continuous renal-replacement therapy crrt
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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 - PowerPoint PPT PresentationTRANSCRIPT
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Continuous Renal-Replacement TherapyCRRT
Kianoush Kashani
5th Anesthesia and Critical Care ConferenceKuwait 2013
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RRT indications (traditional)
Gibney et al. cJASN 3: 876-880, 2008.
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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
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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) • 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
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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• 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 Access Return
UFFlow
Replacement fluid
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CVVH -postdilution
• Higher clearance
• ↑ chance of clotting Access Return
UFFlow
Replacement fluid
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Effect of filtration on CVVH
Hematocrit30%
Hematocrit60%
Maintain filtration fraction at 25%
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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%
1. Decrease Quf to 3000 ml/hour (50 ml/min)2. Increase Qb to 300 ml/min• FF = 50/200 X 100 = 25%• FF = 75/300 X 100 = 25%
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Anticoagulation: Options
• No Heparin protocols
• Heparin• Unfractionated • LMWH
• Citrate
• Others• Prostacyclin • Danaparoid • Hirudin/argatroban• Nafamostate mesylate
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No Heparin Systemically Heparinized
Gail Annich, University of Michigan
Citrate
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Citrate Vs. Heparin
Zhang et al. Intensive Care Med (2012) 38:20–28
Filter life span Risk of bleeding
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CRRT dosing
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Meta-analysisMortality
Jun et al. Clin J Am Soc Nephrol 5: 956–963, 2010.
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Meta-analysisRenal 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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شكر ا
“The best interest of the patient is the only interest to be considered”
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Questions & Discussion