Transcript When to Consider RRT

WHEN TO CONSIDER
RRT
Timothy E Bunchman
Founder PCRRT
www.pcrrt.com
[email protected]
Fluid vs Solute
• Fluid over load as an indication is easy for one can
measure it
• Solute is more difficult
• Elevated K, BUN, Phos, Uric Acid?
• ? Hypermetabolism
• Septic child with fever and hemodynamic instablitiy
Renal Replacement Therapy in the PICU:
Pediatric Outcome Literature
• Few pediatric studies (all single center) use
a severity of illness measure to evaluate
outcomes in pCRRT:
• Lane noted that mortality was greater after bone marrow
transplant who had > 10% fluid overload at the time of HD
initiation
• Faragson3 found PRISM to be a poor outcome predictor in
patients treated with HD
• Zobel4 demonstrated that children who received CRRT with
worse illness severity by PRISM score had increased
mortality
1. Bone Marrow Transplant 13:613-7, 1994
23. Pediatr Nephrol 7:703-7, 1994
4. Child Nephrol Urol 10:14-7, 1990
Renal Replacement Therapy in the PICU
Pediatric Literature
• Lesser % FO at CVVH
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5
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0
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5
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0
p=
0
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2
5
%FOatCVVHInitiation
(D) initiation was
associated with improved
outcome (p=0.03)
• Lesser % FO at CVVH
(D) initiation was also
associated with improved
outcome when sample
was adjusted for severity
of illness (p=0.03;
multiple regression
analysis)
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Goldstein SL et al: Pediatrics 2001 Jun;107(6):1309-12
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Fluid Overload as a Risk Factor
N=113
*p=0.02; **p=0.01
Foland et al, CCM 2004; 32:1771-1776
Kaplan-Meier survival estimates, by percentage fluid overload
category
Gillespie et al, Pediatr Nephrol (2004) 19:1394-1999
ppCRRT MODS Data
BASELINE DEMOGRAPHICS
157 patients entered (1/1/2001 to 5/31/04)
116 with MODS (2+ organs involved)
Mean age 8.5 + 6.8 years (2 days to 25.1 years)
Mean weight 33.7 + 25.1 kg (1.9 to 160 kg)
Median 3 ICU days prior to CRRT initiation
Range 0 to 103 days
67%less than 7 days
Goldstein SL et al: Kidney International 2005
ppCRRT MODS Data:116 children
(ppCRRT KI 2005 Feb;67(2):653-8 )
Variable (values mean +/- SD)
Survivors
NonSurvivors
Age (years)
8.5 + 6.7
8.5 + 7.2
p-value
(t-test)
NS
Weight (kg)
34.2 + 25.4 31.7 + 25.8
NS
PRISM at ICU Admit
14.3 + 8.2
16.2 + 9.7
NS
PRISM at CRRT Initiation
13.9 + 8.2
18.6 + 7.2
< 0.003
CVP at CRRT Initiation
16.5 + 6.1
21.2 + 6.6
< 0.003
BUN at CRRT Initiation
61.1 + 41.8 67.8 + 45.7
NS
% FO at CRRT Initiation
14.2 + 15.9 25.4 + 32.9
< 0.03
No. of Pressors
1.4 + 1.1
1.7 + 1.1
NS
So…
• Now about solute?
• Is it like Art…when you see something you like it is good
or if you know in your heart it needs to happen it should?
•K
• Metabolic Acidosis
• Uremia
Dialysis Dose and Outcome
Ronco et al. Lancet 2000; 351: 26-30
425 patients
Endpoint = survival 15 days
after D/C HF
146 UF rate 20ml/kg/hr
survival significantly lower
in this group compared
to the others

139 UF rate 35ml/kg/hr
p=0.0007
140 UF rate 45ml/kg/hr
p=0.0013
Conclusions:


Minimum UF rates should be ~ 35 ml/kg/hr
Survivors had lower BUNs than non-survivors
prior to commencement of hemofiltration
KDIGO-Kidney Disease Involving Global
Outcomes Kid Int Suppl (2012) 2, 89–115
• ….” The optimal timing of dialysis for
• AKI is not defined. In current practice, the decision to start
• RRT is based most often on clinical features of volume
• overload and biochemical features of solute imbalance
• (azotemia, hyperkalemia, severe acidosis)….
KDIGO-Kidney Disease Involving Global
Outcomes Kid Int Suppl (2012) 2, 89–115
• PICARD Study analyzed dialysis initiation—as inferred by
BUN concentration—in 243 patients from five
geographically and ethnically diverse clinical sites.
Adjusting for age, hepatic failure, sepsis,
thrombocytopenia, and SCr, and stratified by site and
initial dialysis modality, initiation of
• RRT begun at a BUN at higher BUN (> 76 mg/dl [blood
urea > 27.1mmol/l]) was associated with an increased risk
of death (RR 1.85; 95% CI 1.16–2.96).
• Yet other studies have refuted that
Unique Situations-CRRT
• When hemodynamic instability and highly catabolic
conditions are present
• Sepsis
• Bone Marrow Transplantation
• Goldstein SL Seminars in Dialysis 2009; 22; 180-184
• Walters et al Pediatr Neph 2009 24; 37-38
Stem Cell Transplant: ppCRRT
• 51 patients in ppCRRT with SCT
• Mean %FO = 12.41 + 3.7%.
• 45% survival
• Convection: 17/29 survived (59%)
• Diffusion: 6/22 (27%), p<0.05
• Survival lower in MODS and ventilated patients
Flores FX et al: Pediatr Nephrol. 2008 Apr;23(4):625-30
Prospective Pediatric Study
• 40 patients with Sepsis/ARF at 4 ppCRRT centers
• Randomized crossover design
• 24 hours of CVVH or CVVHD, then crossover
• 2500 ml/hr/1.73m2 clearance
• Dialysis/Replacement fluid with [HC03]=35mmol/l
• Citrate ACG
• Serum collection at 0,1, 24, 25 and 48 hours
• TNF-alpha
• IL-1 beta
• IL-6, IL- 8, IL-10, IL-18
• Six hours of effluent for CK’s for clearance estimation
ppCRRT Sepsis Study
• 10 patients enrolled to date
• 6 male, 4 female
• Mean age 12 + 4.8 years
• Mean weight 44 + 21 kg
• PELOD
• Mean = 27 + 10
• Median = 22 (range 11-42)
ppCRRT [Cytokine] % Change:
Convection vs. Diffusion
Cytokine
TNF-alpha
IL-1 beta
IL-6
IL-8
IL-10
IL-18
PELOD
Convection
-3.7 + 9.6
Diffusion
3.9 + 9.1
p
0.08
-2.8 + 14.8
1.4 + 12.9
0.46
32.7 + 102.8
-2.6 + 18.4
0.21
-29.1 + 26.0
- 8.3 + 17.2
0.018
-44.6 + 29.0
3.1 + 45.0
0.007
-13.6 + 17.9
16.9 + 24.7
0.002
-22 + 34
-6 + 30
0.26
Indications are like ART
so
• Fluid is easy
• Easier to put a line in a child who is not “squishy”
• At 5% FO have the conversation and consider diuretics
• At 10-15% warm up the machinery
• Solute is hard
• Perhaps when
• One has insufficient room to delivery nutrition, medications
• The child has a rising K, BUN, Phos
• When the child is febrile (hypermetabolic)
• But it really comes down to “gut sense” and experience. Personally I
find RRT safe and therefore one has a better control of solute and fluid
but being on RRT….