Can We Achieve Precision Solute Control with CRRT?

Transcription

1 Can We Achieve Precision Solute Control with CRRT? Claudio Ronco, M.D. David Selewski, M.D. Rolando Claure-Del Granado, M.D. AKI & CRRT Conference February, 2019

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

3 Outline Prescribe before starting RRT Precision fluid management Precision solute control & quality measures Conclusions

4 Case A 56 year old man with Chagas disease arrives to ER complaining of muscle weakness, disnea, and oliguria. Weight 52 Kg BP 90/54 mmhg SaO2 86% with pulmonary congestion K 7.8, HCO3 17, BUN 126, scr 5.4 (baseline 1.4), Hto 30%, INR 4.5 UO ( less than 2 cups past 24 hours) Medications: Losartan 50 mg day, Carvedilol 3,125 mg c/12 hours, spironolactone 50 mg day, warfarin 5 mg alt. 2.5 mg. RRT prescription?

5 Outline Prescribe before starting RRT Precision fluid management Precision solute control & quality measures Conclusions

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

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

8 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.

9 1 2 3 Davenport and Farrington Lancet; 2010

10 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

11 IHD Session length: 3 hours Dialyzer: Acute Dialysis solution with K 0 mmol/l Temperature 35 C Qb 300 ml/min Qd 500 ml/min UF: Hemodialysis International doi.org/ /hdi.12195

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13 Outline Prescribe before starting RRT Precision fluid management Precision solute control & quality measures Conclusions

14 KDIGO Clinical Practical Guideline for Acute Kidney Injury Fluid control Separate dimension of dose Prescription strategies Fixed rate net ultrafiltration Integrated with overall fluid balance Inadequate achievement of ultrafiltration targets Machine/circuit related Reductions in UF in response to hypotensive episodes Kidney Int suppl 2:89-115; 2012

15 618 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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20 Claure-Del Granado R and Mehta RL. Sem Dialysis; 2011

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23 Bioelectrical impedance vector analysis

24 Bioelectrical impedance vector analysis Amount of UF = 23.7L 17.9L = 5.8 L

25 Outline Prescribe before starting RRT Precision fluid management Precision solute control & quality measures Conclusions

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

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

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29 Post-dilutional CVVH K = [effluent flow rate] Q e *(C e /C b ) Post-dilutional CVVH: Q b 200 ml/min.; Hto 30% Q ef l/h No anticoagulation Prescribed dose K urea = 1500 ml/h * 126/126 = 1500 ml/h = 25 ml/min. (28.8 ml/kg/hr) Efficiency = K (clearance)

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31 Post-dilutional CVVH >20 hours (filter clotted) K = [effluent flow rate] Q e *(C e /C b ) Post-dilutional CVVH: Q b 200 ml/min.; Hto 30% Q ef l/h BUN 85 mg/dl FUN 60 mg/dl K urea = 1500 ml/h * 60/85 (0.7) = 1050 ml/h = 17.5 ml/min. (20 ml/kg/hr) FUN/BUN < 0.8 P/D dose ratio < 0.8 (0.67) 20 hours

32 Post-dilutional CVVH K = [effluent flow rate] Q e *(C e /C b ) Post-dilutional CVVH: Q b 200 ml/min.; Hto 30% Q eff l/h BUN 85 mg/dl FUN 60 mg/dl K urea = 1500 ml/h * 60/85 = 1050 ml/h = 17.5 ml/min. (20 ml/kg/hr) Filtration fraction: Q eff /Q p Q p = Q b ml/hr *(1-Hto) Filter clotting FF=25% FF = 1500 / (12000 * (1-0.30)) = 0.18 (18%) Prevent clotting: Increase Q b Use pre-dilution Anticoagulation

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34 Reasons why delivered dose may be less than prescribed dose Treatment interruptions Diagnostic/Therapeutic procedures Alarms Catheter dysfunction Clotting Process of care Delays in starting the treatment Delays in responding to alarms Delays in restarting the treatment after interruptions Incorrect machine settings

35 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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38 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

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

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

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

42 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

43 Pre-dilution CVVH Q b 200 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 * (12000/( )) = 1620 ml/h Prescribed = 2000 ml/h = 38 ml/kg/hr Delivered = 27 ml/min 31 ml/kg/hr Pre-dilution CVVH FF: 2000 / [(12000(1-0.3)) ] 0.19 (19%) FUN/BUN > 0.8 P/D dose ratio > 0.8 (0.82) 20 hours

44 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 INR 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

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46 Dose Mode Machine automatically calculates replacement (pre/post) and/or dialysate flows Cumulative dose value is display and updated continuously

47 23 treatments Net treatment duration 92.37% P/D 0.91 (26.3 & 24.1 ml/kg/h) CVVH 16h01 ; CVVHD 19h32 ; CVVHDF 25h39 No FUN/BUN Mean down time 7.63%

48 Outline Prescribe before starting RRT Precision fluid management Precision solute control & quality measures Conclusions

49 Dosing in RRT for AKI: Practical considerations Use CRRT and IHD as complementary therapies in AKI patients. An effluent flow of at least ml/kg per hour 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. CRRT allows flexibility to tailor the fluids administered or removed to the individual needs. Fluid removal and fluid balance are equally if not more important parameters to be monitored, we should aim to prevent fluid overload.

50 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