35 definitions in literature ( Kellum et al. Curr Opin Crit Care 2002 ;8:509-514)

1. Advances in Acute renal failureAcute renal failure first proposed by Homer SmithText book: ‘The Kidney Structure and Function in Health and Disease1951

2. 35 definitions in literature(Kellum et al. CurrOpinCrit Care 2002;8:509-514)

3. 35 definitions in literature(Kellum et al. CurrOpinCrit Care 2002;8:509-514) Prevalence: 1 to 25% in ICUMortality: 15 to 60%

4. Why ‘RIFLE’ CriteriaARDS & Sepsis: Definitions not perfect; but found to be usefulNeed to classify the severity of syndrome; rather than only severest formARF= Dialysis dependenceLack of single definition Held ARF research 20 years back (Bellomo R et al. Intensive Care Med.2001Nov;27(11):1685-8)

5. Citated till now in 546 articles

6. Severity classes Oliguria/ARF Outcome classes

7. Decline in GFR Abrupt; 1 to 7 days At all levels  Both UOP & S. Cr Change sustained for >24 hours. Relationship between S. Cr & GFR  Depends on the phase of recovering renal failure Certainly steady state often not reached Both S. Cr & GFR changes  Always be considered in terms of the baseline When baseline is unknown or confronted with a patient who has elevated S.Cr ??? Suggestion MDRD formula Oliguria insensitive marker: many patients remain non-oliguric

8. Conventional definitionRapid decline hours to weeksDecline in GFRRetention of nitrogenous waste products 1. Fails to describe dynamic process initiation, maintenance & recovery 2. Emphasis on overt failure of kidneys; belies that mild decrement of renal function A/w cardiac events Hoste et al. : Only 14% of patients of ‘F’ Received dialysis; but 5 times hospital mortality (Crit Care 2006; 10: R73) AKI Incidence by RIFLE : 2-10 times higher than conventional definition

10. Relationship: RIFLE class V/s Outcome Six studies Mortality Hoste EA CurrOpinCrit Care 2006; 12; 531-537

11. Limitations of RIFLE Urine output Diuretic use: sensitivity & specificty For accurate measurement: requires catheter Need to know baseline S.Cr Not always known RIFLE advises to use MDRD; MDRD for CKD

12. ** NDT 2008; 23 (5);1564-1579

13. JAMA 2005;294:813-818

15. Nature Reviews Nephrology 2006, 2 (7) 364

16. Nature Reviews Nephrology 2006, 2 (7) 364 Hospital incidence

17. Nature Reviews Nephrology 2006, 2 (7) 364

18. Disease categories of AKI ** Accounts for 90% of intrinsic renal category

19. Diagnosis of ARFOften diagnosed Increase in S. Cr & UreaBUN to S. Cr ratio = 15 : 1 Hypercatabolic ARF Hypercatabolic ARF Schrier Kid Int 1979 ; 15: 205-216

21. LR: Likelihood ratio

22. Renal biopsy in ARF Gomez. CJASN 3; 674: 2008 Indications Oliguria > 2 weeks Schrier > 6 weeksOTCN Anuria Flawed Patchy necrosis Angiogram to know perfusion of cortices Systemic disease Heavy proteinuria & haematuria Marked hypertension No circulatory disturbance to account for ATN

23. Gomez. CJASN 3; 674: 2008

24. Past = Contraindications Sheath Needle Protective cover Needle + Specimen Modified Colapinto aspiration needle

25. Feasibility of transjugular biopsy well documented Clinical benefit to be established Interventional radiologist 25  high risk patients 21 (84%) tissue  adequate 17Perforation of renal capsule 6 of them coil embolization 1 RVT after one week

26. CJASN 3; 876-880; 2008 Previous criteria: Early v/s Late; Qualitative Proposed: Quantitative; Based on RIFLE criteria

27. Timing RRT: Early versus Late

28. Mortality V. Seabra et al, AJKD, 52: 272-284; 2008

29. Renalrecovery V. Seabra et al, AJKD, 52: 272-284; 2008

30. V. Seabra et al, AJKD, 52: 272-284; 2008

31. Dosing

32. Dosing Optimal dose is 35 ml/kg/hr = 50.4 L/d

33. Dosing Palevsky et al.

34. Dosing

35. Dosing CORRESPONDENCE • 6 days delay in initiation of treatment • 219 protocol deviations Isolated UF  in less intensive group • SLED more in intensive group • Treatment for 28 d only. Mortality  At 60 d; 10% of patients received extra dialysis

36. Dosing Bellomo et al.

37. Dosing Bellomo et al.

38. 2010Vol. 38, No.5; 1360 Mortality: No difference

40. Eight RCTs in last decade At present  Four discussed

41. Plateau: no further benefit Steep correlation bet the dose & survival

42. What is unknown even after VA/NIH ATN? • Breaking point • BP for diff modes of dialysis • What is gainedVA/NIH ATN • Not to risk under dialysis • Dialysis dose monitoring

43. CRRT v/s IHD: Six RCTs  Last 10 years; In Europe & US

44. Crit Care Med, 36: 610-617; 2008 CRRT v/s IHD Continuous versus intermittent renal replacement therapy for critically ill patients with acute kidney injury: A meta-analysis Bagshaw, Sean M. MD, MSc; Berthiaume, Luc R. MD; Delaney, Anthony MBBS, MSc; Bellomo, Rinaldo MD

45. Crit Care Med, 36: 610-617; 2008 CRRT v/s IHD Continuous versus intermittent renal replacement therapy for critically ill patients with acute kidney injury: A meta-analysis Bagshaw, Sean M. MD, MSc; Berthiaume, Luc R. MD; Delaney, Anthony MBBS, MSc; Bellomo, Rinaldo MD There was suggestion that continuous RRT had fewer episodes of hemodynamic instability and better control of fluid balance. In the context of these limitations, the initial RRT modality did not seem to affect mortality or recovery to RRT independence

46. Death Renal recovery

47. Intermittent, continuous and hybrid techniques offer specific advantages All are part of a medley race in dialysis of critically ill

49. NEJM 347; 12: 895; 2004

50. John T Daugirdas • Predominance of malaria • Comparison of state of art CVVH with rustic PD • CVVH was low intensity; still patients recovered fast