CRRT ICU Fellowship Training Radboudumc
Timing RRT Consider the following: Underlying cause and reversibility. Rapid improvement unlikely with high dose vasopressors and continuous exposure to other risk factors for AKI Urine production in relation to intake and fluid balance Consequences of fluid overload (oxygenation) Degree of metabolic derangement and subsequent consequences Adverse effects of RRT
Timing of RRT and outcome N = 106 - MV - Inotropic agents 28-D mortality (%) 40 30 20 10 0 Start 7 uur 48.2 ml/kg/hr P = 0.80 P = 0.25 Start 7 uur 20.1 ml/kg/hr Start 42 uur 19.0 ml/kg/hr Early HV Early LV Late LV Median duration AKI survivors (D) 8 6 4 2 0 Early HV Early LV Late LV N = 35 N = 35 N = 36 > 50% of patients after cardiac surgery Bouman CS. Crit Care Med 2002;30:2205-2211
Timing of RRT N = 648, postoperative AKI - observational Corrected for multiple risk factors Shiao CC. PLOSOne 2012;7:e42952
Early versus late RRT (Early < 24 hours after AKI III) N = 150 80 Early P = 0.001 Late 77,9 60 % 40 51,5 20 0 Mortality Lower duration of MV and RRT Leite TT. Crit Care 2013;17:R62
Bagshaw SM. Crit Care 2009;13:317
Dutch guideline Start RRT immediately in case of life threatening AKI associated symptoms in fluid balance, acidbase balance or electrolytes Consider RRT if despite optimization of the circulation AKI persists and the patients suffers from persistent metabolic derangements or diuretic resistent fluid overload
Dutch guideline Do not start RRT with mild metabolic derangements that are likely temporary or when treatment appears to be futile
Hemofiltration
Hemodialysis
Dutch guideline Intermittent hemodialysis is a good alternative for the stable patient Friedrich JO. Crit Care 2012;16:R146
RCT SLED vs CVVH N = 232 12 hrs SLED lower costs Better metabolic control, MV - 3D, ICU LOS - 4D Schwenger V. Crit Care 2012;16:R140
CONVINT trial N = 252 - Single centre prospective RCT Daily IHD vs CVVH IHD CVVH 100 75 % 50 60,5 56,1 25 0 Mortality 14 D after stop RRT No differences in LOS -days on RRT - MV duration Schefold JC. Crit Care 2014;18:R11
RRT dose Does should be sufficient to remove uremic toxins and correct metabolic acidosis Higher dose may be needed during hypermetabolism but side effects increase Filter down-time often 20-25% Pre dilution decreases dose (correct: BF + UF / BF)
Critically ill Age 18 Acute Kidney Injury CVVHDF Blood flow > 150 ml/min 40 ml/kg/hr 25 ml/kg/hr N = 721 N = 743 No baseline differences 50 Low dose High dose Mortality (%) 40 30 20 10 0 44,7 44,7 36,9 38,5 90 D mortality 28 D mortality 0 46,2% 47,6% 1 35,4% 35,2% 2 14,7% 13,9% 3 3,4% 3,2% 4 0,4% 0,1% Number non-renal organ failure (%) No difference in need RRT in survivors at D 28 and day 90 RENAL Replacement Therapy Study Investigators. N Engl J Med 2009;361:1627-1638
RRT - dose Study Year N Low dose High dose Survival LD Survival HD Ronco 2000 435 20 ml/kg/hr 35 ml/kg/hr 41% 57% Bouman 2002 106 19 ml/kg/hr 48 ml/kg/hr 72% 74% Saudan 2006 206 25 ml/kg/hr 42 ml/kg/hr 39% 59% Tolwani 2008 200 20 ml/kg/hr 35 ml/kg/hr 56% 49% VA/NIH trial 2008 1124 20 (IHD/ SLED) 35 (IHD/ SLED) 48% 46% Renal study 2009 1508 25 ml/kg/hr 40 ml/kg/hr 55% 55% Survival Dose dependent region Inflection point Dose independent region Hypotension Electrolyte disorders Micro-nutrient depletion Hypothermia Changes in acid-base status Error in drugs RRT dose Schiffl H. Int Urol Nephrol 2010;42:435-440
Dutch guideline CRRT: effluent dosis (filtrate + dialysate) 20-25 ml/ kg/hr with compensation for: filter down-time pre dilution No indication for high-volume CVVH
Citrate versus LMWH for CVVH N = 200 LMWH Citrate 70 P < 0.001 P = 0.02 P = 0.03 P = 0.02 52,5 35 17,5 0 Discontinuation Renal recovery Hospital mortality 3 M mortality No improvement in need for transfusion or circuit survival time Oudemans-van Straaten HM. Crit Care Med 2009;37:545-552
The three citrate trials
CRRT-citrate and elevated T/ I Ca 2+ ratio Prospective observational - N = 208 - need for CRRT (citrate) Independent predictor of 28 D mortality Associated with hepatic failure or MODS Indirect marker of systemic citrate accumulation Necessity to increase citrate clearance Link A. Crit Care 2012;16:R97
Link A. Crit Care 2012;16:R97
Link A. Crit Care 2012;16:R97
Link A. Crit Care 2012;16:R97
Argatroban therapy 100 μg/kg bolus i.v. 1 μg/kg/min continuously aptt (2-3 fold elevated) Dosage adaption In critically ill patients maintenance 0.2 μg/kg/min Link A. Crit Care Med 2009;37:105-110
N = 30 Link A. Crit Care Med 2009;37:105-110
Vaara ST. Acta Anaesthesiol Scand 2012;56:1175-1182 Is there a volume effect with CRRT All ICU s in Finland 18/year 28/year 54/year