CRRT for the Experience User 1. Claudio Ronco, M.D. David Selewski, M.D. Rolando Claure-Del Granado, M.D. AKI & CRRT Conference March, 2018

Transcription

1 CRRT for the Experience User 1 Claudio Ronco, M.D. David Selewski, M.D. Rolando Claure-Del Granado, M.D. AKI & CRRT Conference March, 2018

2 Disclosures I have no actual or potential conflict of interest in relation to this presentation.

3 Outline Prescribe before starting RRT Precision RRT and solute control Factors that affect achieving a prescribed dose: Quality measures Dose is not only urea clearance Conclusions

4 Case A 69 year old man develops AKI after undergoing a total hip replacement surgery. Nephrology is consulted 3 days later for evaluation of RRT. Weight 52 Kg BP 90/54 on dopamine drip SaO2 96% on 2L NC, no pulmonary congestion K 6.1, HCO3 17, BUN 85, scr 5.4, Hto 30% UO 0.1 ml/kg/h (last 8 hours) He had a positive cumulative fluid balance of 4.7 liters. RRT orders: CVVH post filter, Qb 100 ml/min, Qr 1000 ml/hr, no anticoagulation

5 Outline Prescribe before starting RRT Precision RRT and solute control Factors that affect achieving a prescribed dose: Quality measures Not only urea Conclusions

6 KDIGO Clinical Practical Guideline for Acute Kidney Injury Kidney Int suppl 2:89-115; 2012

7 Survey Survey of 26 of questions 26 questions 7 questions 7 questions for IHD for IHD and and SLED SLED that that included: included: - target - target dosage dosage of therapy of therapy - whether - whether and and how how frequently frequently delivered delivered dose was dose asses was asses 9 questions 9 questions for CRRT for CRRT - characterized - characterized dose dose ml/h ml/h vs. ml/kg/h vs. ml/kg/h - no -target no target dosage dosage or assessment or assessment of of delivered delivered dose dose was was evaluate. evaluate. Only Only 21% 21% of practitioners of practitioners assessed assessed delivered delivered dialysis dialysis dose dose (IHD). (IHD). < 20% < 20% of practitioners of practitioners reported reported using using weight-based weight-based dosing dosing of CRRT. of CRRT. Absence Absence of a of consistent a consistent standard standard for for prescription prescription and and monitoring monitoring of RRT of RRT during during AKI. AKI.

8 KDIGO Clinical Practical Guideline for Acute Kidney Injury Kidney Int suppl 2:89-115; 2012

9 Dialysis Dose-Outcome trials and dose measurements Bouchard J et al. Am J Kidney Dis; 2010.

10 Delivered RRT dose and survival Kellum JA and Ronco C Nature Reviews Nephrology; 2010

11 Post-dilutional CVVH K = [effluent flow rate] Q e *(C e /C b ) Post-dilutional CVVH: Q b 100 ml/min.; Hto 30% Q ef l/h BUN 110 mg/dl FUN 110 mg/dl K urea = 1000 ml/h * 110/110 = 1000 ml/h = 17 ml/min. (19 ml/kg/hr)

12 Post-dilutional CVVH Prescribed dose K urea = 1000 ml/h * 110/110 = 1000 ml/h = 17 ml/min. (19 ml/kg/hr) Efficiency = K (clearance) Measuring delivered dose Intensity = efficiency x time Blood volume cleared after a certain period of time (ml/kg) Intensity = 19 ml x 24 h = 456 ml/kg

13 Outline Prescribe before starting RRT Precision RRT and solute control Factors that affect achieving a prescribed dose: Quality measures Not only urea Conclusions

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15 Prescribed dose RRT modality Blood flow Dialysis flow Replacement fluid flow Filter Time Ultra filtration Anticoagulation Vascular access Delivered dose Target solute control Target clearance control Target volume control Evaluate outcomes Achievement of desired clearance, acid-base balance, volume control, etc. Patient clinical status Quality measures Measured solute clearance Delivered/prescribed dose ratio Effective treatment time Circuit and filter pressures trends Bioimpedance

16 Outline Prescribe before starting RRT Precision RRT and solute control Factors that affect achieving a prescribed dose: Quality measures Not only urea Conclusions

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18 Post-dilutional CVVH 20 hours (filter clotted) K = [effluent flow rate] Q e *(C e /C b ) Post-dilutional CVVH: Q b 100 ml/min.; Hto 30% Q ef l/h BUN 90 mg/dl FUN 60 mg/dl K urea = 1000 ml/h * 60/90 (0.66) = 660 ml/h = 11 ml/min. (13 ml/kg/hr) FUN/BUN < 0.8 P/D dose ratio < 0.8 (0.68) 20 hours Intensity = 13 ml x 20 h = 380 ml/kg 456 ml/kg

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20 Post-dilutional CVVH K = [effluent flow rate] Q e *(C e /C b ) Post-dilutional CVVH: Q b 100 ml/min.; Hto 30% Q eff l/h BUN 90 mg/dl FUN 60 mg/dl K urea = 1000 ml/h * 60/90 = 660 ml/h = 11 ml/min. (13 ml/kg/hr) Filtration fraction: Q eff /Q p Q p = Q b ml/hr *(1-Hto) Filter clotting FF=25% FF = 1000 / (6000 * (1-0.30)) = 0.24 (24%) Prevent clotting: Increase Q b Use pre-dilution Anticoagulation type

21 Factors Influencing RRT Clearance Patient factors Treatment factors

22 Treatment Related Factors Catheter Filter Time out of therapy

23 Treatment Related Factors Catheter Filter Time out of therapy

24 Pre-dilution CVVHDF Filter 0.9 m 2 AN69 Anticoagulation LMW Heparin Filter change each 72 hrs. or if clotted Randomized -15 patients (46 treatments) PNT catheter -15 patients (46 treatments) ST catheter Prescribed and delivered clearance was assessed No difference in Qb No difference in recirculation rate ST catheters less catheter related thrombosis and infection Klouche K et al. Am J Kidney Dis, 2007

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27 Treatment Related Factors Catheter Filter Time out of therapy

28 Treatment Related Factors Catheter Filter Down time due to filter clotting is the major reason for reduced RRT dose Concentration polarization reduces ultrafiltration rate and the filtrate concentrations of several medium / large sized proteins Convection Diffusion interactions Time out of therapy

29 Data from 52 critically ill patients, AKI requiring dialysis (Pre-dilution CVVHDF) Regional citrate anticoagulation. Filter efficacy was assessed by calculating FUN/BUN ratios q12 hr. Prescribed urea clearance (K, ml/min) - Effluent volume rate = Qd (ml/min) + Qr (ml/min) + Qnet (ml/min) K Estimated = Effluent volume adjusted for effective time of treatment. K delivered = FUN (mg/dl)/bun (mg/dl)] x effluent volume rate (ml/min) Claure-Del Granado et al. CJASN, 2011

30 Reasons for Discontinuing CRRT and Filter efficacy Claure-Del Granado et al. CJASN, 2011

31 Delivered CRRT Dose Based on Effluent Collection Claure-Del Granado et al, Clin J Am Soc Nephrol 2011 Conclusion: Measured effluent volume normalized for effective treatment time significantly overestimates delivered dose of small solutes in CRRT. To achieve a prescribed dialysis dose, effluent-based dose should be increased by 20-25%* to account for decreases in treatment time and reduced filter efficacy during CRRT.

32 Jaffrin MY. Art Organs, Claure-Del Granado R and Mehta RL. Sem Dialysis; 2011

33 Claure-Del Granado et al. Hemodial Int 18: 641-9; 2014.

34 Type of anticoagulant Median (IQR) Filter Life in Hours Citrate vs. Heparin, p < Citrate vs. no anticoagulant, p < Heparin vs. no anticoagulant, p = Citrate 48 ( ) Heparin 15.9 ( ) 6.1 ( ) 8.1 ( ) 7.4 ( ) No anticoagulant 17.5 (9.5 to 32) p value < Claure-Del Granado et al Hemodialysis Int, 2014

35 Anticoagulation UFH No heparin after mayor surgery, epidural procedures (24 48 h.) Prime circuit with 5000 UI (1st bolus) Second bolus like shown on table UFH infusion 10,000 UI en 1000 ml = 10 UI/ml Label as just for CRRT use Add the volume of heparin to the final amount of UF Pre-filter administration Lab control at 6 h, then each 12 h. UFH NIR TTPa Platelets 70 UI*kg 10 UI Kg/h 35 UI*Kg 5 UI Kg/h <1.5 <40 s >150 >1.5 - < 2.5 > 40 s <150 - >60 No bolus >2.5 >60 s <60

36 Pre-dilution CVVH Q b 100 ml/min.; Hto 30% Q r pre 2000 ml/hr Started on anticoagulation Dilution factor: Q b /(Q b +Q r ) Pre-dilution CVVH K = Q eff * (C e /C b )* [Q b /(Q b + Q r )] K = 2000 ml/h * 0.95 * (6000/( )) = 1425 ml/h Prescribed = 1500 ml/h = 29 ml/kg/hr Delivered = 23 ml/min 27 ml/kg/hr Pre-dilution CVVH FF: 1000 / [(6000(1-0.3)) ] 0.19 (19%) FUN/BUN > 0.8 P/D dose ratio > 0.8 (0.93) 20 hours

37 Outline Prescribe before starting RRT Precision RRT and solute control Factors that affect achieving a prescribed dose: Quality measures Dose is not only urea clearance Conclusions

38 Urea as the only marker of RRT dose? The marker solute (urea) cannot and does not represent all the solutes that accumulate in AKI. Its kinetics and volume of distribution are also different from those of the solutes of interest. Its removal during RRT is not representative of the removal of other solutes. The use of a single marker molecule to define treatment adequacy should be abandoned. Adequacy should be a broader term that includes several aspects of treatment.

39 Davenport and Farrington Lancet; 2010

40 618 patients enrolled in a prospective multicenter observational study (PICARD). Fluid overload was defined as more than a 10% increase in body weight relative to baseline. ( daily (fluid intake (L) total output (L))/body weight (in kilograms)) x100. Dialyzed patients, survivors had significantly lower fluid accumulation when dialysis was initiated compared to non-survivors after adjustments for dialysis modality and severity score. Non-dialyzed patients, survivors had significantly less fluid accumulation at the peak of their serum creatinine. Bouchard et al. Kidney Int; 2009

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42 Proposed parameters for Dose Assessment Claure-Del Granado R and Mehta RL. Sem Dialysis; 2011

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44 Dosing in RRT for AKI: Practical considerations An effluent flow of at least ml/kg per hour and a Kt/V of 3.9 per week could be sufficient, so long as there is careful attention to ensuring that the target dose of therapy is actually delivered. In order to ensure delivery of the target dose, a prescription of ml/kg per hour and a Kt/V of per week may be needed. Solute Clearances are not the sole measure of dialysis adequacy. Fluid removal and fluid balance are equally if not more important parameters to be monitored.

45 Spock s Advice on Dialysis in AKI Allow clinical trials and clinical practice guidelines to inform, not define practice. Think logically Don t allow emotions alter decision-making Listen to humanoids (patients) Glenn Chertow AKI&CRRT 2017