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Extracorporális szervpótlás helyzete az intenzív betegellátásban

Extracorporális szervpótlás helyzete az intenzív betegellátásban. Prof. Dr. Balla József 1. Prof. Dr. Fülesdi Béla 2. tanszékvezető egyetemi tanár. tanszékvezető egyetemi tanár. 1 Debreceni Egyetem OEC Belgyógyászati Intézet Nephrologiai Tanszék,

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Extracorporális szervpótlás helyzete az intenzív betegellátásban

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  1. Extracorporálisszervpótláshelyzete azintenzívbetegellátásban Prof. Dr. Balla József1 Prof. Dr. Fülesdi Béla2 tanszékvezető egyetemi tanár tanszékvezető egyetemi tanár 1Debreceni Egyetem OEC Belgyógyászati Intézet Nephrologiai Tanszék, FMC Extracorporalis Szervpótló Centrum, Debrecen 2Debreceni Egyetem OEC Aneszteziológiai és Intenzív Terápiás tanszék, Debrecen

  2. Acute Kidney Injury– Renal Replacement Therapies József Balla & Béla Fülesdi University of Debrecen Hungary

  3. Medical and Health Scince CenterUniversity of Debrecen

  4. Renal Replacement TherapiesUniversity of Debrecen AKI (221) – RRT (112) Hybridform IHD(39)SLED (5)CRRT (72) CVVHDF(31) + CRRT (41) HD (15)+ HDF (25)CVVHD (29) + CVVH (12) CVVHD-LMWH/Hirudin(17/3) + CVVHD-CiCa (9) Alternate (27), Daily (9), Extended (3) Medical and Health Science Center; March, 2013

  5. SLED CVVH, HVHF, CVVHD, CVVHDF

  6. „Prometheus” Németh Csilla Palotai Ilona

  7. AKI: Acute Kidney Injury/Impairment • The shift of terminology from ARF to AKI has been well received by the research and clinical communities • AKI as defined by the RIFLE criteria is now recognized as an important syndrome Kidney Disease: Improving Global Outcomes (KDIGO), 2012

  8. Acute Kidney Injury (AKI ) Renal Replacement Therapies (RRT) Intermittent (IHD) Continuous (CRRT) Slow Low Efficiancy Dialysis (SLED) Akut vesekárosodás (AVK) Vesepótló kezelés Intermittáló Folyamatos vesepótló kezelés Alacsony hatékonyságú elnyújtott, tartós

  9. AKI: Acute Kidney Injury/Impairment • Definition - Stage 1 (RIFLE-Risk) Serum creatinine increased 1.5-1.9 times baseline (known or presumed to have occurred within the prior 7 days) or Serum creatinine increase >26.5 μmol/l (within 48 hours) Urine volume <0.5 ml/kg/h for 6-12 hours Kidney Disease: Improving Global Outcomes (KDIGO), 2012

  10. Hemodialysis

  11. Hemofiltration

  12. AKI – RRT Modality of renal replacement therapy for patients with AKI • Use continuous and intermittent RRT as complementary • therapies in AKI patients. (Not Graded) Kidney Disease: Improving Global Outcomes (KDIGO), 2012

  13. Modality of renal replacement therapyfor patients with AKI • We suggest using CRRT, rather than standard intermittent RRT, for hemodynamically unstable patients (2B). In non-septic AKI, 20-25 ml/kg/h remains optimal. • We suggest using CRRT, rather than intermittent RRT, for AKI patients with acute brain injury or other causes of increased intracranial pressure or generalized brain edema. (2B). In non-septic AKI, 20-25 ml/kg/h remains optimal. Kidney Disease: Improving Global Outcomes (KDIGO), 2012

  14. AKI – RRT Modality of renal replacement therapy for patients with AKI • Until the IVOIRE trial becomes available, septic AKI should betreated by continuous veno-venous hemofiltration at 35 ml/kg/h. Honoré PM, Jacobs R, Boer W, Joannes-Boyau O, De Regt J, De Waele E, Van Gorp V, Collin V, Spapen HD. New insights regarding rationale, therapeutic target and dose of hemofiltration and hybrid therapies in septic acute kidney injury. Blood Purif. 2012;33:44-51 CVVHD-CiCa: BW = 70 kg, 24 x 2,4L = 35 ml/kg/h

  15. AKI: Acute Kidney Injury/Impairment The optimal timing of RRT for AKI is not defined Kidney Disease: Improving Global Outcomes (KDIGO), 2012

  16. Maintaining fluid homeostasis • Fluid overload in critical illness and AKI is associated with adverse outcomes. • Payen D, de Pont AC, Sakr Y, et al. A positive fluid balance is associated with a worse outcome in patients with acute renal failure. Crit Care 2008;12: R74. • Foland JA, Fortenberry JD, Warshaw BL, et al. Fluid overload before continuous hemofiltration and survival in critically ill children: a retrospective analysis. Crit Care Med 2004; 32: 1771–1776. • Gillespie RS, Seidel K, Symons JM. Effect of fluid overload and dose of replacement fluid on survival in hemofiltration. Pediatr Nephrol 2004; 19:1394–1399. • Goldstein SL, Currier H, Graf C, et al. Outcome in children receiving continuous venovenous hemofiltration. Pediatrics 2001; 107: 1309–1312. • Goldstein SL, Somers MJ, Baum MA, et al. Pediatric patients with multiorgan dysfunction syndrome receiving continuous renal replacement therapy. Kidney Int 2005; 67: 653–658. • Hayes LW, Oster RA, Tofil NM, et al. Outcomes of critically ill children requiring continuous renal replacement therapy. J Crit Care 2009; 24:394–400. • Sutherland SM, Zappitelli M, Alexander SR, et al. Fluid overload and mortality in children receiving continuous renal replacement therapy:the prospective pediatric continuous renal replacement therapy registry.Am J Kidney Dis 2010; 55: 316–325. • Wiedemann HP, Wheeler AP, Bernard GR, et al. Comparison of two fluidmanagement strategies in acute lung injury. N Engl J Med 2006; 354:2564–2575.

  17. Maintaining fluid homeostasis • Patients dialyzed for control of both azotemia and volume overload experienced the worst outcome. • Payen D, de Pont AC, Sakr Y, et al. A positive fluid balance is associated with a worse outcome in patients with acute renal failure. Crit Care 2008;12: R74. • Foland JA, Fortenberry JD, Warshaw BL, et al. Fluid overload before continuous hemofiltration and survival in critically ill children: a retrospective analysis. Crit Care Med 2004; 32: 1771–1776. • Gillespie RS, Seidel K, Symons JM. Effect of fluid overload and dose of replacement fluid on survival in hemofiltration. Pediatr Nephrol 2004; 19:1394–1399. • Goldstein SL, Currier H, Graf C, et al. Outcome in children receiving continuous venovenous hemofiltration. Pediatrics 2001; 107: 1309–1312. • Goldstein SL, Somers MJ, Baum MA, et al. Pediatric patients with multiorgan dysfunction syndrome receiving continuous renal replacement therapy. Kidney Int 2005; 67: 653–658. • Hayes LW, Oster RA, Tofil NM, et al. Outcomes of critically ill children requiring continuous renal replacement therapy. J Crit Care 2009; 24:394–400. • Sutherland SM, Zappitelli M, Alexander SR, et al. Fluid overload and mortality in children receiving continuous renal replacement therapy:the prospective pediatric continuous renal replacement therapy registry.Am J Kidney Dis 2010; 55: 316–325. • Wiedemann HP, Wheeler AP, Bernard GR, et al. Comparison of two fluidmanagement strategies in acute lung injury. N Engl J Med 2006; 354:2564–2575. • Mehta RL, McDonald B, Pahl M, et al. Continuous vs. intermittent dialysis for acute renal failure in the ICU: Results from a randomized multicenter trial (abstract). J Am Soc Nephrol 1996; 7: 1456.

  18. Underlying disease • Whento start RRT • Type and severity of the underlying disease • ANCA vasculitis Brockmann et al: Proteinase-3 as the major autoantigen of c-ANCA is strongly expressed in lung tissue of patients with Wegener's granulomatosis. Arthritis Res. 2002;4(3):220-5.

  19. Timing of initiation of RRT on outcome early vs. late initiation • Observational studies: • Single-center observational studies that were restricted to AKI after trauma (HD) and coronary artery bypass surgery (CVVHDF, CVVH) early starters - BUN 15 mM, late starters - BUN 33 mM early starters – urine output is less than 100 mL/8 hours time between the operation and the initiation Conclusion: Suggested a benefit (survival ) to RRT initiation at early start (at lower BUN concentrations) Gettings LG, Intensive Care Med 1999; 25: 805–813., Demirkilic U, J Card Surg 2004; 19: 17–20. Elahi MM, Eur J Cardiothorac Surg 2004; 26: 1027–1031.

  20. Timing of initiation of RRT on outcome early vs. late initiation • Observational studies: • A prospective multicenter observational cohort study Program to Improve Care in Acute Renal Disease (PICARD) 243 patients, adjusted for age, hepatic failure, sepsis, thrombocytopenia, and SCr Conclusion: initiation of RRT at higher BUN [blood urea > 27.1 mmol/l] was associated with an increased risk of death (RR 1.85; 95% CI 1.16–2.96) • Liu KD, et al. Timing of initiation of dialysis in critically ill patients with acute kidney injury. • Clin J Am Soc Nephrol 2006; 1:915–919.

  21. Late initiation of renal replacement therapy is associated with worse outcomes in acute kidney injury after major abdominal surgery. Shiao CC, et al. Crit Care 2009; 13: R171. indications for RRT Underscore the importance of predicting prognoses of major abdominal surgical patients with AKI by using RIFLE classification

  22. Timing of renal replacement therapy initiation in acute renal failure: a meta-analysis early vs. late initiation • Meta-analysis of randomized trials, early RRT was associated with a nonsignificant 36% mortality risk reduction (RR, 0.64; 95% confidence interval, 0.40 to 1.05; P = 0.08) • In cohort studies, early RRT was associated with a statistically significant 28% mortality risk reduction (RR, 0.72; 95% confidence interval, 0.64 to 0.82; P < 0.001). Seabra VF, Balk EM, Liangos O, Sosa MA, Cendoroglo M, Jaber BL. Am J Kidney Dis. 2008;52:272–284

  23. The optimal timing of RRT for AKI is not defined AKI: Acute Kidney Injury/Impairment Urea > 36 mM Kidney Disease: Improving Global Outcomes (KDIGO), 2012

  24. The optimal timing of RRT for AKI is not defined AKI: Acute Kidney Injury/Impairment Urea > 36 mM Potesium> 6 mM pH < 7.15 etc. Kidney Disease: Improving Global Outcomes (KDIGO), 2012

  25. The optimal timing of dialysis for AKI=Indications for RRT • Initiate RRT emergently when • Life-threatening changes in fluid • electrolyte • acid-base balance • uremic complications: pericarditis, pleuritis, encephalopathy, coagulopathy Kidney Disease: Improving Global Outcomes (KDIGO), 2012

  26. Medical and Health Science Center University of Debrecen Hungary Thank you

  27. The treatment of AKI with RRT has the following goals • to maintain fluid and electrolyte, acid-base, and solute homeostasis • to prevent further insults to the kidney • to permit renal recovery; and iv) to allow other supportive measures (e.g., antibiotics, nutrition support) Kidney Disease: Improving Global Outcomes (KDIGO), 2012

  28. AKI: Acute Kidney Injury/Impairment Only one RCT has evaluated the effect of timing of initiation of RRT on outcome Kidney Disease: Improving Global Outcomes (KDIGO), 2012

  29. Timing of initiation of RRT on outcome early vs. late initiation • Bouman et al. Effects of early high-volume continuous venovenous hemofiltration on survival and recovery of renal function in intensive care patients with acute renal failure: a prospective, randomized trial • Randomized 106 critically ill patients with AKI to early vs. late initiation of RRT • The early initiation group started RRT within 12 hours oliguria (30 ml/h for 6 hours, not responding to diuretics or hemodynamic optimization) or CrCl <20 ml/min The late-initiation group started RRT when classic indications were met • Conclusion: did not find differences in ICU or hospital mortality, or in renal recovery among survivors Bouman CS, Oudemans-Van Straaten HM, Tijssen JG, Zandstra DF, Kesecioglu J. Crit Care Med 2002; 30: 2205–2211. Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands

  30. Timing of initiation of RRT on outcome early vs. late initiation • Observational studies: • in the 1960 s and 1970 s • (Conger JD. J Trauma 1975; 15: 1056–1063, Fischer RP. Surg Gynecol Obstet 1966; 123: 1019–1023, Kleinknecht D. Kidney Int 1972; 1: 190–196) blood urea or BUN were used to distinguish early vs. late start of dialysis. However, these studies mostly combined early start with more-intensive dialysis and late start with less-intensive dialysis. • Not conclusive

  31. Timing of initiation of RRT on outcome early vs. late initiation • Observational studies: • A prospective multicenter observational study (54 ICUs in 23 countries) Stratified into ‘‘early’’ or ‘‘late’’ by median urea at the time RRT started (24.2 mmol/l) Also categorized temporally from ICU admission into early (less than 2days), delayed (between 2–5 days), or late (more than 5 days). Conclusion: - timing by serum urea showed a tendency but no significant difference in mortality - in relation to ICU admission, late RRT was associated with greater crude mortality • Bagshaw SM, et al. Timing of renal replacement therapy and clinical outcomes in critically ill patients with severe acute kidney injury. J Crit Care 2009; 24: 129–140.

  32. Timing of initiation of RRT on outcome early vs. late initiation • Observational studies: • A prospective multicenter observational study Major abdominal surgery AKI early or late start of renal replacement therapy defined by simplified RIFLE early start: sRIFLE-0 or Risk;late start: sRIFLE -Injury or Failure • Shiao CC, et al. Late initiation of renal replacement therapy is associated with worse outcomes in acute kidney injury after major abdominal surgery. Crit Care 2009; 13: R171.

  33. Timing of renal replacement therapy initiation in acute renal failure: a meta-analysis • Meta-analysis suggests that early initiation of RRT in patients with ARF might be associated with improved survival. • calling for an adequately powered randomized controlled trial to address this question Seabra VF, Balk EM, Liangos O, Sosa MA, Cendoroglo M, Jaber BL. Am J Kidney Dis. 2008;52:272–284

  34. Maintaining fluid homeostasis • Patients receiving RRT predominantly for solute control experienced better outcomes than those predominantly treated for volume overload. • Payen D, de Pont AC, Sakr Y, et al. A positive fluid balance is associated with a worse outcome in patients with acute renal failure. Crit Care 2008;12: R74. • Foland JA, Fortenberry JD, Warshaw BL, et al. Fluid overload before continuous hemofiltration and survival in critically ill children: a retrospective analysis. Crit Care Med 2004; 32: 1771–1776. • Gillespie RS, Seidel K, Symons JM. Effect of fluid overload and dose of replacement fluid on survival in hemofiltration. Pediatr Nephrol 2004; 19:1394–1399. • Goldstein SL, Currier H, Graf C, et al. Outcome in children receiving continuous venovenous hemofiltration. Pediatrics 2001; 107: 1309–1312. • Goldstein SL, Somers MJ, Baum MA, et al. Pediatric patients with multiorgan dysfunction syndrome receiving continuous renal replacement therapy. Kidney Int 2005; 67: 653–658. • Hayes LW, Oster RA, Tofil NM, et al. Outcomes of critically ill children requiring continuous renal replacement therapy. J Crit Care 2009; 24:394–400. • Sutherland SM, Zappitelli M, Alexander SR, et al. Fluid overload and mortality in children receiving continuous renal replacement therapy:the prospective pediatric continuous renal replacement therapy registry.Am J Kidney Dis 2010; 55: 316–325. • Wiedemann HP, Wheeler AP, Bernard GR, et al. Comparison of two fluidmanagement strategies in acute lung injury. N Engl J Med 2006; 354:2564–2575.

  35. Maintaining fluid homeostasis • Analysis of a multicenterobservationalcohortshowedthatmeandaily fluid balancein AKI patientswassignificantly more positiveamongnonsurvivorsthansurvivors. • Payen D, de Pont AC, Sakr Y, et al. A positive fluid balance is associatedwith a worseoutcomeinpatientswithacuterenalfailure. CritCare 2008;12: R74. • Survivors had lower fluid accumulationatdialysisinitiationcomparedtononsurvivors (8.8% vs. 14.2% of baseline body weight; P=0.01 adjustedfordialysismodality and severityscore). • PICARD: Liu KD, et al. Timing of initiation of dialysis in critically ill patients with acute kidney injury. Clin J Am SocNephrol 2006; 1:915–919.

  36. Indications for RRT fluid homeostasis • Massive volume overload resulting from volume resuscitation may be an indication for RRT even in the absence of significant elevations in BUN or SCr. – not RRT but renal support

  37. AKI – RRT Modality of renal replacement therapy for patients with AKI • We suggest using CRRT, rather than standard intermittent RRT, for hemodynamically unstable patients (2B). • In non-septic AKI, 25 ml/kg/h remains optimal. • We suggest using CRRT, rather than intermittent RRT, for AKI patients with acute brain injury or other causes of increased intracranial pressure or generalized brain edema. (2B). • In non-septic AKI, 25 ml/kg/h remains optimal. Kidney Disease: Improving Global Outcomes (KDIGO), 2012

  38. AKI: Acute Kidney Injury/Impairment • Stage 2 (RIFLE-Injury) Serum creatinine increased 2.0-2.9 times baseline Urine volume <0.5 ml/kg/h for more than 12 hours Kidney Disease: Improving Global Outcomes (KDIGO), 2012

  39. AKI: Acute Kidney Injury/Impairment • Stage 3 (RIFLE-Failure) Serum creatinine increased >3.0 times baseline or Serum creatinine >354 μmol/l with an abrupt rise of at least 44 mmol/l or Initiation of renal replacement therapy Urine volume <0.3 ml/kg/h for more than 24 hours or anuria for more than 12 hours Kidney Disease: Improving Global Outcomes (KDIGO), 2012

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