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Advances in Continuous Renal Replacement Therapy

Advances in Continuous Renal Replacement Therapy. CSM 2011 Dr Anne Leung 17 th May 2011. Overview. Timing of initiation. Fluid and anticoagulation. Membrane. DOSE. To begin the “Dosing” story of CRRT…. Lancet 2000. Higher the dose the better. Piccinni ICM 2006. EIHF vs Conventional

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Advances in Continuous Renal Replacement Therapy

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  1. Advances in Continuous Renal Replacement Therapy CSM 2011 Dr Anne Leung 17th May 2011

  2. Overview Timing of initiation Fluid and anticoagulation Membrane DOSE

  3. To begin the “Dosing” story of CRRT…. Lancet 2000

  4. Higher the dose the better Piccinni ICM 2006 EIHF vs Conventional 45mL/Kg/hr for 6 hours then 20mL/Kg/hr vs 20mL/Kg/hr 28-day Survival: 55% vs 27.5%

  5. CVVHDF: more may not be better Tolwani et al JASN 2008 PRCT Single Center N=200 Pre-dilution CVVHDF: 20mL/Kg/Hr CVVDHF: 35mL/Kg/Hr

  6. Intensive RRT = Equal ATN trial PRCT N=1124 60 days mortality Intensive: 53.6% Less Intensive: 51.5%

  7. What Dose ? • Before the ATN trial • CRRT: 35mL/Kg/Hr • Daily iHD • After the ATN trial • SOFA 0-2: 3x/week iHD (Kt/V 1.2) • SOFA 3-4: CRRT 20 mL/Kg/hr or SLED 3x/week • But beware for the need for extra treatment!

  8. Randomized (Post-dilution CVVH) 1508 Low dose (25ml/Kg/hr) 761 High dose (40ml/Kg/hr) 747 Lost to follow-up = 0 Consent withdrawn = 2 Consent not obtained = 16 Lost to follow up = 1 Consent withdrawn = 2 Consent not obtained = 23 Analyzed 743 Analyzed 722

  9. RENAL Study

  10. Conclusion • Intensity of RRT DOES matter • Beyond the threshold dose ( 25ml/kg/hr), increasing intensity does not provide further clinical benefit • Be-aware of the difference between prescribed and delivered dose of RRT • ATN study: 89% -95% • RENAL study: 84-88% • Minimize the interruption of the treatment time

  11. IVOIRE (hIgh Volume in Intensive Care)—French Study • Inclusion criteria: Septic shock <24 hrs and RIFLE criteria of injury or worse • Intervention: High volume (70ml/kg/hr) vs Standard (35ml/Kg/hr) for 96 hours • Patient number: total of 460 patients • Primary outcome: 28-day mortality • Study period: 3 years and completed by Oct 2010

  12. INITIATION OF THERAPY

  13. RIFLE Criteria Level of injury Outcome measures Currr Opin Crit Care 8: 509-514 (2002)

  14. From RIFLE to AKIN Serum Creatinine Increase SCr ≥24.6mmol/L Stage 1 Stage 2 2-3 folds Stage 3

  15. The Acute Kidney Injury Network Classification ( AKIN) Crti Care 11:R31 (2007)

  16. Biomarkers of AKI Serum Cystatin C uNGAL

  17. MEMBRANE OF FILTER

  18. Super High-Flux or High Cut-ff Membranes Achieve greater clearance of inflammatory cytokines Superior elimination of IL-6 Decrease need of Nor-adrenaline over time

  19. SepteX—High Cut Off Membrane

  20. Pilot Randomized Controlled Study Comparing the Effect of High Cut-off Point Hemofiltration with Standard Hemofiltration in Patient with Acute Renal Failure • Study Population: • Critically ill patient with AKI and shock that require Nor-adrenaline • Intervention: • Standard polyamide high flux membrane vs High cut-off polyamide membrane (P2SH) • CVVH: Qb: 200ml/min, UF of 25ml/Kg/hr • Size of the study: • 72 patients • Primary measures • NA-free time in first week after randomization • Status: • start in Jun 2009 and still recruiting

  21. Early Use of Polymyxin B Hemoperfusion in Abdominal Septic Shock--The EUPHAS Randomized controlled Trial JAMA 2009 Early Use of Polymyxin B Hemoperfusion in Abdominal sepsis Decrease vasopressor requirement Better BP and low SOFA score Polymyxin B immobilized fiber Direct Hemo-Perfusion Mortality of 32 % vs 53%

  22. FLUID & ANTICOAGULANT

  23. Continuous renal replacement therapy: B.E.S.T. Kidney (The Beginning and Ending Supportive Therapy for the kidney).a worldwide practice survey. 23 Countries, 54 ICUs, 1006 patients with ARF on CRRT Intensive Care Med. 2007;33(9):1563-70

  24. Less clotting in Hollow Fibers membrane Kid Int 1999

  25. Commercial preparation of citrate solution—Morgera S. et al .CCM 2009

  26. A safe citrate anticoagulation protocol with variable treatment efficacy and excellent control of the acid-base status—CCM 2009 • Result • Median filter time of 61.5 hrs • 5% had filter clot • Excellent control of acid-base and electrolyte

  27. Use of citrate CVVH was safer and reduced mortality Oudemans MH et al CCM 37:545-552 ( 2009)

  28. Hospital mortality 41 vs 57% (p=0.03)3-month Mortality 45 vs 62% (p=0.02) Surgical HigherSOFA Sepsis Younger than 73 CCM 37: 545 - 552 ( 2009)

  29. Negative Fluid Balance Predicts Survival in Patients with Septic Shock--Alsous F. et al Chest2000 Net negative fluid balance within first 3 days in ICU 100% 20% 3 5 6 7 1 2 4

  30. The Importance of Fluid Management in Acute Lung Injury Secondary to Septic Shock— Murphy CB et al Chest 2009 20ml/Kg with CVP≥8 within 4 hrs after vasopressors Neutral or negative fluid for 2 consecutive days during first 7 days Hospital mortality of 18.3% 3 5 6 7 1 2 4

  31. The Importance of Fluid Management in Acute Lung Injury Secondary to Septic Shock— Murphy CB et al Chest 2009 20ml/Kg with CVP≥8 within 4 hrs after vasopressors Neutral or negative fluid for 2 consecutive days during first 7 days Hospital mortality of 77.1% 3 5 6 7 1 2 4

  32. Survivor: Fluid balance non-positive by D4 3 5 6 7 1 2 4

  33. Sepsis in European Intensive Care Units: Results of the SOFA study— JL Vincent et al 2006;344-353 Cumulative fluid balance within 72 hrs after onset of sepsis was independent predictor of mortality 10% increase in mortality with each 1L increase in cumulative fluid balance 3 5 6 7 1 2 4

  34. Conservative fluid mx -higher ventilator-free and ICU free days -Less cardiovascular failure -Less on dialysis Comparison of Two Fluid-Management Strategies in Acute Lung Injury— NEJM 2006 Conservative group: zero balance by D4 3 5 6 7 1 2 4

  35. Fluid Accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury— (PICARD study)Bouchard J et al KI 2009id removal Fluid overload patient tended to be sicker patient For each weight change class, fluid overload is independent predictor of mortality

  36. ? “Fluid” as the AKI biomarker

  37. If I find 10,000 ways something won't work, I haven't failed. I am not discouraged, because every wrong attempt discarded is often a step forward....Thomas Edison USE OF RCA IN QEH ICU

  38. Citrate dose

  39. Who can do that ? Genius Brain

  40. PYNEH ICU (1995-2003)

  41. AK 10 machine Non-integrated approach

  42. Ci-Ca Dialysate solution

  43. Solution for RCA--Gambro

  44. PYNEH ICU ( 2004 …..

  45. RCA CRRT—QEH Regime

  46. RCA CRRT—QEH Regime

  47. RCA CRRT—QEH Regime CaCl2 infusion

  48. Summary of the regime • Machine: Prismaflex • Pre-dilution with Primocitrate 10/2 at rate of 2500mL/hr • Blood flow at 150ml/min • Both UF and blood flow rate fixed • Separate infusion of NaHCO3 ( initial 50ml/hr for 2 hr then 30ml/hr ) and Calcium chloride infusion via CVC at 6 ml/hr • For fluid removal= desired fluid removal + flowrate of NaHCO3 • Measure Na, K, BE, ABG and ionized calcium Q4-6 hr • Target ionized calcium 0.9 – 1.3 mmol/L

  49. Implementation • Theory Session • For both nurses and doctors • Practical Session • By Gambro in early March • Guideline as the reference • Case selection • Avoid those with liver dysfunction, after massive transfusion and severe metabolic acidosis with pH<7.1 • Start with post-op case with mild to moderate acidosis and fluid problems • Start during the daytime • Gambro technical support stand-by during the initial phase • Trouble shooting • Contact Dr Anne Leung

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