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Dr Ross Freebairn Hawke’s Bay N.Z.
Renal Replacement Therapy What, When, Why & How Much.
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Oliguria
• urine output < 0.5 ml/kg/hr
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Matter of perspective
• Heart stops – Cardiac arrest
• Breathing stops – Respiratory arrest
• Kidneys stop – Oliguria – Renal arrest
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Acute renal failure
• failure of solute and (usually) water clearance
• common
• associated with increased mortality
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Oliguria
• warning sign of impaired tissue perfusion
• leads to acute renal failure if not corrected
• 2 hours’ oliguria MUST be treated urgently
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Pathophysiology • outer renal
medulla prone to ischaemia
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Pathophysiology
• reduced renal blood flow worsens medullary ischaemia
• ischaemia causes structural changes and ultimately acute tubular necrosis
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Management
• treatable factors • hypovolaemia and shock - resuscitate • infection - source control and antibiotics • nephrotoxic drugs - discontinue where
possible • abdominal compartment syndrome -
decompress • rhabdomyolysis - alkalinise, mannitol • hypercalcaemia • obstruction
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Resuscitation
• correct hypovolaemia • volume repletion • CVP guidance using serial fluid challenges
• restore cardiac output • vasopressors/inotropes if other evidence of
tissue hypoperfusion • restore perfusion pressure
• may need MAP > 80 mm Hg if previously hypertensive
• volume repletion and vasopressors
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Frusemide is NOT
a resuscitation fluid
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Dopamine • inconsistent diuretic effect
• but this may cause dehydration • does not
• increase creatinine clearance • prevent acute renal failure
• does cause serious toxicity problems • tachyarrhythmias • exacerbates renal and mesenteric ischaemia • impaired immune function
• fundamentally not useful
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Frusemide
• does • reduce juxtamedullary oxygen
consumption • has not been shown to
• improve creatinine clearance • affect survival either way
• disadvantages • of diuresis
• may be used but ONLY after adequate volume resuscitation
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Established acute renal failure
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Management of renal failure
• avoid volume overload – input = previous hour’s output +20 ml – BUT do not withold nutrition
• treat complications • adjust drug doses • renal replacement therapy
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Temporizing measures
• hyperkalaemia • insulin/dextrose, NaHCO3, β2 agonists
• severe acidosis • NaHCO3 infusion
• volume overload • GTN infusion if BP permits • frusemide if still passing urine
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Indications for CRRT • Urgent
– Severe ↑ K – Severe metabolic
acidosis – Severe pulmonary
oedema due to fluid overload
– Uraemic pericarditis
• Less urgent/definite – Non-obstructive oliguria
>12 h – Creatinine 2 x baseline – Uraemic encephalopathy,
neuropathy or myopathy – Progressive dysnatraemia – Hyperthermia – Significant oedema – Requirement for large
volume transfusion in patients with/at risk of pulmonary oedema/ARDS
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From: Effect of Early vs Delayed Initiation of Renal Replacement Therapy on Mortality in Critically Ill Patients With Acute Kidney Injury: The ELAIN Randomized Clinical TrialJAMA. 2016;315(20):2190-2199. doi:10.1001/jama.2016.5828
Mortality Probability Within 90 Days After Study Enrollment for Patients Receiving Early and Delayed Initiation of Renal Replacement Therapy (RRT)KDIGO indicates Kidney Disease: Improving Global Outcomes. In the delayed group, 18 patients received RRT without reaching KDIGO stage 3 (these patients had an absolute indication). The median (quartile 1 [Q1], quartile 3 [Q3]) duration of follow-up was 90 days (Q1, Q3: 90, 90) in the early group and 90 days (Q1, Q3: 90, 90) in the delayed group. The vertical ticks indicate censored cases.
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Factors affecting RRT
Patient focused System Imposed Clinician Influenced
Comorbidity Health structure Indications (timing)
Kidney reserve ICU organization Prescription
Metabolic rate Resource /Costs Local Practice
Primary diagnosis Resource/ equipment Goals of therapy
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Continuous venovenous haemodiafiltration--an audit demonstrating control of electrolytes with haemodynamic stability in the critically ill. Freebairn RC, Lipman J. S Afr J Surg. 1994 Jun;32(2):77-82
80
85
90
95
100
105
110
115
Heart rate MAP SBP CVP
Time 036hrs
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Pump
Ultrafiltrate
Pump
Replacement fluid
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Solute
Plasma protein
Replacement fluid
Ultrafiltrate
Blood
Haemofilter membrane
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Replacement fluid
• Determines plasma electrolyte concentration
• Bicarbonate lost, needs to be replaced
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Replacement fluid
• Bicarbonate replacement – Bicarbonate – Lactate
• Metabolized to bicarbonate by liver (or not!)
• Risk of metabolic acidosis
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Dialysate
Effluent
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Dialysis fluid
• Solutes will reach equilibrium • Plasma electrolyte & bicarbonate
concentration will tend towards dialysis fluid concentration
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Anticoagulation
• None • Heparin
– Unfractionated – Low molecular weight
• Citrate • Prostacyclin • Systemic anticoagulation
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Anticoagulation
• Avoid: – Active, recent bleeding evident – Baseline INR >2, APTT >60s, platelets
<60 • Relative contra-indications
– Less severe coagulopathy/thrombocytopaenia
– Surgery within 24 h
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Summary
• Haemofiltration – convection • Haemodialysis – diffusion • Adjust dose (effluent rate) according
to patient’s needs, interuptions to treatment – Starting point 25 ml/kg/h
• Consider need for anticoagulation • Caution when starting CRRT in
haemodynamically unstable patients
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Outcome with IRRT vs CRRT (3)
Vinsonneau, S et al. Lancet 2006; 368: 379-‐385
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Choice of RRT • 1218 patients CRRT or IRRT for ARF • 54 ICUs in 23 countries. • Multivariable logistic regression
– choice of CRRT • Not independent predictor of
– hospital survival – dialysis-free hospital survival.
• But is predictor of dialysis independence at hospital discharge among survivors (OR: 3.333, 95% CI: 1.845 - 6.024, p<0.0001).
Uchino S et al Patient and kidney survival by dialysis modality in critically ill patients with acute kidney injury. Int J Artif Organs. 2007 Apr;30(4):281-92.
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0
.2
.4
.6
.8
1
0 20 40 60 80 100
IRRT
CRRT
days
Recovery from Dialysis Dependence- BEST Re
cove
ry fr
om d
ialy
sis
depe
nden
ce
Uchino S et al Patient and kidney survival by dialysis modality in critically ill patients with acute kidney injury. Int J Artif Organs. 2007 Apr;30(4):281-92.
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How much replacement and dialysate do you use?
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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
Sur
viva
l (%
)
Effects of different doses in CVVH on outcome of ARF - Ronco & Bellomo study. Lancet . july 00
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Conclusions:
• 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.
Effects of different doses in CVVH on outcome of ARF - Ronco & Bellomo study. Lancet . july 00
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High Volume 37 vs 70 ml/kg
Joannes-Boyau O et al High-volume versus standard-volume haemofiltration for septic shock patients with acute kidney injury (IVOIRE study): a multicentre randomized controlled trial Intensive Care Med (2013) 39:1535–1546
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• Blood Purification: It must work!!! • maybe, • possibly, • Unlikely, • No
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Never let evidence get in the way of a good opinion
• The fact that an opinion has been widely held is no evidence whatever that it is not utterly absurd; indeed in view of the silliness of the majority of mankind, a widespread belief is more likely to be foolish than sensible.
Bertrand Russell, Marriage and Morals (1929)
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Recommendation • Renal replacement therapy
– When • Acute renal Failure • Exogenous toxin removal (lithium) • Early may be better-Probably is !!!!
– Dose : • 35+ ml/kg/hr (averaged) • No evidence for high dose
– Mode : • Whatever works for you
– Frusemide is not a resuscitation fluid