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Renal replacement therapy in acute and chronic conditions

1. RENAL REPLACEMENT THERAPY WHEN & HOW DR SHASHIDHAR PULGAM, MD,FNB,EDIC., SENIOR CONSULTANT INTENSIVIST YASHODA SECBAD

2. Indications of RRT in AKI Volume overload refractory to diuretic therapy Hyperkalemia or metabolic acidosis refractory to medical management Intoxication with dialyzable drug or toxin.( BLAST) Overt uremic symptoms encephalopathy, pericarditis, bleeding diathesis Progressive or advanced asymptomatic azotemia

3. WHY RRT in AKI DEMAND CAPACITY mismatch in AKI Metabolic disturbances Hypercatabolism Fluid management (fluids, medication, blood & nutrition)

4. FUROSEMIDE STRESS TEST FST 1mg/kg or 1.5 mg/kg Uop <200ml next 2hrs

5. BICARBONATE ADMINISTARTION Day 28 mortality: 54% in the control group vs 45% in the bicarbonate group; p=0.07 One or more organ failure at day 7: 69% in the control group vs 62% in the bicarbonate group; p=0.15 In patients with Acute Kidney Injury (AKIN) score of 2-3 (n=182), there was a statistically significant difference in: primary composite outcome: 74/90 (82%) in the control group vs 64/92 (70%) in the bicarbonate group; p=0·0462 day 28 mortality: 57/90 (63%) in the control group vs 42/92 (46%) in the bicarbonate group; p=0·0166 one or more organ failure at day 7: 74/90 (82%)in the control group vs 61/92 (66%) in the bicarbonate group; p=0·0142

6. Summary of RCTs –Early Vs Late RRT

7. MODALITIES OF RRT IHD ( intermittent hemodialysis) Continuous renal replacement therapy Hybrid therapies SLED Peritoneal dialysis

8. Principle Diffusion Concentration based Convection Solvent drag

9. RRT settings Blood flow Dialysate flow Filtrate Replacement fluid

10. SLED VS CRRT Treatment Modality: SLED: SLED is a form of intermittent hemodialysis, meaning it is delivered intermittently over a few hours in a single session. The duration of each SLED session is typically 6-8 hours. CRRT: CRRT is a continuous therapy, meaning it runs 24 hours a day and provides a slower, continuous flow of dialysis fluid. Intensity of Treatment : SLED: SLED is considered a low-efficiency dialysis method. It provides lower clearance of solutes and fluid removal compared to CRRT. CRRT: CRRT is considered a high-efficiency dialysis method. It offers higher clearance of solutes and fluid removal compared to SLED.

11. Hemodynamic Stability: SLED VS CRRT generally better tolerated hemodynamically, making it suitable for hemodynamically unstable patients who may not tolerate the fluid shifts and rapid changes in solute levels associated with SLED. Equipment and Cost: SLED: SLED requires less complex equipment and may be more cost-effective than CRRT. CRRT: CRRT involves more advanced equipment and may be associated with higher costs due to its continuous nature and the need for ongoing monitoring .

12. SLED Vs CRRT-final conclusion T he evidence comparing SLED and CRRT is limited and may vary based on the study population, study design, and other factors. At present No modality of RRT is considered superior in terms of mortality benefit or incidence of complications. The choice between SLED and CRRT should be individualized , taking into consideration the patient's hemodynamic stability, severity of AKI, desired intensity of dialysis, and resource availability.

13. The way forward: Identifying Biomarkers: Incorporating ideal biomarkers, such as Nephrocheck and the furosemide stress test, to better determine the point of no return and confidently assess the need for R RT. Clinical Criteria: Besides BUN, other clinical criteria such as hyperkalemia and volume overload should continue to be considered as important indicators for RRT initiation. Safety of Delaying RRT: The trial provides reasonable assurance that delaying RRT in patients with stage 3 AKI, prolonged oliguria, and BUN <112 without other urgent indications may be safe and can help avoid harm in patients who may not require RRT.

14. THE CURRENT APPROACH URGENT INDICATIONS include 1.Fluid overload 2.Severe metabolic acidosis ( ph <7.10 /Hco3<12 meq /l 3.Hyperkalemia (k >6.0 mmol/l 4.Complications attributable to uraemia such as bleeding , encephalopathy,pericarditis )

15. Case 1 67 yrs old male known CLD, DM, HTN admitted with Right IT fracture of femur to ward. Shifted to ICU after MET call in view of drowsiness, intubated for airway protection, foleys inserted, uop hrly 40-50 mlph . Serum ammonia 342. creatinine increased from 1.5 to 2.4. Ph 7.40 pco2 17 po2 157 HCO3 12.6 lactates 5.6 on ventilator with fio2 30% BP 124/78 HR 102.

16. Case 2 62 yrs old female DM, HTN, s/p bladder augmentation surgery for frequent urination 6 yrs back with history of recurrent UTIs, Admitted to ICU with history of fever, evaluated at Warangal treating as UTI, blood and urine klebsiella came for further management. Drowsy arousable BP 130/70 HR 112, foleys changed, uop hrly 40-50 mlph . creatinine 2.6 BUN 38. Ph 7.03 pco2 23.6 po2 78 HCO3 8 lactates 0.8 @ admission Repeat abg after 3 hrs Ph 6.97 pco2 31.1 po2 63 HCO3 7 lactates 1.31.