Extracorporális szervpótlás helyzete az intenzív betegellátásban

Extracorporális szervpótlás helyzeteExtracorporális szervpótlás helyzeteaz intenzív betegellátásbanaz intenzív betegellátásban

11Debreceni Egyetem OEC Belgyógyászati Intézet Nephrologiai Tanszék,FMC Extracorporalis Szervpótló Centrum, Debrecen

22Debreceni Egyetem OEC Aneszteziológiai és Intenzív Terápiás tanszék, Debrecen

Prof. Dr. Fülesdi BélaProf. Dr. Fülesdi Béla22

tanszékvezető egyetemi tanártanszékvezető egyetemi tanár

Prof. Dr. Balla JózsefProf. Dr. Balla József11

Acute Kidney Injury – Renal Replacement Therapies

József Balla & Béla Fülesdi

University of DebrecenHungary

Medical and Health Scince CenterUniversity of Debrecen

AKI (221) – RRT (112) Hybrid form

IHD (39) SLED (5) CRRT (72)

CVVHDF (31) + CRRT (41)

HD (15) + HDF (25) CVVHD (29) + CVVH (12)

CVVHD-LMWH/Hirudin (17/3) + CVVHD-

CiCa (9)

Alternate (27), Daily (9), Extended (3)

Renal Replacement TherapiesUniversity of Debrecen

Medical and Health Science Center; March, 2013

CVVH, HVHF, CVVHD, CVVHDF SLED

Németh Csilla Palotai Ilona

„Prometheus”

The shift of terminology from ARF to AKI has been well received by the research and clinical communities

AKI as defined by the RIFLE criteria is now recognized as an important syndrome

AKI: Acute Kidney Injury/Impairment

Kidney Disease: Improving Global Outcomes (KDIGO), 2012

Acute Kidney Injury (AKI )

Renal Replacement Therapies (RRT) Intermittent (IHD) Continuous (CRRT) Slow Low Efficiancy Dialysis (SLED)

Akut vesekárosodás (AVK)

Vesepótló kezelés

Intermittáló Folyamatos vesepótló kezelés Alacsony hatékonyságú

elnyújtott, tartós


Definition - Stage 1 (RIFLE-Risk)Serum creatinine increased 1.5-1.9 times baseline (known or presumed to have occurred within the prior 7 days)or

Serum creatinine increase > 26.5 μmol/l (within 48 hours)

Urine volume < 0.5 ml/kg/h for 6-12 hours


Hemodialysis

Hemofiltration

AKI – RRTModality of renal replacement therapy for patients with AKI

Use continuous and intermittent RRT as complementary

therapies in AKI patients. (Not Graded)


Modality of renal replacement therapyfor patients with AKI

We suggest using CRRT, rather than standard intermittent RRT, for hemodynamically unstable patients (2B).

In non-septic AKI, 20-25 ml/kg/h remains optimal.

We suggest using CRRT, rather than intermittent RRT, for AKI patients with acute brain injury or other causes of increased intracranial pressure or generalized brain edema. (2B).

In non-septic AKI, 20-25 ml/kg/h remains optimal.



Until the IVOIRE trial becomes available, septic AKI should be treated by continuous veno-venous hemofiltration at 35 ml/kg/h.

Honoré PM, Jacobs R, Boer W, Joannes-Boyau O, De Regt J, De Waele E, Van Gorp V, Collin V, Spapen HD.New insights regarding rationale, therapeutic target and dose of hemofiltration and hybrid therapies in septic acute kidney injury. Blood Purif.2012;33:44-51CVVHD-CiCa: BW = 70 kg, 24 x 2,4L = 35 ml/kg/h

The optimal timing of RRT for AKI is not defined



Maintaining fluid homeostasis

Fluid overload in critical illness and AKI is associated with adverse outcomes.

Payen D, de Pont AC, Sakr Y, et al. A positive fluid balance is associated with a worse outcome in patients with acute renal failure. Crit Care 2008;12: R74.

Foland JA, Fortenberry JD, Warshaw BL, et al. Fluid overload before continuous hemofiltration and survival in critically ill children: a retrospective analysis. Crit Care Med 2004; 32: 1771–1776.

Gillespie RS, Seidel K, Symons JM. Effect of fluid overload and dose of replacement fluid on survival in hemofiltration. Pediatr Nephrol 2004; 19:1394–1399.

Goldstein SL, Currier H, Graf C, et al. Outcome in children receiving continuous venovenous hemofiltration. Pediatrics 2001; 107: 1309–1312.

Goldstein SL, Somers MJ, Baum MA, et al. Pediatric patients with multiorgan dysfunction syndrome receiving continuous renal replacement therapy. Kidney Int 2005; 67: 653–658.

Hayes LW, Oster RA, Tofil NM, et al. Outcomes of critically ill children requiring continuous renal replacement therapy. J Crit Care 2009; 24:394–400.

Sutherland SM, Zappitelli M, Alexander SR, et al. Fluid overload and mortality in children receiving continuous renal replacement therapy:the prospective pediatric continuous renal replacement therapy registry.Am J Kidney Dis 2010; 55: 316–325.

Wiedemann HP, Wheeler AP, Bernard GR, et al. Comparison of two fluidmanagement strategies in acute lung injury. N Engl J Med 2006; 354:2564–2575.

Patients dialyzed for control of both azotemia and volume overload experienced the worst outcome.









Mehta RL, McDonald B, Pahl M, et al. Continuous vs. intermittent dialysis for acute renal failure in the ICU: Results from a randomized multicenter trial (abstract). J Am Soc Nephrol 1996; 7: 1456.


Underlying disease

When to start RRT Type and severity of the underlying disease ANCA vasculitis

Brockmann et al: Proteinase-3 as the major autoantigen of c-ANCA is strongly expressed in lung tissue of patients with Wegener's granulomatosis. Arthritis Res. 2002;4(3):220-5.

Observational studies: Single-center observational studies that were restricted to AKI after trauma

(HD) and coronary artery bypass surgery (CVVHDF, CVVH)

early starters - BUN 15 mM, late starters - BUN 33 mM early starters – urine output is less than 100 mL/8 hours

time between the operation and the initiation

Conclusion: Suggested a benefit (survival ) to RRT initiation at early start (at lower BUN concentrations)

Timing of initiation of RRT on outcome

Gettings LG, Intensive Care Med 1999; 25: 805–813., Demirkilic U, J Card Surg 2004; 19: 17–20.Elahi MM, Eur J Cardiothorac Surg 2004; 26: 1027–1031.

early vs. late initiation

Observational studies: A prospective multicenter observational cohort study

Program to Improve Care in Acute Renal Disease (PICARD)

243 patients, adjusted for age, hepatic failure, sepsis, thrombocytopenia, and SCr

Conclusion: initiation of RRT at higher BUN [blood urea > 27.1 mmol/l]was associated with an increased risk of death (RR 1.85; 95%CI 1.16–2.96)


Liu KD, et al. Timing of initiation of dialysis in critically ill patients with acute kidney injury. Clin J Am Soc Nephrol 2006; 1:915–919.


Late initiation of renal replacement therapy is associated with worse outcomes in acute kidney injury after major abdominal surgery.

Shiao CC, et al. Crit Care 2009; 13: R171.

Underscore the importance of predicting prognoses of major abdominal surgical patientswith AKI by using RIFLE classification

indications for RRT

Timing of renal replacement therapy initiation in acute renal failure: a meta-analysis

Meta-analysis of randomized trials, early RRT was associated with a nonsignificant 36% mortality risk reduction (RR, 0.64; 95% confidence interval, 0.40 to 1.05; P = 0.08)

In cohort studies, early RRT was associated with a statistically significant 28% mortality risk reduction (RR, 0.72; 95% confidence interval, 0.64 to 0.82; P < 0.001).

Seabra VF, Balk EM, Liangos O, Sosa MA, Cendoroglo M, Jaber BL. Am J Kidney Dis. 2008;52:272–284





Urea > 36 mM




Urea > 36 mMPotesium > 6 mM

pH < 7.15etc.

Initiate RRT emergently when

Life-threatening changes in fluid electrolyte acid-base balance uremic complications: pericarditis, pleuritis, encephalopathy,

coagulopathy

The optimal timing of dialysis for AKI= Indications for RRT


RENÁLIS INDIKÁCIÓ Nonobstruktív oliguria (vizelet kiválasztás < 200 mL/12 h) vagy anuria Progresszív azotemia, még klinikai jelek nélkül (vér urea > 36 mmol/L) Hyperkalaemia, gyógyszeres terápiára refrakter (plazma K+ > 6,0 mmol/L, vagy gyorsan emelkedik) Metabolikus acidózis, szérum pH ≤ 7,15 (gyógyszeres terápiára refrakter) Urémiás szervi tünetek megléte: encephalopathia, myopathia, pericarditis, urémiás diathesises vérzés Progresszív súlyos hyper/hyponatraemia (Na+ > 160 vagy < 115 mmol/L) Folyadékretenció, diuretikum rezisztens szervoedema (pl. tüdőoedema) AKI meglétével NON RENÁLIS INDIKÁCIÓ Mérgezés dialzálható ágenssel (gyógyszer, méreg) Hyperthermia (mag hőmérséklet > 39,5 °C) Nagy mennyiségű vérkészítmény igény coagulopathiában, amelynek során fennáll a tüdőoedema/ ARDS veszélye

Medical and Health Science CenterUniversity of Debrecen

Hungary

Thank you

The treatment of AKI with RRT has the following goals

to maintain fluid and electrolyte, acid-base, and solute homeostasis

to prevent further insults to the kidney to permit renal recovery; and iv) to allow other

supportive measures (e.g., antibiotics, nutrition support)


Only one RCT has evaluated the effect of timing of initiation of RRT on outcome



Bouman et al. Effects of early high-volume continuous venovenous hemofiltration on survival and recovery of renal function in intensive care patients with acute renal failure: a prospective, randomized trial Randomized 106 critically ill patients with AKI to early vs. late initiation of RRT The early initiation group started RRT within 12 hours oliguria (30 ml/h for 6

hours, not responding to diuretics or hemodynamic optimization) or CrCl < 20 ml/minThe late-initiation group started RRT when classic indications were met

Conclusion: did not find differences in ICU or hospital mortality, or in renal recovery among survivors


Bouman CS, Oudemans-Van Straaten HM, Tijssen JG, Zandstra DF, Kesecioglu J. Crit Care Med 2002; 30: 2205–2211.Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands


Observational studies: in the 1960 s and 1970 s

(Conger JD. J Trauma 1975; 15: 1056–1063, Fischer RP. Surg Gynecol Obstet 1966; 123: 1019–1023, Kleinknecht D. Kidney Int 1972; 1: 190–196) blood urea or BUN were used to distinguish early vs. late start of dialysis. However, these studies mostly combined early start with more-intensive dialysis and late start with less-intensive dialysis.

Not conclusive

Timing of initiation of RRT on outcomeearly vs. late initiation

Observational studies: A prospective multicenter observational study

(54 ICUs in 23 countries)Stratified into ‘‘early’’ or ‘‘late’’ by median urea at the time RRT started (24.2 mmol/l)

Also categorized temporally from ICU admission into early (less than 2days), delayed (between 2–5 days), or late (more than 5 days).

Conclusion: - timing by serum urea showed a tendency but no significant difference in mortality

- in relation to ICU admission, late RRT was associated with greater crude mortality


Bagshaw SM, et al. Timing of renal replacement therapy and clinical outcomes in critically ill patients with severe acute kidney injury. J Crit Care 2009; 24: 129–140.


Observational studies: A prospective multicenter observational study

Major abdominal surgery AKI

early or late start of renal replacement therapy defined by simplified RIFLE early start: sRIFLE-0 or Risk; late start: sRIFLE -Injury or Failure


Shiao CC, et al. Late initiation of renal replacement therapy is associated with worse outcomes in acute kidney injury after major abdominal surgery. Crit Care 2009; 13: R171.


Timing of renal replacement therapy initiation in acute renal failure: a meta-analysis

Meta-analysis suggests that early initiation of RRT in patients with ARF might be associated with improved survival.

calling for an adequately powered randomized controlled trial to address this question

Seabra VF, Balk EM, Liangos O, Sosa MA, Cendoroglo M, Jaber BL. Am J Kidney Dis. 2008;52:272–284

Patients receiving RRT predominantly for solute control experienced better outcomes than those predominantly treated for volume overload.










Analysis of a multicenter observational cohort showed that mean daily fluid balance in AKI patients was significantly more positive among nonsurvivors than survivors.


Survivors had lower fluid accumulation at dialysis initiation compared to nonsurvivors (8.8% vs. 14.2% of baseline body weight; P=0.01 adjusted for dialysis modality and severity score).

PICARD: Liu KD, et al. Timing of initiation of dialysis in critically ill patients with acute kidney injury. Clin J Am Soc Nephrol 2006; 1:915–919.


Indications for RRT

Massive volume overload resulting from volume resuscitation may be an indication for RRT even in the absence of significant elevations in BUN or SCr. – not RRT but renal support

fluid homeostasis


We suggest using CRRT, rather than standard intermittent RRT, for hemodynamically unstable patients (2B).

In non-septic AKI, 25 ml/kg/h remains optimal.

We suggest using CRRT, rather than intermittent RRT, for AKI patients with acute brain injury or other causes of increased intracranial pressure or generalized brain edema. (2B).

In non-septic AKI, 25 ml/kg/h remains optimal.



Stage 2 (RIFLE-Injury)

Serum creatinine increased 2.0-2.9 times baseline

Urine volume < 0.5 ml/kg/h for more than 12 hours


Stage 3 (RIFLE-Failure)Serum creatinine increased > 3.0 times baselineor Serum creatinine > 354 μmol/l with an abrupt rise of at least 44 mmol/lorInitiation of renal replacement therapy

Urine volume < 0.3 ml/kg/h for more than 24 hoursoranuria for more than 12 hours



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Extracorporális szervpótlás helyzete az intenzív betegellátásban