Crrt sudan 2017 dr. osama el shahat

1. Dr. Osama El-Shahat
Consultant Nephrologist
Head of Nephrology Department
New Mansoura General Hospital (international)
ISN Educational Ambassador

2. When
What
HOW
to start ?
Modality ?
can we do it ?

3. Stage-based management
General Principles
Stage 1 (Risk)
Risk for more severe AKI
Monitor (prevent
progression)
Stage 2 (Injury)
Risk of AKI-related
mortality/morbidity high
Conservative therapy)
Stage 3 (Failure)
Highest risk of death
Consider RRT
Avoid subclavian catheters if possible
Discontinue all nephrotoxic agents when possible
Consider invasive diagnostic workup
Consider Renal Replacement Therapy
1 2 3
Non-invasive diagnostic workup
Ensure volume status and perfusion pressure
Check for changes in drug dosing
AKI Stage
Consider functional hemodynamic monitoring
Monitoring Serum creatinine and urine output
Consider ICU admission
Avoid hyperglycemia
Consider alternatives to radiocontrast procedures

4. Whento start ?

5. Renal Indications
Life-threatening indications
Hyperkalemia
Metabolic Acidosis
Pulmonary edema
Uremic complications
Non Renal Indications
Fluid removal in congestive
heart failure& Fluid
management in multiorgan
failure
Cytokine manipulation in
sepsis
Treatment of drug overdose
Nutrition support

6. Crit Care Med 2008, Vol. 36, No 4 (suppl.)
Early RRT seems better

7. What Modality?

8. 1. Peritoneal dialysis (PD)
2. Intermittent Hemodialysis (IHD)
3. Slow Low-Efficiency Dialysis (SLED)
4. Continuous Renal Replacement Therapy (CRRT)
• Slow Continuous Ultrafiltration (SCUF)
• Continuous Venovenous Hemofiltration (CVVH)
• Continuous Venovenous Hemodialysis (CVVHD)
• Continuous Venovenous Diafiltration (CVVHDF)

9. Advantages
Hemodynamic stability
Slow correction
Easy access placement
No Anticoagulation
Tolerated in children
Disadvantages
 Risk of infections
 Difficulty to use with abdominals surgery
 Logestics

10. PD … the modality first used for the treatment of KI

11. Blood Purif 2013;36:226–230 DOI: 10.1159/000356627

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 Is an extracorporeal blood purification therapy
intended to substitute for impaired renal function over
an extended period of time and applied for or aimed
at being applied for Extended time 24 -72 h.
Bellomo R., Ronco C., Mehta R, Nomenclature for Continuous Renal Replacement Therapies, AJKD, Vol 28, No. 5, Suppl 3, November 1996

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 Mimic the functions and physiology of the native organ
 Qualitative and quantitative blood purification
 Restore and maintain of homeostasis
 Avoid complications and good clinical tolerance
 Provide conditions favoring recovery of renal function

16. Mode of
therapy
Principle method of
solute clearance
CVVH Convection
CVVHD Diffusion
CVVHDF Convection & Diffusion
SCUF Ultrafiltration (fluids)

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• CRRT clearance of solute is dependent on the following:
◦ The molecule size of the solute
◦ The pore size of the semi-permeable membrane
• The higher the ultrafiltration rate (UFR), the greater the
solute clearance.

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• Small molecules easily pass through a membrane driven by
diffusion and convection.
• Middle and large size molecules are cleared primarily by
convection.
• Semi-permeable membrane remove solutes with a molecular
weight of up to 50,000 Daltons.
• Plasma proteins or substances highly protein—bound will not
be cleared.

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• Sieving Coefficient
◦ The ability of a substance to pass through a membrane from
the blood compartment of the hemofilter to the fluid
compartment.
◦ A sieving coefficient of 1 will allow free passage of a
substance; but at a coefficient of 0, the substance is unable to
pass.
• .94 Na+
• 1.0 K+
• 1.0 Cr
• 0 albumin will not pass

27. Ronco C et al Kidney Int 56 ( suppl 72 ) s-8-s-14 , 1999

28.  5.6.2: We suggest using CRRT, rather than standard
intermittent RRT, for hemodynamically unstable patients. (2B)
 5.6.1: Use continuous and intermittent RRT as complementary
therapies in AKI patients. (Not Graded

29. Study Modality % recovering renal function
SUPPORT IHD* 67%**
Morgera et al. CRRT 90%
Ronco et al. CRRT 90%
Mehta et al.
IHD
CRRT
59%
92%
BEST Kidney†
IHD
CRRT
65%
89%

30. Davenport, A Sem Dialysis, 2009
 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)
KDIGO® AKI Guideline March 2012

31.  The elimination of
inflamatory mediator
occurs only during the 1st
hour after application of
new filter.
 Cytokines removal
capacity of curently
available membranes
hardly matches the
productin observed in
severly affected septic
patients.
De Vriese As-JAM Soc Nephrol 10-846-853 1999

32.  Typically performed over 6-12 hours
 Can be performed with a conventional dialysis
machine
– A little less labor intensive
– Requires less training/startup
Fliser D and Kielstei JT Nat Clin Pract Nephrol, 2006
Slow Low-Efficiency Daily Dialysis (SLED)

33.  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

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 CRRT requires:
◦ A central double-lumen veno-venous hemodialysis catheter
◦ An extracorporeal circuit and a hemofilter
◦ A blood pump and a effluent pump.
◦ With specific CRRT therapies dialysate and/or replacement
pumps are required.
Solution
 Anticoagulation
Dose

35.  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

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• 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

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• Physician Rx and adjusted based on pt. clinical need.
• Sterile replacement solutions may be:
 Bicarbonate-based or Lactate-based solutions
 Electrolyte solutions
 Must be sterile and labeled for IV Use
 Higher rates increase convective clearances
 You are what you replace

38. 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
barenborck and colleague
Barenbrock M et al; Kidney Int (2000
Replacement Fluids

39. 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)
KDIGO® AKI Guideline March 2012

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• Through diffusion, dialysate corrects underlying metabolic
problems
• Dialysate is dependent on buffering agent, electrolytes, and
glucose
• Dialysate formulas should reflect normal plasma values to
achieve homeostasis

41.  5.5.1: We suggest to use dialyzers with a biocompatible membrane
for IHD and CRRT in patients with AKI. (2C)
 High Flux membrane , synthetic , biocompatable ,
acting by providing both methods of detoxications:
A. Diffusion : for low molecular weight toxins.
B. Convection : for large molecules.
KDIGO® AKI Guideline March 2012

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• Hemofilter membrane are composed of:
 High flux material
 Synthetic/biocompatible material
• Structural design is characterized by:
 High fluid removal
 Molecular cut-off weight of 30,000-50,000 Daltons.

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• The semi-permeable membrane provides:
 An interface between the blood and dialysate
compartment.
• Biocompatibility minimizes:
 Severe patient reactions
 Decreases the complement activation

44. Modality Advantages Disadvantages
Heparin Good 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

45. 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

46. Dose ?

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 Prospective study on 425 patients - 3 groups:
 Study:
 Survival after 15 days of HF stop
 Recovery of renal function

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100
90
80
70
60
50
40
30
20
10
0
Group 1(n=146)
(Uf = 20 ml/h/Kg)
Group 2 (n=139)
(Uf = 35 ml/h/Kg)
Group 3 (n=140)
(Uf = 45 ml/h/Kg)
41 % 57 % 58 %
p < 0.001 p n..s.
p < 0.001
Survival(%)
Effects of different doses in CVVH on outcome of ARF - Ronco & Bellomo study.
Lancet . july 00

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 An increased treatment dose from 20 ml/h/kg to 35 ml/h/kg
significantly improved survival.
 A delivery of 45ml/kg/hr did not result in further benefit in
terms of survival, but in the septic patient an improvement was
observed.
 Our data suggest an early initiation of treatment and a
minimum dose delivery of 35 ml/h/kg (ex. 70 kg patient =
2450 ml/h) improve patient survival rate.
Effects of different doses in CVVH on outcome of ARF - Ronco & Bellomo study. Lancet . july 00

50.  RCT of 1124 critically ill pts with AKI and sepsis or at least one
organ failure to intensive or less intensive renal-replacement
therapy
 Hemodynamically unstable pts received CRRT or SLEDD,
 Stable pts IRRT
 Intensive RRT= IRRT or SLEDD 6x/wk or CRRT at 35 ml/kg/hr
 Less intensive RRT= IRRT or SLED 3x/wk or CRRT at 20
ml/kg/hr
VA/NIH Acute Renal Failure Trial Network. (NEJM 2008;359:7):

51. VA/NIH Acute Renal Failure Trial Network. (NEJM 2008;359:7):
No difference in mortality

52.  1508 Critically ill patients with ARF on CVVHF were randomized to:-
 low (25 mL/kg/hr – 747 patients)
 high intensity (40 mL/kg/hr – 761 patients) effluent rates.
N Engl J Med. 2009 Oct 22;361(17):1627-38
The RENAL Replacement Therapy Study
There was no
difference in 90 day
mortality rate (44.7%)
or the need for RRT at
90 day between the
two treatment groups.

53. 5.8.1: The dose of RRT to be delivered should be prescribed
before starting each session of RRT. (Not Graded)
We recommend frequent assessment of the actual
delivered dose in order to adjust the prescription. (1B)
5.8.2: Provide RRT to achieve the goals of electrolyte, acid-
base, solute, and fluid balance that will meet the
patient’s needs. (Not Graded)
KDIGO® AKI Guideline March 2012

54.  CRRT is the modality of choice for hemodynamically
unstable patients who needs RRT .
 The current trend is to provide RRT earlier in AKI
 There may be a recovery advantage to using CRRT vs.
HD for initial management of AKI but no difference on
mortality
 CRRT has many non renal indication which must be
considered
Dose: Optimal intensity of CRRT is controversial
Dialytic Support by CRRT = Individualization

56. When no plan ! Higher
morbidity & mortality

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 An increased treatment dose from 20 ml/h/kg to 35 ml/h/kg
significantly improved survival.
 A delivery of 45ml/kg/hr did not result in further benefit in
terms of survival, but in the septic patient an improvement was
observed.
 Our data suggest an early initiation of treatment and a
minimum dose delivery of 35 ml/h/kg (ex. 70 kg patient =
2450 ml/h) improve patient survival rate.
Effects of different doses in CVVH on outcome of ARF - Ronco & Bellomo study. Lancet . july 00

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