Continuous Renal-Replacement Therapy CRRT Kianoush Kashani 5 th Anesthesia and Critical Care Conference Kuwait 2013 ©2011 MFMER | slide-1

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 ©2011 MFMER | slide-3

MultiOrgan Support Therapy (MOST) ©2011 MFMER | slide-4

Heart ©2011 MFMER | slide-5

• 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 ©2011 MFMER | slide-6

Liver ©2011 MFMER | slide-7

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 ©2011 MFMER | slide-8

• 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 ©2011 MFMER | slide-9

Sepsis ©2011 MFMER | slide-10

Systemic Inflammatory Response Syndrome (SIRS) Vs. Compensatory Anti-inflammatory Response Syndrome (CARS) ©2011 MFMER | slide-11

• 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 ©2011 MFMER | slide-12

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.

Lung ©2011 MFMER | slide-15

Respiratory support • Refractory ARDS • TV decreased from 6ml/kg to 4 ml/kg Terragni et al. Anesthesiology 2009; 111:826 –35 ©2011 MFMER | slide-16

RRT modalities ©2011 MFMER | slide-17

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 ©2011 MFMER | slide-19

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 ©2011 MFMER | slide-20

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 ©2011 MFMER | slide-22

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 Replacement fluid Return UF Flow ©2011 MFMER | slide-24

CVVH -postdilution

• Higher clearance • ↑ chance of clotting Access Replacement fluid Return UF Flow ©2011 MFMER | slide-25

Effect of filtration on CVVH Hematocrit 60% Hematocrit 30% Maintain filtration fraction at 25% ©2011 MFMER | slide-26

Case Filtration fraction = [ Q uf (ml/min) / Q b (ml/min)] X 100 • • • Q uf Q b = 4500 ml/hour = 4500/60 = 75 ml/min = 200 ml/min Current FF = (75/200) X 100 = 37.5% 1.

• • 2.

Decrease Q uf to 3000 ml/hour (50 ml/min) Increase Q b  to 300 ml/min FF = 50/200 X 100 = 25%  FF = 75/300 X 100 = 25% ©2011 MFMER | slide-27

Anticoagulation: Options • No Heparin protocols • Heparin • Unfractionated • LMWH • Citrate • Others • • • Prostacyclin Danaparoid Hirudin/argatroban • Nafamostate mesylate ©2011 MFMER | slide-28

No Heparin Systemically Heparinized

Citrate

Gail Annich, University of Michigan ©2011 MFMER | slide-29

Citrate Vs. Heparin Filter life span Risk of bleeding Zhang et al. Intensive Care Med (2012) 38:20 –28 ©2011 MFMER | slide-30

CRRT dosing ©2011 MFMER | slide-31

Meta-analysis Mortality Jun et al.

Clin J Am Soc Nephrol

5: 956 –963, 2010.

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Meta-analysis Renal recovery Jun et al.

Clin J Am Soc Nephrol

5: 956 –963, 2010.

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CRRT Timing ©2011 MFMER | slide-34

Early versus late RRT (Mortality) Karvellas et al. Critical Care 2011, 15:R72 ©2011 MFMER | slide-35

Early versus late RRT (Mortality) Karvellas et al. Critical Care 2011, 15:R72 ©2011 MFMER | slide-36

Early versus late RRT (RRT independence) Karvellas et al. Critical Care 2011, 15:R72 ©2011 MFMER | slide-37

ً ا ركش

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

©2011 MFMER | slide-38

Questions & Discussion ©2011 MFMER | slide-39