CRRT -WHEN , WHY, WHO AND HOW (JOURNAL REVIEW).pptx

JOURNAL REVIEW ON CRRT

1. JOURNAL REVIEW Dr. Meena Sonone MBBS DTCD IDCCM FID CONSULTANT INTENSIVIST, KIMS HOSPITAL NASHIK

2. Continuous Renal Replacement Therapy Who, When, Why, and How Srijan Tandukar, MD; and Paul M. Palevsky, MD

3. Review article AIM : Compare CRRT with other modalities of renal support Review indications for initiation of renal replacement therapy, dosing and technical aspects in the management of CRRT

4. Modalities of RRT CRRT PIRRT /SLED IHD Duration Intended to run 24 h/day Typically run in 6–12 h 3–7 times/week Typically run in 3–6 h 3–7 times/week Effect on solute Slow ,continuous urea clearance avoid spikes in BUN levels Intermittent nature variable BUN levels Intermittent nature variable BUN levels Patient selection Hemodynamically unstable Hemodynamically unstable Stable

5. Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for AKI recommends the use of CRRT for patients who are hemodynamically unstable Patients with fulminant hepatic failure or brain injury with increased intracranial pressure, CRRT is associated with better maintenance of cerebral perfusion than IHD.

6. Selection of CRRT modality CAVH : not used nowadays CVVH : High rate of UF across semipermeable membrane due to hydrostaticgradient and solute transport by onvection (solvent drag).Desired net fluid removal is replaced by IV balanced crystalloids CVVHD : D ialysate is perfused across the external surface of the dialysis membrane, and solutes exit from blood to dialysate by diffusion . UF rate is lowwith net negative balance without need for IV replacement of fluids CVVHDF :Hybrid

7. Indications of CRRT Volume overload Metabolic acidosis Electrolyte abnormalities Hyperkalemia Hyponatremia Hyperphosphatemia Uremia Encephalopathy Pericarditis Persistent/progressive acute kidney injury Drugs and Toxins removal

8. Timing of initiation of RRT RCT ELAIN TRIAL AKIKI IDEAL ICU TYPE single- center , unblinded 231 pt multicentre, RCT across 31 ICUs in France multicentre, RCT across 29 ICUs in France CRITERIA Early :stage 2 AKI (2X creatinine or UO< 0.5 mL/kg per hR for 12 h) Late : stage 3 AKI( 3X creat leve or UO < 0.3 mL/kg per hr f or 12 h) Stage 3 AKI ,no emergency indications for HD Stage 3 AKI ,no emergency indications for HD

9. Timing of initiation of RRT No significant difference in all cause mortality in 90 days A bsence of emergent indications such as intractable hyperkalemia or severe volume overload, an approach of delayed RRT initiation is not unreasonable

10. Dose of CRRT B ased on the ef fl uent fl ow rate, the sum of dialysate and total ultra fi ltrate fl ow clearance of urea and other low-molecular-weight solutes is approx. equal to ef fl uent fl ow. VA/NIH Acute Renal Failure Trial Network (ATN) study, compared more-intensive strategy (CVVHDF at an ef fl uent fl ow of 35 mL/kg per hour, or IHD or PIRRT six times per week) or a less-intensive strategy (CVVHDF at an ef fl uent fl ow of 20 mL/kg per hour, or IHD or PIRRT three times per week) – no difference in mortality, kidney function recovery or nonrenal organ failure observed KDIGO Clinical Practice Guidelines recommend a target dose for CRRT of 20 to 25 mL/kg per hour

11. Volume Management S everity of volume overload is strongly associated with mortality risk in both children and adults with RRT-requiring AKI optimal Strategies for volume management are uncertain, balance between the provision of net ultra fi ltration to achieve euvolemia, optimization of cardiopulmonary status, and the risk of exacerbating hypotension.

12. CRRT in sepsis current data do not support the use of CRRT as an adjunctive therapy in sepsis beyond its role for renal support

13. Technical Issues in CRRT Management Vascular Access catheter design and position must be suf fi cient to sustain blood fl ow rates of 200 to 300 mL/min KDIGO Clinical Practice Guidelines for AKI recommend the right internal jugular vein as the preferred location for catheter placement, followed by the femoral and the left internal jugular veins T unneled catheters are not recommended for routine use, decreased risks of infection and higher blood fl ow rates,and should be considered when the need for RRT is expected to exceed 1 to 3 weeks

14. Anticoagulation for CRRT In coagulopathy or thrombocytopenia use of higher blood fl owrates; minimization of fi ltration fraction by using CVVHD rather than CVVH, by infusing replacement fl uids pre fi lter during CVVH and CVVHDF; ensuring optimal catheter function and responding promptly to machine alarms to minimize interruptions in blood. fl ow ; increasing the frequency of scheduled replacement of the extracorporeal circuit

15. Anticoagulation for CRRT Mostly heparin or citrate UFH : bolus of 500-1,000 units followed by infusions of 300-500 units per hour . T arget Aptt 1.5 to 2. Consistent superiority of LMWH compared with UFH has not been shown HIT: direct thrombin inhibitors Argatroban ( Hepatically metabolised ) . In both liver failure and AKI, bivalirudin is preferred given its signi fi cant nonrenal and nonhepatic metabolis RCA : based on its rapid chelation of calcium in the extracorporeal circuit Which inhibits calcium-dependent steps in the coagulation cascade

16. RCA G oal of ionized calcium concentration to < 0.4 mmol/L. Close monitoring of both circuit and systemic blood ionized calcium levels is required to ensure suf fi cient ef fi cacy without systemic hypocalcemia A dditional to monitoring the systemic electrolytes, magnesium, total and ionized calcium, and blood Ph. It is recommended to check at one hr after initiating and every 6 hrly . Citrate Toxicity calcium infusion to maintain systemic ionized calcium levels increaseses increasing anion-gap metabolic acidosis, the ratio of systemic total calcium to ionized calcium is > 2.5.

17. Drug Dosing During CRRT challenging Needs to account extracorporeal drug removal, nonrenal clearance, residual kidney function and changes in volume of distribution and protein binding Analgesia , sedation, vasopressor as per clinical response Drugs with readily measurable levels , dose adjustments as per pharmacokinetic monitoring.

18. Nutritional Management Caloric intake of approx 35 kcal/kg per day a target protein intake of 1.5 g/kg per day and withsupplementation of water-soluble vitamins Although enteral feeding is preferred, parenteral support may be necessary.

19. Complications of CRRT Extracorporeal circuit-related complications Catheter-related complications Allergic reaction to hemodialyzer/hemo fi lter or tubing Circuit thrombosis Hemolysis Air embolism Hypothermia Hypotension Electrolyte disturbance Incorrect medication dosing

20. Discontinuation of CRRT In the observational Beginning and Ending Supportive Therapy for the Kidney (BEST Kidney) study, a urine output > 400 mL/d without concomitant diuretic therapy was a predictor of successful CRRT discontinuation ATN study, a 6-h timed urine collection was obtained when the urine output was > 750 mL/d. RRT was continued if the measured creatinine clearance was < 12 mL/min, wasdiscontinued if > 20 mL/min, and was left to clinician judgment if the measured creatinine clearance was between 12 and 20 mL/min.

21. CONCLUSION T he optimal timing of RRT remains controversial Existing data do not show that use of CRRT results in improved survival or recovery of kidney function compared with alternatives such as conventional IHD and PIRRT The majority of patients, augmenting solute clearance using ef fl uent fl ow rates > 20 to 25 mL/kg per hour is not associated with improved outcomes Other aspect of CRRT are subject to variation in practice

22. Methodology : Network metaanalysis Electronic databases (PubMed, Embase, Web of Science, and the Cochrane database) were searched from inception to October 31, 2022. All randomized controlled trials (RCTs) that examined the following outcomes were ncluded : filter lifespan, all-cause mortality, length of stay, duration of CRRT, recovery of kidney function, adverse events and costs

23. CONCLUSION Between the RCA and UFH groups, RCA is the priority anticoagulant in prolonging filter lifespan and reducing the risk of bleeding No statistically significant difference was observed in all-cause mortality, duration of CRRT, recovery of kidney function, and adverse events among most evaluated anticoagulation options