SLED vs CRRT: la scelta tra una Rolls ed una Ferrari

SLED vs CRRT: la scelta tra una Rolls ed una Ferrari Carlo Basile Associazione Nefrologica Gabriella Sebastio, Martina Franca

INTERMITTENT RENAL REPLACEMENT THERAPY (IRRT) • Intermittent HemoDialysis (IHD) • IntermittentHemoFiltration(IHF) • Sustained Low Efficiency Dialysis (SLED) • Extended Daily Dialysis (EDD)

INTERMITTENT RENAL REPLACEMENT THERAPY • Intermittent hemodialysis (IHD): standard bicarbonate dialysis (4h, 3 times a week) • Sustained low-efficiency dialysis (SLED): longer treatment (8-10 h, 6-7 times a week)

CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT) • Slow Continuous UltraFiltration(SCUF) • Continuous Venovenous or ArteroVenousHemoFiltration(CVVH/CAVH) • Continuous VenoVenous or ArteroVenous HemoDialysis (CVVHD/CAVHD) • Continuous VenoVenous or ArteroVenousHemoDiaFiltration(CVVHDF/CAVHDF)

Comparison of continuous replacement therapy (CRRT), intermittent hemodialysis ( IHD) and extended dialysis (ED) KIELSTEIN / SCHIFFER / HAFER J Nephrol 23:494-501, 2010

Continuous dialysis is not superior to intermittent dialysis in acute kidney injury of the critically ill patient Jonathan Himmelfarb Nature Clinical Practice Nephrology 2007; 3:120-121

Theoretical advantages of CRRT • Better correction of metabolic acidosis • Better recovery of renal function • Better removal of cytokines

Theoretical advantages of CRRT • Better correction of metabolic acidosis

SLED A randomized controlled study showed very clearly that a 12-h SLED session compared with a 24-h CRRT session (with 72 l of substitution fluid) allowed: • A faster correction of metabolic acidosis

Efficacy and cardiovascular tolerability of EDD incritically ill patients: a randomized controlled study KIELSTEIN et al. AJKD 43: 342-349, 2004

Theoretical advantages of CRRT • Better recovery of renal function

Cochrane database of systematic reviews 2007, issue 3 • 15 studies were identified (1550 patients) • Recovery of renal function: no difference between CRRT and intermittent strategies

Theoretical advantages of CRRT • Better removal of cytokines

CYTOKINES 1. Sieving coefficient of these mediators is very far from 1 2. The non-specific action of CRRT membranes allows the simultaneous removal also of anti-inflammatory cytokines 3. It is clear that a prevalently adsorbitive mechanism is responsible for cytokine removal (about 10 times higher than convection) • De Vriese AS, Colardyn FA, Philippe JJ, et al. Citokine removal during continuous hemofiltration in septic patients. J Am Soc Nephrol 10: 846 – 53, 1999

SLED A randomized controlled study showed very clearly that a 12-h SLED session compared with a 24-h CRRT session (with 72 l of substitution fluid) allowed: • A significantly lower heparin dose: (8.761 + 1.179 vs 17.149 + 3.034 U, p < 0.01)

Heparin needs are lower with SLED than with CRRT Heparin, UI/day Kumar VA et al, Am J Kidney Dis 2000; 32:396-400

2007 Higher risk of clotting filters in CRRT vs IHD (15 studies; 1550 patients; RR 8.50)

…we recommend starting continuous haemofiltration early, at 2 l per hRONCO et al. Lancet 365: 26-30, 2000 20 x 4.5 Liters = 90 Liters

A microbiological survey of bicarbonate-based replacement circuits in CVVHMOORE et al. Crit Care Med. 37(2):754-5, 2009

Biofilm in bicarbonate-based replacement fluid circuits in CVVH KANAGASUNDARAM et al. Kidney Int. 76: 682, 2009

HEMODYNAMIC STABILITY Several retrospective studies reported a lower incidence of hypotension with CRRT compared to IHD. However, 6 randomized controlled studies were unable to show this difference • Misset B, Timsit JF, Chevret S, et al. A randomized cross-over comparison of the hemodynamic response to intermittent hemodialysis and continuous hemofiltration in ICU patients with acute renal failure. Intensive Care Med 22: 742 – 6, 1996 • Augustine JJ, Sandy D, Seifert TH, et al. A randomised controlled trial comparing intermittent with continuous dialysis in patients with ARF. Am J Kidney Dis 44: 1000 – 7, 2004 • John S, Griesbach D, Baumgartel M, et al. Effects of continuous hemofiltration vs intermittent haemodialysis on systemic haemodynamics and spanchnic regional perfusion in septic shock patients: a prospective, randomized clinical trial. Nephrol Dial Transplant 16: 320 – 7, 2001 • Vinsonneau C, Camus C, Combes A, et al. Continuous venovenous hemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trial. Lancet 368: 379 – 85, 2006 • Uehlinger DE, Jakob SM, Ferrari P, et al. Comparison of continuous and intermittent renal replacement therapy for acute renal failure. Nephrol Dial Transplant 2005; 20: 1630–7. • Gasparović V, Filipović-Grcić I, Merkler M, Pisl Z. Continuous renal replacement therapy (CRRT) or intermittent hemodialysis (IHD) – what is the procedure of choice in critically ill patients? Renal Fail 2003; 25: 855–62.

Cochrane database of systematic reviews 2007, issue 3 • 15 studies were identified (1550 patients) • Cardiovascular stability: • no difference between CRRT and intermittent strategies as far as hemodynamic instability, hypotension and the administration of vasoactive drugs are concerned

SLED A randomized controlled study showed very clearly that a 12-h SLED session compared with a 24-h CRRT session (with 72 l of substitution fluid) allowed: • A quite similar cardiovascular stability

Efficacy and cardiovascular tolerability of EDD incritically ill patients: a randomized controlled studyKIELSTEIN et al. AJKD 43: 342-349, 2004 Norepinephrine dose at 0 h EDD 0.47 ± 0.11 CVVH 0.47 ± 0.14 μg/kg/min Norepinephrine dose at 12 h EDD 0.45 ± 0.12 CVVH 0.42 ± 0.13 μg/kg/min UF volume EDD 2.97± 0.55 L/12h CVVH 3.28 ± 0.39 L/24 h

Extended daily dialysis: a new approachto renal replacement for ARF in the ICU KUMAR et al AJKD 36: 294-300, 2000

Net fluid removal: SLED vs CVVH ml/day Kumar VA et al, Am J Kidney Dis 2000; 32:396-400

MORTALITY Several retrospective studies reported a better survival of CRRT compared with IHD. However, 10 randomized controlled studies • Misset B et al. A randomized cross-over comparison of the hemodynamic response to intermittent hemodialysis and continuous hemofiltration in ICU patients with acute renal failure. Intensive Care Med 1996; 22: 742–6. • John S et al. Effects of continuous hemofiltration vs intermittent haemodialysis on systemic haemodynamics and splanchnic regional perfusion in septic shock patients: a prospective, randomized clinical trial. Nephrol Dial Transplant 2001; 16: 320–7. • Augustine JJ et al. A randomised controlled trial comparing intermittent with continuous dialysis in patients with ARF. Am J Kidney Dis 2004; 44: 1000–7. • Vinsonneau C et al; Hemodiafe Study Group. Continuous venovenous hemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trial. Lancet 2006; 368: 379–85. • Mehta RL et al; Collaborative Group for Treatment of ARF in the ICU. A randomized clinical trial of continuous versus intermittent dialysis for acute renal failure. Kidney Int 2001; 60: 1154–63. • Uehlinger DE et al. Comparison of continuous and intermittent renal replacement therapy for acute renal failure. Nephrol Dial Transplant 2005; 20: 1630–7. • VA/NIH Acute Renal Failure Trial Network, Palevsky PM, Zhang JH, O'Connor TZ, et al. Intensity of renal support in critically ill patients with acute kidney injury. NEJM 2008; 359: 7–20. • Lins RL et al; SHARF investigators. Intermittent versus continuous renal replacement therapy for acute kidney injury patients admitted to the intensive care unit: results of a randomized clinical trial. Nephrol Dial Transplant 2009; 24: 512–8. • Gasparović V et al. Continuous renal replacement therapy (CRRT) or intermittent hemodialysis (IHD) – what is the procedure of choice in critically ill patients? Renal Fail 2003; 25: 855–62. • Schwenger V et al.Sustained low efficiency dialysis using a single-pass batch system in acute kidney injury - a randomized interventional trial: the REnal Replacement Therapy Study in Intensive Care Unit PatiEnts. Crit Care 2012; 16: R140

Vinsonneau C et al; Hemodiafe Study Group: a multicentre randomised trial Lancet 2006; 368: 379–85 • Slide 16

MORTALITY 4 systematic reviews • Tonelli M, Manns B, Feller-Koppman D. Acute renal failure in the intensive care unit: a systematic review of the impact of dialytic modality on mortality and renal recovery. Am J Kidney Dis 40: 875 – 85, 2002 • Rabindranath K, MacLeod AM, Muirhead N. Intermittent versus continuous renal replacement therapy for acute renal failure in adultsCochrane database of systematic reviews 2007, issue 3 • Ghahramani N, Shadrou S, Hollenbeak C. A systematic review of continuous renal replacement therapy and intermittent haemodialysis in management of patients with acute renal failure. Nephrology (Carlton) 2008 Jun 1 [Epub ahead of print] • Pannu N, Klarenbach S, Wiebe N, Manns B, Tonelli M; Alberta Kidney Disease Network. Renal replacement therapy in patients with acute renal failure: a systematic review. JAMA 2008; 299: 793 – 805

Cochrane database of systematic reviews 2007, issue 3 15 studies were identified (1550 patients) Mortality: no difference between CRRT and intermittent strategies as far as in-hospital mortality and ICU mortality are concerned

Pannu N, Klarenbach S, Wiebe N, Manns B, Tonelli M; Alberta Kidney Disease Network

MORTALITY 3 meta-analyses • Kellum J et al. Continuous versus intermittent renal replacement therapy: a meta-analysis. Intensive Care Med 28: 29 – 37, 2002 • Bagshaw SM et al. Continuous versus intermittent renal replacement therapy for critically ill patients with acute kidney injury: A meta-analysis. Crit Care Med 36: 610 – 7, 2008 • Zhang L et al. Extended daily dialysis versus continuous renal replacement therapy for acute kidney injury: A meta-analysis. Am J Kidney Dis 66: 322 - 30, 2015

SLED vs CRRT: la scelta tra una Rolls ed una Ferrari