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Dialytic support for aki
1) The document discusses different modalities for providing dialytic support for acute kidney injury (AKI) patients, including intermittent and continuous renal replacement therapies. 2) It compares the pros and cons of different modalities and notes there is no clear evidence of differences in mortality or renal recovery between intermittent and continuous therapies. 3) Guidelines recommend considering patient hemodynamic stability and using continuous renal replacement therapy for unstable patients or those with brain injury, and emphasize starting renal replacement therapy based on clinical criteria rather than a single laboratory value.
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Dialytic support for aki
- 1. Dialytic Support forAKI patients By Dr. Ahmed Mohammed Abd El Wahab Lecturer of Internal Medicine(Nephrology) Director of Critical Care and Convalescence Hospital Mansoura Faculty of medicine
- 2.
- 3. RIFLE Strata The 2ndInternational Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group
- 7. Where are we- too many questions? What do we aim for? When should we start it? What therapy should we use? Which vascular access? How much therapy is enough? When do we stop/switch?
- 8. The Ideal RenalReplacement 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 (?)
- 11. Serum Creatinine asa trigger for RRT When to initiate? Early vs Late
- 12. Serum Urea asa trigger for RRT When to initiate? Early vs Late
- 13. UOP as atrigger for RRT When to initiate? Early vs Late
- 14. To ConsiderRRT: ◦ Urea 21 mmol/L ◦ Volume overload ◦ Persistent hyperkalemia (K+ > 6.2 mEq/L or ECG changes) ◦ Severe metabolic acidosis (pH < 7.20) ◦ Uremic signs or symptoms VA/NIH Acute Renal Failure Trial Network, Palevsky PM et al. N Engl J Med. 2008;359:7-20
- 15. To ConsiderRRT: ◦ Oliguria: urine output <100 ml in 6h ◦ Potassium >6.5 mmol/L ◦ pH <7.2 ◦ BUN >70 mg/dl ◦ Creatinine >3.5 mg/dl ◦ Clinically significant organ edema RENAL, Bellomo R, Cass A, Cole L, et al. N Engl J Med 2009; 361: 1627–1638.
- 23. Whatever the criteriaused 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
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- 26. Major Renal Replacement Techniques IntermittentContinuousHybrid IHD Intermittent haemodialysis IUF Isolated Ultrafiltration SLEDD Sustained (or slow) low efficiency daily dialysis SLEDD- F Sustained (or slow) low efficiency daily dialysis with filtration CVVH Continuous veno- venous haemofiltration CVVHD Continuous veno- venous haemodialysis CVVHDF Continuous veno- venous haemodiafiltration SCUF Slow continuous ultrafiltration
- 27. 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
- 28. Intermittent Therapies -CON Hypotension 30- 60% Cerebral oedema Limited therapy duration Renal injury & ischaemia Gut/coronary ischaemia
- 29. 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)?
- 30. Continuous Therapies -CON Anticoagulation requirements Higher potential for filter clotting Expense – fluids etc. Immobility & Transport issues Increased bleeding risk High heparin exposure
- 32. Solute Clearance -Diffusion Small (< 500d) molecules cleared efficiently Concentration gradient critical Gradient achieved by countercurrent flow Principal clearance mode of dialysis techniques
- 33. Solute Clearance –Ultrafiltration & Convection (Haemofiltration) Water movement “drags” solute across membrane At high UF rates (> 1L/hour) enough solute is dragged to produce significant clearance Convective clearance dehydrates the blood passing through the filter If filtration fraction > 30% there is high risk of filter clotting* Also clears larger molecular weight substances (e.g. B12, TNF, inulin) * In post-dilution haemofiltration
- 34. SCUF • High fluxmembranes • Up to 24 hrs per day • Objective VOLUME control • Not suitable for solute clearance • Blood flow 50-200 ml/min • UF rate 2-8 ml/min
- 35. CA/VVH • Extended durationup to weeks • High flux membranes • Mainly convective clearance • UF > volume control amount • Excess UF replaced • Replacement pre- or post- filter • Blood flow 50-200 ml/min • UF rate 10-60 ml/min
- 36. CA/VVHD • Mid/high fluxmembranes • Extended period up to weeks • Diffusive solute clearance • Countercurrent dialysate • UF for volume control • Blood flow 50-200 ml/min • UF rate 1-8 ml/min • Dialysate flow 15-60 ml/min
- 37. CVVHDF • High fluxmembranes • Extended period up to weeks • Diffusive & convective solute clearance • Countercurrent dialysate • UF exceeds volume control • Replacement fluid as required • Blood flow 50-200 ml/min • UF rate 10-60 ml/min • Dialysate flow 15-30 ml/min • Replacement 10-30 ml/min
- 38. SLED(D) & SLED(D)-F: Hybrid therapy Conventional dialysis equipment Online dialysis fluid preparation Excellent small molecule detoxification Cardiovascular stability as good as CRRT Reduced anticoagulation requirement 11 hrs SLED comparable to 23 hrs CVVH Decreased costs compared to CRRT Phosphate supplementation requiredFliser, T & Kielstein JT. Nature Clin Practice Neph 2006; 2: 32-39 Berbece, AN & Richardson, RMA. Kidney International 2006; 70: 963-968
- 39. Uraemia Control Liao, Zet al. Artificial Organs 2003; 27: 802-807
- 40. Large molecule clearance Liao,Z et al. Artificial Organs 2003; 27: 802-807
- 43. Outcome with IRRTvs CRRT 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
- 49.
- 52. 5.6.2: We suggestusing CRRT, rather than standard intermittent RRT, for hemodynamically unstable patients. (2B) Dialysis Interventions for Treatment of AKI KDIGO® AKI Guideline March 2012 5.6.3: 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. (2B)
- 53.
- 54. 5.4.1: Wesuggest 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
- 55. Bicarbonate versus lactatebasedfluid 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 barenborck and colleague Barenbrock M et al; Kidney Int (2000) Solutions for CRRT cardiovascular complications hypotensive episodes
- 56. 5.7.3: We suggestusing 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
- 57. The Membrane HighFlux 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
- 58. Anticoagulation Modality Advantages Disadvantages HeparinGood anticoagulation Thrombocytopenia bleeding LMWH Less thrombocytopenia bleeding Citrate Lowest risk of bleeding Metabolic alkalosis, hypocalcemia special dialysate Regional Heparin Reduced bleeding Complex management Saline flushes No bleeding risk Poor efficacy Prostacycline Reduced bleeding risk Hypotension poor efficacy
- 59. 5.3.2.1: For anticoagulationin 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
- 60.
- 63. Kidney International Supplements(2012) 2, 89–115 RENAL, Bellomo R, Cass A, Cole L, et al. N Engl J Med 2009; 361: 1627–1638.
- 64. Kidney International Supplements(2012) 2, 89–115
- 66. Kidney International Supplements(2012) 2, 89–115
- 67.
- 68. Recovery Uchino S, BellomoR, Morimatsu H, et al. Crit Care Med 2009; 37: 2576–
- 69. Uchino S, BellomoR, Morimatsu H, et al. Crit Care Med 2009; 37: 2576–
- 70. Uchino S, BellomoR, Morimatsu H, et al. Crit Care Med 2009; 37: 2576–
- 71. When to Stop? KidneyInternational 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 careLassnigg A, Schmidlin D, Mouhieddine M et al. J Am Soc Nephrol 2004; 15:1597–1605
- 72. How to improveoutcome?
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- 77. Implications of theavailable data ARF is not an innocent bystander in ICU We must ensure adequate dosing of RRT Choice of RRT mode may not be critical Septic ARF may be a different beast We must strive to avert acute renal failure
- 78.