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Continuous Renal Replacement Therapy PowerPoint Presentation

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Description : Continuous renal replacement therapy (CRRT) has become a mainstay therapy in the intensive care unit (ICU) and its utilization continues to increase in developed countries.

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Published on : Oct 13, 2023 | Views : 2712 | Downloads : 7

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CRRT in ICU: the right time, the right patient, the right team Damir Mihic Department of medical ICU, University hospital Osijek, Croatia
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Continuous renal replacement therapy (CRRT) has become a mainstay therapy in the intensive care unit (ICU) and its utilization continues to increase in developed countries. Srisawat N, Chakravarthi R. CRRT in developing world. Semin Dial. 2021 Nov;34(6):567-575.
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Over the last 40 years, acute renal replacement therapy (RRT) in the intensive care units (ICUs) has transitioned from the predominant use of intermittent hemodialysis (and the much less common use of peritoneal dialysis) to the almost exclusive use of continuous renal replacement therapy (CRRT). See E, Ronco C, Bellomo R. The future of continuous renal replacement therapy. Semin Dial. 2021 Nov;34(6):576-585.
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CAVHD: bridge between IHD and CRRT In 1982, the use of CAVH in Vicenza was extended for the first time to a neonate with the application of specific minifilters. Two years later, CAVH began to be used to treat septic patients, burn patients and patients after transplantation and cardiac surgery, even with regional citrate anticoagulation. Ronco, C. Continuous Renal Replacement Therapy: Forty-year Anniversary. Int. J. Artif. Organs 2017, 40, 257–264.
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AKI, CRRT and ICU Acute kidney injury (AKI) is a common complication in critically ill patients and is associated with substantial morbidity and risk of death. Approximately 5% to 10% of patients with AKI require renal replacement therapy (RRT) during their ICU stay, with mortality rates of 30% to 70%. CRRT is utilised for a haemodynamically unstable patient with AKI in an intensive care unit (ICU) setting due to its accurate volume control, steady acid-base and electrolyte correction and achievement of hemodynamic stability. Karkar A, Ronco C. Prescription of CRRT: a pathway to optimize therapy. Ann Intensive Care. 2020 Mar 6;10(1):32. Chertow G. M., Burdick E., Honour M. Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. Journal of the American Society of Nephrology. 2005;16(11):3365–3370.
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CRRT in ICU Hemodynamic stability Consistent fluid elimination Elimination of inflammatory mediators Better protection of cerebral perfusion Possibility of regional citrate anticoagulation Steady acid-base and electrolyte correction Macedo E, Mehta RL. Continuous Dialysis Therapies: Core Curriculum 2016. Am J Kidney Dis 2016; 68:645.
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CRRT is a more physiological method than IHD Macedo E, Mehta RL. Continuous Dialysis Therapies: Core Curriculum 2016. Am J Kidney Dis 2016; 68:645.
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Conventional indications for CRRT in ICU 1.1. Fluid overload resistant to diuretic therapy 1.2. Metabolic acidosis (pH < 7.15) refractory to medical management 1.3. Hyperkalaemia (K > 6.5 mEq/L) refractory to medical management 1.4. Uraemic symptoms or signs (encephalopathy, pericarditis and bleeding diathesis) Other important indications for RRT 1.5. Poisoning with a dialyzable drug or toxin 1.6. Hyperthermia refractory to regular cooling techniques 1.7. Life-threatening electrolyte derangements in the setting of acute kidney injury 1.8. Progressive azotaemia or oliguria unresponsive to medical management Wang AY, Bellomo R. Renal replacement therapy in the ICU. Curr Opin Crit Care. 2018 Dec;24(6):437-442.
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Unconventional indications for CRRT in ICU 2.1. Sepsis and septic shock 2.2. Acute pancreatitis 2.3. Haert failure 2.4. Acute respiratory distress syndrome 2.5. Liver failure Extracorporeal blood purification and organ suport Wang AY, Bellomo R. Renal replacement therapy in the ICU. Curr Opin Crit Care. 2018 Dec;24(6):437-442.
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Extracorporeal Blood Purification beyond AKI in Sepsis It is widely believed that CRRT removes, or alters the production of, inflammatory mediators and thereby might restore immune homeostasis Adsorption of inflammatory mediators onto the surface of haemofilters plays a complementary role to simple convection in this process It must be noted that haemofiltration may cause the removal of both proinflammatory and anti-inflammatory cytokines High cut off (HCO) membranes and high effluent flow rate have been combined with CRRT for cytokine removal in septic patients Haemoperfusion therapy has been considered in septic shock to reduce inflammatory mediators and improve haemodynamic stability
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CRRT database in Croatia
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CRRT in Heart Failure The UNLOAD trial compared the safety and efficacy of early ultrafiltration (UF) versus standard diuretic therapy in patients presenting with decompensated heart failure (HF) Early UF produced greater fluid and weight loss at 48 hrs with reduced rehospitalization, number of hospital days, and unscheduled clinic visits at 90-day follow-up In light of the above results recommendations of American College of Cardiology (ACC) is that UF is a reasonable therapeutic modality in refractory heart failure not responding to medical management Felker G. M., Mentz R. J. Diuretics and ultrafiltration in acute decompensated heart failure. Journal of the American College of Cardiology. 2012;59(24):2145–2153. doi: 10.1016/j.jacc.2011.10.910.
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CRRT in Acute Respiratory Distress Syndrome The FACCT trial demonstrated that a conservative fluid management strategy was associated with a reduction in mechanical ventilation and RRT requirement A post hoc analysis of the same trial showed a decrease in AKI incidence with a conservative fluid strategy A few small studies have shown reduced ventilatory requirements and improvement in oxygenation with use of CRRT in ARDS A small study of 53 patients showed the benefit of initiating CRRT within 12 hrs of developing ARDS compared to after 48 hrs Han F., Sun R., Ni Y., et al. Early initiation of continuous renal replacement therapy improves clinical outcomes in patients with acute respiratory distress syndrome. American Journal of the Medical Sciences. 2015;349(3):199–205.
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CRRT in Liver Failure Small studies using CRRT techniques in the management of hepatic failure showed benefit in patients with acute-on-chronic hepatic failure, hepatorenal syndrome and even fulminant hepatic failure In the absence of more robust evidence to confirm these findings, no recommendation can be given to support their routine use in clinical practice There is no evidence to suggest that CRRT increases long-term survival in HRS without liver transplantation CRRT should only be utilised if a reversible element to liver failure exists or the patient is listed for liver transplantation Allegretti A. S., Parada X. V., Eneanya N. D., et al. Prognosis of patients with cirrhosis and AKI who initiate RRT. Clinical Journal of the American Society of Nephrology. 2018;13(1):16–25.
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Timing of CRRT The timing of initiating RRT in critically ill patients with AKI, in the absence of absolute indications, is challenging There is a general trend to initiate RRT before a patient develops absolute indications in the ICU setting This trend is mostly driven by observational data suggesting that relatively earlier initiation of RRT is associated with decreased mortality Bagshaw S. M., Wald R., Barton J., et al. Clinical factors associated with initiation of renal replacement therapy in critically ill patients with acute kidney injury-a prospective multicenter observational study. Journal of Critical Care. 2012;27(3):268–275.
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Early versus Delayed CRRT strategy: a comparison of ELAIN, AKIKI, and IDEAL-ICU studies Ahmed, Adeel Rafi et al. “Renal Replacement Therapy in the Critical Care Setting.” Critical care research and practice vol. 2019 6948710.
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Non-ICU and ICU patients Based on limited evidence, the timing of initiating of CRRT it should individual based on age, cardiovascular risk factors, pulmonary comorbidities, baseline renal function and the trend of inflammatory and renal injury markers A delayed strategy of waiting for 48–72 hrs after progressing to AKI KDIGO 3 or until an absolute indication which arises may be applicable to most non ICU patients ICU patients with low physiological reserve and AKI may benefit from “early CRRT” before absolute indications develop, especially fluid overload Jamale T. E., Hase N. K., Kulkarni M., et al. Earlier-start versus usual-start dialysis in patients with community-acquired acute kidney injury: a randomized controlled trial. American Journal of Kidney Diseases. 2013;62(6):1116–1121.
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Furosemide stress test (FST) Furosemide stress test (FST) can be used in euvolemic patients with acute tubular necrosis and no underlying CKD If bolus of furosemide 1–1.5 mg/kg producing less than 200 ml of urine output over 2 hr this reflects an increased risk for progression of AKI and RRT requirement Chawla L. S., Davison D. L., Brasha-Mitchell E., et al. Development and standardization of a furosemide stress test to predict the severity of acute kidney injury. Critical Care. 2013;17(5):p. R207.
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17th Acute Disease Quality Initiative (ADQI) consensus on patient selection and timing of CRRT (2016) Acute CRRT should be considered when metabolic and fluid demands exceed total kidney capacity and are recommended in situations where shifts in fluid balance and metabolic fluctuations are poorly tolerated Once the decision to initiate CRRT has been made, the therapy should be started as soon as possible, typically within less than 3 h In situations where other extracorporeal therapies are required, CRRT is recommended and integrated systems are preferred over parallel systems CRRT should be discontinued if kidney function has recovered sufficiently to reduce the demand-capacity imbalance (to determine sustained recovery of kidney function, we recommend monitoring of urine output and SCr) Ostermann M., Joannidis M., Pani A., et al. Patient selection and timing of continuous renal replacement therapy. Blood Purification. 2016;42(3):224–237.
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Optimal Dosing of CRRT The dialysis dose is the flow rate of the effluent, based on the patient's weight and calculated according to the formula:
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The RENAL study The RENAL study, to date, is the most comprehensive work on the subject of CRRT dosing 1508 patients were randomly assigned to high-intensity treatment (40 ml/kg/hr) or lower intensity treatment (25 ml/kg/hr) Mode of CRRT was CVVHDF in both groups Higher intensity of CRRT did not reduce the mortality at 90 days and the rate of dialysis dependence or improve haemodynamic profile but was associated with significantly higher rates of hypophosphatemia Bellomo R., Bellomo R., Cass A, et al. Intensity of continuous renal-replacement therapy in critically ill patients. New England Journal of Medicine. 2009;361(17):1627–1638.
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The problem of hypophosphatemia was solved by the use of appropriate replacement solutions.
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In order to achieve a "delivered dose" of 20-25 ml/kg/h it is necessary to increase the prescription to 25-30 ml/kg/h
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CRRT: the right team Who should treat AKI in critically ill people? Who indicates CRRT? Intensivist or nephrologist?
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Question? The questions as to which treatment is the most effective for the replacement of renal function in critically ill patients with acute renal failure and the qualifications needed by nurses to manage the continuous renal replacement therapy (CRRT) device are part of an ongoing debate between nephrologists and intensivists, between nurses of the renal ward and the ICU. De Becker W. Starting up a continuous renal replacement therapy program on ICU. Contrib Nephrol. 2007;156:185-90.
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True answer: The keys to a successful CRRT program are a well-balanced and practical education program (intensivist or nephrologist), a user-friendly dialysis machine, and technical support 24 h/day. De Becker W. Starting up a continuous renal replacement therapy program on ICU. Contrib Nephrol. 2007;156:185-90.
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The role of the specialized team in the operation of continuous renal replacement therapy: a single-center experience This retrospective single-center study evaluated AKI patients who underwent CRRT in the intensive care unit (ICU) from March 2011 to February 2015 in Denmark. Patients were divided into two groups based on whether they received specialized CRRT team intervention. This study shows that specialized CRRT team intervention reduced CRRT initiation time, down-time and in-hospital mortality. This study could serve as a logical basis for implementing specialized CRRT teams hospital-wide. Rhee H, Jang GS, Han M, et al. The role of the specialized team in the operation of continuous renal replacement therapy: a single-center experience. BMC Nephrol. 2017;18(1):332.
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Take home messages CRRT is the primary treatment for AKI in critically ill patients CRRT is increasingly used in other conditions in critically ill patients In critically ill patients, early is preferred over late CRRT A well-educated doctor and nurse make the right team in CRRT
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Thank you!