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Continuous Renal-Replacement Therapy CRRT

Continuous Renal-Replacement Therapy CRRT. Kianoush Kashani. 5 th Anesthesia and Critical Care Conference Kuwait 2013. RRT indications (traditional). Gibney et al. cJASN 3: 876-880, 2008. RRT. Support pt and effects of complications from MOF Improve metabolic milieu for

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Continuous Renal-Replacement Therapy CRRT

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  1. Continuous Renal-Replacement TherapyCRRT Kianoush Kashani 5th Anesthesia and Critical Care Conference Kuwait 2013

  2. RRT indications (traditional) Gibney et al. cJASN3: 876-880, 2008.

  3. 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

  4. MultiOrgan Support Therapy (MOST)

  5. Heart

  6. 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) 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

  7. Liver

  8. 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

  9. 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

  10. Sepsis

  11. Systemic Inflammatory Response Syndrome (SIRS) Vs. Compensatory Anti-inflammatory Response Syndrome (CARS)

  12. 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.JCrit Care 1992;7:67–75. Bellomo et al: Intensive CareMed 29:1222–1228, 2003

  13. 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 Honoreet al. Proc 10th WFSCICCM,Florence, Italy, 2009.

  14. 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.

  15. Lung

  16. Respiratory support Refractory ARDS TV decreased from 6ml/kg to 4 ml/kg Terragni et al. Anesthesiology 2009; 111:826–35

  17. RRT modalities

  18. Modalities of RRT Hemodyalisis IRRT CRRT Peritoneal dialysis Transplant

  19. RRT modality and mortality Bagshaw et al. Crit Care Med 2008 Vol. 36, No. 2

  20. 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

  21. 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.

  22. Anticoagulation

  23. Case 65 yo ♀ with PMH of ESLD, DM, HTN Presented with sepsis, DIC, AKI Started on CVVH for AKI stage III 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?

  24. CVVH -predilution Partial loss of delivered RF by HF ↓ need for anticoagulation Replacement fluid Access Return UF Flow

  25. CVVH -postdilution Higher clearance ↑ chance of clotting Replacement fluid Access Return UF Flow

  26. Effect of filtration on CVVH Hematocrit 60% Hematocrit 30% Maintain filtration fraction at 25%

  27. Case Filtration fraction = [Quf(ml/min) / Qb (ml/min)] X 100 Quf = 4500 ml/hour = 4500/60 = 75 ml/min Qb = 200 ml/min Current FF = (75/200) X 100 = 37.5% 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%

  28. Anticoagulation: Options No Heparin protocols Heparin Unfractionated LMWH Citrate Others Prostacyclin Danaparoid Hirudin/argatroban Nafamostate mesylate

  29. No Heparin Systemically Heparinized Citrate Gail Annich, University of Michigan

  30. Citrate Vs. Heparin Filter life span Risk of bleeding Zhang et al. Intensive Care Med (2012) 38:20–28

  31. CRRT dosing

  32. Meta-analysisMortality Jun et al. Clin J Am SocNephrol5: 956–963, 2010.

  33. Meta-analysisRenal recovery Jun et al. Clin J Am SocNephrol5: 956–963, 2010.

  34. CRRT Timing

  35. Early versus late RRT (Mortality) Karvellas et al. Critical Care 2011, 15:R72

  36. Early versus late RRT (Mortality) Karvellas et al. Critical Care 2011, 15:R72

  37. Early versus late RRT (RRT independence) Karvellas et al. Critical Care 2011, 15:R72

  38. شكراً “The best interest of the patient is the only interest to be considered”

  39. Questions & Discussion

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