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.
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
5.
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
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%)
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
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