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
Disclosures I have no actual or potential conflict of interest in relation to this presentation.
Outline Prescribe before starting RRT Precision RRT and solute control Precision fluid management Factors that affect achieving a prescribed dose: Quality measures Conclusions
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, warfarin5 mg alt. 2.5 mg. RRT prescription?
KDIGO Clinical Practical Guideline for Acute Kidney Injury Kidney Int suppl 2:89-115; 2012
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.
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 Quality measures Measured solute clearance Delivered/prescribed dose ratio Effective treatment time Circuit and filter pressures trends Bioimpedance Evaluate outcomes Achievement of desired clearance, acid-base balance, volume control, etc. Patient clinical status
1 2 3 Davenport and Farrington Lancet; 2010
KDIGO Clinical Practical Guideline for Acute Kidney Injury Kidney Int suppl 2:89-115; 2012
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: 0 Hemodialysis International doi.org/10.1111/hdi.12195
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
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
KDIGO Clinical Practical Guideline for Acute Kidney Injury Kidney Int suppl 2:89-115; 2012
Delivered RRT dose and survival Kellum JA and Ronco C Nature Reviews Nephrology; 2010
Post-dilutional CVVH K = [effluent flow rate] Q e *(C e /C b ) Post-dilutionalCVVH: Q b 200 ml/min.; Hto 30% Q ef 1.500 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)
Post-dilutional CVVH 20 hours (filter clotted) K = [effluent flow rate] Q e *(C e /C b ) Post-dilutionalCVVH: Q b 200 ml/min.; Hto 30% Q ef 1.500 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
Post-dilutional CVVH K = [effluent flow rate] Q e *(C e /C b ) Post-dilutionalCVVH: Q b 200 ml/min.; Hto 30% Q eff 1.500 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
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
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
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
Reasons for Discontinuing CRRT and Filter efficacy Claure-Del Granado et al. CJASN, 2011
Jaffrin MY. Art Organs, 1995. Claure-Del Granado R and Mehta RL. Sem Dialysis; 2011
Claure-Del Granado et al. Hemodial Int 18: 641-9; 2014.
Type of anticoagulant Median (IQR) Filter Life in Hours Citrate vs. Heparin, p < 0.001 Citrate vs. no anticoagulant, p < 0.001 Heparin vs. no anticoagulant, p = 0.012 Citrate 48 (20.3-75.0) Heparin 15.9 (8.5-27.0) 6.1 (4.4 8.1) 8.1 (5.9 10.4) 7.4 (5.4 9.8) No anticoagulant 17.5 (9.5 to 32) p value < 0.0001 Claure-Del Granado et al Hemodialysis Int, 2014
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
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/(12000 + 2000)) = 1620 ml/h Prescribed = 2000 ml/h = 38 ml/kg/hr Delivered = 27 ml/min à 31 ml/kg/hr Pre-dilution CVVH FF: 2000 / [(12000(1-0.3)) + 2000] 0.19 à (19%) FUN/BUN > 0.8 P/D dose ratio > 0.8 (0.82) 20 hours
Proposed parameters for Dose Assessment Claure-Del Granado R and Mehta RL. Sem Dialysis; 2011
Bioelectrical impedance vector analysis
Dosing in RRT for AKI: Practical considerations Use CRRT and IHD as complementary therapies in AKI patients. An effluent flow of at least 20-25 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 25-30 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.
Spock s Advice on Dialysis in AKI Glenn Chertow AKI&CRRT 2017 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)