CRRT in ICU - AKI - Dr. Gawad

CRRT in ICU – AKI
What is the Evidence?
Mohammed Abdel Gawad
Nephrology Specialist
Kidney & Urology Center (KUC)
Alexandria – EGY
drgawad@gmail.com
The Annual Egyptian Dialysis Conference
10-11, September, 2015

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contact me on drgawad@gmail.com
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Talk Outline
• Is CRRT the best modality for ICU-AKI patients?
• When to initiate?
• When to stop?
• What is the dose – Effluent volume?
• Sepsis Considerations
• Filtration Fraction
19

Talk Outline
• When to stop?
19
Marshall MR, Golper TA. Semin Dial. 2011;24:142-148.Marshall MR, Golper TA. Semin Dial. 2011;24:142-148.

Talk Outline
• When to stop?
Haemodynamic Stability !!!
ICP !!! 19

Analyzing 15 RCTs in 1550 AKI patients
CRRT vs IRRT
Cochrane Database Syst Rev 2007: CD003773.
19

Cochrane Database Syst Rev 2007: CD003773.
18

Kidney International Supplements (2012) 2, 89–115
Hemodynamicaly stable patients
17

Hemodynamicaly unstable patients / ↑ ICP
17

Cochrane Database Syst Rev 2007: CD003773. 16

• In current clinical practice, the choice of the initial
modality for RRT is primarily based on:
– the availability
– experience
– patient’s hemodynamic status.
• SLED may also be tolerated in hemodynamically
unstable patients with AKI in settings where other
forms of CRRT are not available, (but data on
comparative efficacy and harm are limited).
Marshall MR et al. Nephrol Dial Transplant 2011; 26:2169–2175.
16

Talk Outline
• When to stop?
16

Talk Outline
• When to stop?
15

When to initiate? Early vs Late
What is meant by EARLY?
What is meant by LATE?
Studies aimed at determining the optimal time for starting
RRT have evaluated various arbitrary cut-offs for:
• serum creatinine
• serum urea
• urine output
• time from ICU admission or duration of AKI
15

Serum Creatinine as a trigger for RRT
Higher creatinine >300μmol/L (3.4mg/dl); better prognosis
Bagshaw et al. J Crit Care 2009; 24: 129–140
Lower creatinine <300 μmol/L (3.4mg/dl); better prognosis
Ostermann et al. Crit Care 2009; 13: R175
15

Serum Urea as a trigger for RRT
Lower urea better prognosis Better results
when Urea
Wu et al.
J Am Coll Surg 2007;205: 266–276
<27.1 mmol/L
Gettings et al.
Intensive Care Med 1999; 25: 805–813
<21.4 mmol/L
Carl et al.
Hemodial Int 2010; 14: 11–17
<35.7 mmol/L
14

RIFLE as a trigger for RRT
Lower RIFLE better prognosis
Shiao et al. Crit Care 2009; 13: R171
Similar prognosis across RIFLE categories
Chou et al. Crit Care 2011; 15: R134
14

UOP as a trigger for RRT
Better prognosis Early dialysis:
Better results when UOP
Elahi et al.
Eur J Cardiothorac Surg 2004; 26: 1027–1031
<100 mL in 8 h
Demirkilic et al.
J Card Surg 2004;19: 17–20
<100 mL within 8 h
Sugahara et al. RCT
Hemodial Int 2004; 8: 320–325
<30 mL/h for 3 h
Ji et al.
Heart Vessels 2011; 26: 183–189
<0.5 mL/kg/h for <12h
14

UOP as a trigger for RRT
Similar prognosis across UOP
different volumes
Early dialysis defined when
UOP
Bouman et al. RCT
Crit Care Med 2002; 30:2205–2211
<30 mL/h for 6 h
and creatinine clearance <20 mL/min
Iyem et al.
Hemodial Int 2009; 13: 55–61
0.5 mL/kg/h
and a 50% increase in preoperative
urea and creatinine
13

The optimal timing of dialysis for
AKI is not defined
• Fluid overload (refractory to medical measures)
• Hyperkalemia (refractory to medical measures)
• Severe metabolic acidosis (refractory to medical measures)
• Signs of uremia (such as pericarditis, neuropathy, or an otherwise
unexplained decline in mental status)
• Certain alcohol and drug intoxications
Kidney International Supplements (2012) 2, 89–115 13

13

• Considered RRT:
– Urea  21 mmol/L (60 mg/dl)
– Volume overload
– Persistent hyperkalemia (K+ > 6.2 mEq/L or ECG changes)
– Severe metabolic acidosis (pH < 7.20)
– Uremic signs or symptoms Palevsky PM et al. N Engl J Med. 2008;359:7-20
ATN
• Considered RRT:
– Oliguria: urine output <100 ml
in 6h
– Urea >70 mg/dl
– Creatinine >3.5 mg/dl
– Potassium > 6.5 mmol/L
– pH <7.2
– Clinically significant organ
edema
Bellomo R, Cass A, Cole L, et al. N Engl J Med 2009; 361:
1627–1638.
RENAL
12

Whatever criteria are 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
12

Other factors that might influence the decision of when to
start RRT are:
• the severity of the underlying disease (affecting the likelihood of
recovery of kidney function),
• the degree of dysfunction in other organs (affecting the tolerance
e.g., fluid overload),
• the prevalent or expected solute burden (e.g.,in tumor lysis
syndrome),
• the need for fluid input related to nutrition or drug therapy
11

Sean M Bagshaw et al. Critical Care 2009, 13:317
A proposed algorithm
for initiation RRT in
adult critically ill
patients
11

What is the most important to be
early?
• AKI diagnosis?
• Initiation of RRT?
11

Talk Outline
• When to stop?
11

Talk Outline
• When to stop?
10

When to Stop?
Creatinine Clearance
Urine Output
10

When to Stop?
Assessment of kidney function during RRT
Shealy CB, Campbell RC, Hey JC, et al. 24-hr creatinine clearance as a guide for
CRRT withdrawal: a retrospective study (abstr). Blood Purif 2003;21: 192.
Successful termination of CRRT, defined as the absence of
CRRT requirement for at least 14 days following cessation
10
CrCl

When to Stop?
CrCl RRT
<12 mL/min RRT was continued
12 to 20 mL/min Decision was left to the discretion of
providers
> 20 mL/min RRT was discontinued
Palevsky PM et al. N Engl J Med. 2008;359:7-20
10
ATN
CrCl

When to Stop?
When the UOP > 30 mL/hour
CrCl Assessment methodology
1 hr 3hr 6h
Urine
collection
9
CrCl

When to Stop?
1 hr 3hr 6h
Urine
collection
Midpoint
serum Cr
9
CrCl

When to Stop?
1 hr 3hr 6h
Urine
collection
serum Cr serum Cr
Average serum Cr
9
CrCl

When to Stop?
Uchino S, Bellomo R, Morimatsu H, et al. Crit Care Med 2009; 37: 2576–2582. 9
UOP

When to Stop?
Uchino S, Bellomo R, Morimatsu H, et al. Crit Care Med 2009; 37: 2576–2582. 8
UOP

How to Stop?
The process of stopping RRT may consist of:
• Simple discontinuation of RRT,
• or may include a change in the modality,
frequency, or duration of RRT.
8

When to Stop?
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
7

Talk Outline
• When to stop?
7

The Dose – Effluent Volume
6

6
ATN
RENAL
Bellomo R, Cass A, Cole L, et al. N Engl J Med 2009; 361: 1627–1638.

6
ATN

VA/NIH Acute Renal Failure Trial Network, Palevsky PM et al. N Engl J Med. 2008;359:7-20Palevsky PM et al. N Engl J Med. 2008;359:7-20
5
ATN

Bellomo R, Cass A, Cole L, et al. N Engl J Med 2009; 361: 1627–1638.
5
RENAL

4

Talk Outline
• When to stop?
4

Joannes-Boyau O et al. Intensive Care Med. 2013 Sep;39(9):1535-46
3

Coupled plasma filtration and
adsorption (CPFA)
+ CRRT
Plasma
filtration:
Plasma filter
separates
plasma from
blood
Plasma
Adsorption:
Plasma is then
passed through
a synthetic resin
cartridge
CRRT:
Plasma
returned to
blood to pass
through blood
filter
CPFA - Adsorption
Very effective in removing
large solutes 3
CRRT
Removes excess fluid
and small-MW toxins
Ronco et al. Critical Care (2015) 19:146

Talk Outline
• When to stop?
2

CRRT – Filtration Fraction
• UFR should not exceed 30% of the plasma water flow
rate (i.e., filtration fraction should be below 0.30).
• The problem can be resolved by:
– increasing Qb to at least 200 to 250 ml/ min
– or by diluting the blood and clotting factors with
replacement fluid before it reaches the hemofilter
(predilution)
1

1Kidney International Supplements (2012) 2, 89–115
The problem can be resolved by:
• increasing Qb to at least 200 to
250 ml/ min
• or by diluting the blood and
clotting factors with replacement
fluid before it reaches the
hemofilter (predilution)
Avoid extra-
corporeal
clotting

1Kidney International Supplements (2012) 2, 89–115
The problem can be resolved by:
• increasing Qb to at least 200 to
250 ml/ min
• or by diluting the blood and
clotting factors with replacement
fluid before it reaches the
hemofilter (predilution)

Pre-dilution Post-dilution
Low risk of clotting High risk of clotting
less efficient More efficient
No clinical study has definitively addressed when pre- or
post-dilution HF should be used, so this decision is
largely a matter of local experience and preference.
Ronco et al. Critical Care (2015) 19:146
1

To Summarize
• Hemodynamic stable = IRRT & CRRT no
difference regarding outcomes
• Hemodynamic unstable/↑ICP = CRRT is
preferred
1

To Summarize
• Emergency indication = Start RRT immediately
• If No Emergency indication consider:
– broader clinical context
– laboratory trends rather than single values
0

To Summarize
• Early AKI diagnosis ensures early effective
management
• Late AKI diagnosis = Always late initiation of
RRT
0

To Summarize
• Stop CRRT when CrCl > 15-20ml/min (weak
evidence)
• UOP is an important parameter when
termination of CRRT is considered
0

To Summarize
• CRRT Dose
= Delivered effluent volume of 20-25ml/kg/hr
= Prescribed effluent volume of 25-30ml/kg/hr
• Filtration fraction during CRRT must be < 30%
0

To Summarize
• No evidence that septic shock patients will
benefit from higher effluent volumes
• Plasma Adsorption may have an important
role in management of septic AKI patients
0

CRRT in ICU - AKI - Dr. Gawad

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