated in four
countries It found no significant
difference in mortality rate for
critically ill patients with ARF treated
with IHD compared to CRRT
68.
69. • It is disappointing that CRRT has been a
therapeutic option in critical care medicine for
25 years without comprehensive evaluation of
its definitive benefits
• ‘‘The difficulty lies, not in new ideas, but
in escaping old ones ”
• John Maynard Keynes (1933)
• “Which therapy is more user friendly, safer and helpful
to the overall management of critically ill patients ?”
• Hybrid therapies will become the dominant RRT for
AKI over the next 5 to 10 years
70. Acute RRT: Modalities (3)
• SLED ('Hybrid‘ renal replacement therapies)
– Sometimes referred to as extended dialysis, is
considered a ‘hybrid’ of IHD and CRRT
• Administered using conventional dialysis
technology but typical sessions run for 8–12 h
using blood & dialysis flows that are intermediate
to those prescribed in IHD and CRRT
Davenport A .,Saudi J Kidney Dis Transplant 2008;19(4):529-536
Vanholder et al. Critical Care 2011, 15:204
73. Sustained Low Efficiency Daily Dialysis SLEDD
• CRRT and its increasing use by intensivists has put a
great deal of pressure on nephrologists to adapt &
compete
• Hybrid strategies seek a middle ground between CRRT
and standard HD
• Makes it possible for IHD to return to the ICU in a more
competitive manner
Lonnemann G et al. (2000) . Nephrol Dial Transplant 15: 1189–1193
• Marshall MR et al. (2001) . Kidney Int 60: 777–785
74. Is SLEDD the answer?
• Hybrid therapy with flexibility of duration and intensity
• SLEDD vs CRRT
• Major advantages: flexibility, reduced costs, low or
absent anticoagulation
• Similar adequacy and hemodynamics
– One small study (16 pts) showed slightly higher acidosis and lower BP
(Baldwin 2007)
– VA trial (Palevsky NEJM 2008) suggests similar outcomes as CRRT and
IRRT.
Vanholder et al. Critical Care 2011,15:204
81. Accelerated Venovenous Hemofiltration
• A strategy has recently been described whereby
– CRRT machinery was applied over a contracted treatment time of 9 h,
using increased blood and effluent flow rates
• Termed accelerated venovenous hemofiltration, this
modality retains many of the feasibility advantages of SLED,
– but dedicated commercial solutions were still required
• A retrospective case series demonstrated
– adequate solute removal, acceptable hemodynamic tolerability and
the ability to avoid systemic anticoagulation
Gashti et al.,Am JKidney Dis 2008; 51: 804–810.
82. Sustained low-efficiency dialysis in the ICU: Cost,
anticoagulation, and solute removal
Daily and weekly cost of SLED and CRRT
Berbece A N and Richardson R M A, KI (2006) 70, 963-968
SLED($) CRRT citrate ($) CRRT heparin ($)
Supply cost/day 69.75 402.8 334.95
HD RN cost/day 168.75a 37.5 37.5
Total cost /day 238.5 440.3 372.45
Total cost / week 1431 3089 2607
83. CRRT versus SLED
• In addition to the absence of a survival advantage,
CRRT is more costly than IHD & is associated with a
number of obstacles such as
– Continuous patient immobilization,
– The requirement for anticoagulation and
– The need for specialized machines and premixed commercial solutions
• This has stimulated a search for a strategy that
– Incorporates the putative hemodynamic benefits of CRRT without the
associated logistic and resource constraints
• SLED meets many of these criteria
Nephron Clin Pract 2009;112:c222–c229
84. CRRT versus SLED
• SLED
– Observational data from single centers suggest
that SLED is a feasible way of providing RRT that is
• Adequate, hemodynamically well tolerated, potentially
anticoagulation-free and possibly cost-effective
– However, only a few small RCTs have compared
SLED and CRRT
Nephron Clin Pract 2009;112:c222–c229
85. CRRT versus SLED
• Kielstein et al.,(Am J Kidney Dis 2004; 43: 342–349) randomized 39
critically ill patients with AKI to receive
– Either 24 h of CVVH or 12h of SLED
• Using invasive monitoring, these authors found
– No significant differences in all measured hemodynamic parameters
(MABP, SVR, CO) with comparable removal of creatinine and urea
– Berbece and Richardson (KI. 2006., 70, 963–968.)
compared SLED (23 patients, 165 treatments) with CRRT (11 patients, 209
days), they concluded that SLED may be routinely performed
without anticoagulation; it provides solute removal equivalent
to CRRT at significantly lower cost.
91. HD treatment in ICU depend
• Treatment behavior
• Availability of treatment methods
• Organization of the unit
• Knowledge & experience of nurses
• Existence of nephrological unit in the hospital
• Cost
• Individual doctor must therefore know the
advantages & disadvantage of different ttt options.
Kidney Blood Press Res2003;26:123-127
94. Evaluating AKI :
Comparison with AMI
Period Acute Myocardial
infarction
Acute Kidney Injury
1960’s LDH S Cr
1970’s CPK, Myoglobin S Cr
1980’s CPKMB S Cr
1990’s Troponin T S Cr
2000’s Troponin I S Cr
Multiple therapies
50% reduction in
mortality
Supportive therapy
High mortality, largely
unchanged
97. RRT for Acute Kidney Injury
• There is some evidence for a relationship
between higher therapy dose and better
outcome, at least up to a point
• This is true for IHD* and for CVVH**
• There is no definitive evidence for superiority
of one therapy over another, and wide
practice variation exists***
• Accepted indications for RTT vary
• No definitive evidence on timing of RRT
*Schiffl, H et al. NEJM 2002; 346: 305-310 ** Ronco, C et al. Lancet 2000; 355: 26-30
*** Uchino, S. Curr Opin Crit Care 2006; 12: 538-543
98. Conclusions - 1
• Despite the conceptual advantages of CRRT, multiple RCTs
have shown no evidence of improved patient outcomes with
this modality, as compared to conventional IHD
• The logistic challenges associated with CRRT and the relatively high
costs of this modality may stimulate the increased use of SLED
• However, well-designed RCTs are still needed to better
characterize the reported benefits of SLED prior to its
widespread adoption
99. Conclusions - 2
• The current balance of evidence suggests that among hemodynamically
unstable patients, CRRT need not be administered at doses >20
ml/kg/h, & in more stable patients, alternate day IHD is acceptable.
• SLEDD is a hybrid therapy combining most of the advantages of both
CRRT & IHD. All these options should not be considered as
competitors, but rather as alternatives that may be switched in the same
patient depending on his/her condition. Vanholder et al. Critical Care 2011, 15:204
• From the practical point of view, among these modalities, SLEDD
seems to offer the highest flexibility to tailor ttt according to the
individual needs of the patient.
100. Conclusions - 3
• In a country like Egypt where often there are
economical constraints, the judicious use of SLED
will help us optimize the need for CRRT.
SLEDD
“The Poor Man’s
CRRT”
T. El Baz, MD, Professor of Medicine ,Division
of Nephrology, Al Azhar Univ
101.
102.
103. The best evidence in the past,
may be the worst today,
may be the best in the future again,
however patients are the same !!!!
Welcome to MEDICINE
104. GENIUS 90 Therapy System
-Hybrid therapies encompass a group of Rxs, which are
essentially based on extending the duration & slowing down
the rate of diffusion of IHD
-Most regimens use standard IHD machines with slower blood
& dialysate flow rates.
- In addition, there is a batch IHD machine (Genius, Fresenius
Bad Homberg, Germany) in which the blood & dialysate flows
are linked by a single pump, so that the flow rates are of
similar magnitude.
Davenport A .,Saudi J Kidney Dis Transplant 2008;19(4):529-536
105. Key messages
• Mortality and hemodynamic stability did not differ
in AKI patients treated either with SLED or CVVH
• SLED treatment was associated with a lower quantity
of blood transfusions given, a shorter ICU stay,
shorter duration of mechanical ventilation and faster
recovery of renal function
• SLED was accompanied with reduced nursing time
spent for RRT and lower costs for providing RRT
106. GENIUS 90 Therapy System
-This system enables the safe & efficient implementation
of subsequent therapy procedures in the ch. dialysis
center or in the ICU: (IHD),(SLEDD)(SCUF).
-The heart of GENIUS 90 is a thermally-insulated glass tank
with a capacity of 90 litres.
-This glass tank is filled with ready-to-use dialysis
fluid, which can be varied individually before each ttt
& complies with the highest hygienic requirements.
107. This characteristic as well as the high mobility
permits highly efficient Rx at any desired
location.
-This is independent of the availability of the otherwise
necessary installations at the dialysis unit for water, waste
water & the central supply of concentrate.
-During the ttt, blood & dialysis fluid are
pumped to the dialyser through the peristaltic
pump.
-The used dialysis fluid is then returned to the bottom of
the glass tank through a glass distributor tube and forms a
layer below the fresh dialysis fluid.
-The latter remains separated from the used
dialysis fluid throughout the entire ttt because
of such physical effects as density & temp.
differences
