Continuous Renal-Replacement Therapy CRRT Kianoush Kashani 5

Continuous Renal-Replacement Therapy
CRRT
Kianoush Kashani
5th Anesthesia and Critical Care Conference
Kuwait 2013
©2011 MFMER | slide-1
RRT indications (traditional)
Gibney et al. cJASN 3: 876-880, 2008.
©2011 MFMER | slide-2
RRT
• Support pt and effects of complications from MOF
• Improve metabolic milieu for
• Increasing survival
• Recovery of multiple organ systems
• Volume overload without oligoanuria or azotemia
• CHF
• Postoperative
• Withhold RRT
• If return of renal function is likely
• Conservative management likely to succeed
©2011 MFMER | slide-3
MultiOrgan Support Therapy (MOST)
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Heart
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MOST: Cardiac Support
• Uncontrolled studies
•  improve myocardial elastance with HF and
adequate fluid balance
• UNLOAD Trial (Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart
failure)
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•
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•
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RCT, multicenter, (N=200) excluded sCR > 3 mg/dL
Improved 48-hours weight loss
↓ re-hospitalization rates and ED visits at 90 days
↑ diuretic responsiveness
No change in mortality, CHF class and QOL
Costanzo et al. J Am Coll Cardiol 49:675–683, 2007
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Liver
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Liver extracorporeal support therapies
• Non-cell based
• RRT (IRRT, CRRT, SLED)
• Hemoperfusion, hemoabsorption
• Plasma exchange
• Plasmaphoresis, Plasma filtration absorption,
Selective plasma filtration technology (SEPET)
• Albumin based
• Molecular adsorbent recirculating system (MARS)
• Single pass albumin dialysis (SPAD)
• Cell-based  synthetic function
• Human hepatocytes
• Porcine hepatocytes
Cerda et al. Seminars in Dialysis—Vol 24, No 2 2011. 197–202
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Cell-based Liver
• Purposes
• Detoxification
• Provide synthetic
• Provide regulatory functions
• Cell sources
• Primary porcine hepatocytes
• Immunologic reactions
• Immortalized human cells
• Rare source
• Loose their liver function by time
• Cells derived from hepatic tumors
• Fear of tumorgenicity
• Small single-center phase I and II trials
• Proof of principle
Cerda et al. Seminars in Dialysis—Vol 24, No 2 2011. 197–202
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Sepsis
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Systemic Inflammatory Response Syndrome (SIRS) Vs.
Compensatory Anti-inflammatory Response Syndrome (CARS)
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Sepsis management - MOST
• HVHF
• High cut-off hemofilters
• Hemoadsorption
• Non-specific
• Charcoal
• Resin
• Plasma filtration coupled with adsorption (CPFA)
• Improved MAP
• Decrease the need for norepinephrine
Grootendorst et al.J Crit Care 1992;7:67–75.
Bellomo et al: Intensive CareMed 29:1222–1228, 2003
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HICOSS trial (High Cut-Off Sepsis study)
• N = 120
• Septic shock with AKI
• Conventional membrane vs. HCO membrane (cut-off
of 60 kD)
• 5 days on CVVHD
• Stopped prematurely after 81 patients
• No difference in 28-day mortality (31% vs. 33%)
• No difference in vasopressor need, MV, or LOS
• No difference in albumin levels
Honore et al. Proc 10th WFSCICCM,Florence, Italy, 2009.
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Sepsis management - MOST
• Specific
• Polymyxin B
• EUPHAS trial (single center_Italy)
• Improve MAP/vasopressor use
• ↑PaO2 ⁄FIO2
• ↓Mortality and SOFA
• EUPHRATES trial (multicenter_US)
Cruz et al. JAMA. 2009;301(23):2445-2452
Ding et al. ASAIO Journal 2011; 57:426
– 432.
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Lung
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Respiratory support
• Refractory ARDS
• TV decreased from 6ml/kg to
4 ml/kg
Terragni et al. Anesthesiology 2009; 111:826–35
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RRT modalities
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Modalities of RRT
• Hemodyalisis
• IRRT
• CRRT
• Peritoneal dialysis
• Transplant
©2011 MFMER | slide-18
RRT modality and mortality
Bagshaw et al. Crit Care Med 2008 Vol. 36, No. 2
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Renal recovery
• Evidence for CRRT benefit on renal recovery
• Strong physiologic rationale
• Observational studies
• Epidemiologic studies (n=3000)
• No benefit found in RCTs
• All RCTs have significant limitations
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Cost
• Mayo Clinic study
• N= 161, retrospective observational study
• Mean adjusted total costs through hospital
discharge
• $93 611 for IHD
• $140,733 for CRRT (P< .001).
Rauf et al. J Intensive Care Med. 2008 May-Jun;23(3):195-203.
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Anticoagulation
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Case
• 65 yo ♀ with PMH of ESLD, DM, HTN
• Presented with sepsis, DIC, AKI
• Started on CVVH for AKI stage III
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Qb 200 ml/min
RF 4500 ml/h
Citrate 300 ml/h
22 mEq/L Bicarbonate Prismasate® bath
• Her dialyzer clots every four hours
What to do?
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CVVH -predilution
• Partial loss of delivered RF
by HF
• ↓ need for anticoagulation
Replacement fluid
Access
Flow
Return
UF
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CVVH -postdilution
• Higher clearance
• ↑ chance of clotting
Replacement fluid
Access
Flow
Return
UF
©2011 MFMER | slide-25
Effect of filtration on CVVH
Hematocrit
60%
Hematocrit
30%
Maintain filtration fraction at 25%
©2011 MFMER | slide-26
Case
Filtration fraction = [Quf (ml/min) / Qb (ml/min)] X 100
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•
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Quf = 4500 ml/hour = 4500/60 = 75 ml/min
Qb = 200 ml/min
Current FF = (75/200) X 100 = 37.5%
1.
2.
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Decrease Quf to 3000 ml/hour (50 ml/min)
Increase Qb to 300 ml/min
 FF = 50/200 X 100 = 25%
 FF = 75/300 X 100 = 25%
©2011 MFMER | slide-27
Anticoagulation: Options
• No Heparin protocols
• Heparin
• Unfractionated
• LMWH
• Citrate
• Others
• Prostacyclin
• Danaparoid
• Hirudin/argatroban
• Nafamostate mesylate
©2011 MFMER | slide-28
No Heparin
Systemically Heparinized
Citrate
Gail Annich, University of Michigan
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Citrate Vs. Heparin
Filter life span
Risk of bleeding
Zhang et al. Intensive Care Med (2012) 38:20–28
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CRRT dosing
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Meta-analysis
Mortality
Jun et al. Clin J Am Soc Nephrol 5: 956–963, 2010.
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Meta-analysis
Renal recovery
Jun et al. Clin J Am Soc Nephrol 5: 956–963, 2010.
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CRRT Timing
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Early versus late RRT
(Mortality)
Karvellas et al. Critical Care 2011, 15:R72
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Early versus late RRT
(Mortality)
Karvellas et al. Critical Care 2011, 15:R72
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Early versus late RRT
(RRT independence)
Karvellas et al. Critical Care 2011, 15:R72
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‫شكرا‬
“The best interest of the patient is the only interest to be considered”
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Questions & Discussion
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