Transcript CRRT
林口長庚紀念醫院 加護腎臟科/陳永昌 Outline Introduction CRRT Nomenclature Applications for CRRT Fluid Management in CRRT Clinical Aspects Evidence Based Medicine Conclusions AKI in ICUs In ICUs, acute kidney injury (AKI) frequently occurs in patients with medical or surgical complications and multiorgan failure Worse prognosis Standard intermittent renal replacement (IHD) treatments are often contraindicated RIFLE Classification Risk Injury Failure Loss ESRD GFR criteria Urine output criteria Increase SCr x 1.5 or UO < 0.5ml/kg/h x 6 hr GFR decrease >25% Increase SCr x 2 or UO < 0.5ml/kg/h x 12 hr GFR decrease >50% Increase SCr x 3 or UO < 0.3ml/kg/h x 24 hr or GFR decrease >75% or anuria x 12 hr SCr > 4 mg/dl Complete loss of kidney function > 4 weeks End stage renal disease (> 3 months) (Bellomo R et. al. Critcal Care 2004) Contraindication to Hemodialysis Hemodynamic instability (hypotension, presence of significant cardiovascular disease) Lack of access to circulation Lack of highly trained staff and/or equipment Indication and Timing of Dialysis for AKI Renal Replacement vs. Renal Support Renal replacement Purpose Timing of intervention Replace renal function Based on level biochemical markers Indications for dialysis Narrow Dialysis dose Extrapolated from ESRD Renal support Support other organs Based on individual need Broad Targeted for overall support CRRT vs. IHD Hemodynamic stability Fluid removal Dialysis efficiency Anticoagulation Patient mobilization Specialty personnel Drug dosing/delivery Volume restriction CRRT IHD Stable Slow, gentle, complete Low efficiency, long time Frequently necessary Possible Perhaps Easier Minimal Unstable Rapid, harsh, incomplete High efficiecy, short time Zero heparin possible Possible Definitely Difficult Significant Continuous Renal Replacement Therapy (CRRT) CAVH: Continuous arteriovenous hemofiltration CAVHD: Continuous arteriovenous hemodialysis CAVHDF: Continuous arteriovenous hemodiafiltration CVVH: Continuous venovenous hemofiltration CVVHD: Continuous venovenous hemodialysis CVVHDF: Continuous venovenous hemodiafiltration AVSCUF: Arteriovenous slow continuous ultralfiltration VVSCUF: Venovenous slow continuous ultralfiltration V X X CRRT: AV vs. VV Arteriovenous therapies (AV) Technique simplicity Required large-bore arterial catheter Blood flow dependent on MAP Venovenous therapies (VV) No arterial line Pump-assisted Blood flow independent of blood pressure CGMH CRRT Order 1. Diagnosis 2. CVVH Solution A 3000 cc + 15% KCl __ cc IVF (500~ cc/hr) 3. CVVH Solution B 3000 cc + 7% NaHCO3 240 cc IVF(500~cc/hr) 4. Record I/O Q1h and Keep I/O _____ 5. Check: BUN,Cr, Na, K, Cl, Ca, P QD; Mg QW1,4 6. Blood flow 120ml/min 7. Check ACT Q6h and Keep ACT at 200~250 sec P.S. 15% KCl 6 cc/3L 2.012 meq/L K 7.5 cc/3L 9 cc/3L 10.5 cc/3L 12 cc/3L 2.515 meq/L K 3.018 meq/L K 3.521 meq/L K 4.024 meq/L K Multi-mode continuous renal replacement machine Applications for CRRT (1) Renal application (renal replacement and renal support) Acute renal failure (specifically complicated ARF with multiple organ failure) Oligouric ARF needs large amount of fluid or nutrition Fluid overloading An alternative to HD in the mass casualty situation Electrolytes and acid base disturbance Applications for CRRT (2) Non-renal application Hepatic failure complicated with hepatic coma Congestive heart failure refractory to diuretics Overhydration during & after cardiac surgery (CPB & after) Sepsis Life-threatening hyperthermia Hemofiltration for poisoning (lactic acidosis, lithium poisoning) Cytokine removal: Acute respiratory distress syndrome Chemofiltration, chemoperfusion Potential Complications of CRRT Technical Vascular access malfunction Circuit clotting Circuit explosion Catheter and circuit kinking Insufficient blood flow Line-catheter disconnection Fluid balance errors Loss of efficiency Clinical Bleeding, Hematomas Thrombosis Infection and sepsis Allergic reactions Hypothermia Nutrient losses Insufficient blood purification Hypotension, arrhythmia Fluid Removal vs. Fluid Regulation Fluid removal Fluid regulation Normal kidney IHD PD CRRT ＋＋＋ ＋＋＋ ＋＋ ＋＋＋ ＋＋＋＋ － － ＋＋＋ Fluid and Solute Removal in CRRT Fluid Solute Back transport Hemofiltration Hemodialysis Hemodiafiltration (CAVH, CVVH) (CAVHD, CVVHD) (CAVHDF, CVVHDF) Convection Convection Convection Convection Diffusion None Possible Convection＋Diffusion Possible Components of Fluid Regulation Fluid Balance Fluid composition Electrolyte and Acid Base homeostasis Nutritional balance Temperature control Volume Adjustment for Fluid Management Level 1: Ultrafiltrate volume limited to match anticipated needs for fluid balance over 8-24 hours. Limited replacement fluid. Level 2: Ultrafiltrate volume greater than hourly intake. Net fluid balance achieved by hourly replacement fluid administration. Level 3: Ultrafiltrate volume adjusted greater than hourly intake. Net fluid balance targeted to achieve specific hemodynamic parameters eg. CVP, PAWA, MAP. Sliding Scale for Volume Adjustment Desired volume change (ml/hr) PAWP < 6 PAWP 6-8 PAWP 9-11 PAWP 12-14 PAWP 15-17 PAWP 18-20 PAWP 21-22 PAWP >22 + 175 ml and notify nephrologist + 125 ml + 75 ml Zero balance 50 ml 75 ml 100 ml 125 ml and notify nephrologist Electrolyte and Acid Base Derangements Continuous therapies can be used to correct water and electrolyte imbalances Hypo-hypernatremia can be corrected not only achieving a normal plasma sodium concentration, but also by restoring the normal body sodium content Hyperkalemia can also be corrected: the efficiency of continuous arteriovenous and venovenous hemofiltration in removing potassium is low AKI in Neonates Continuous arteriovenous hemofiltration is especially useful in the treatment of acute renal failure in neonates and small babies (Ronco et al. 1984, 1986) CRRT as a successful bridge to liver transplantation should be considered in children with unrelenting hyperammonemia not amenable to routine medical therapy (Chen CY et al. 2000) Treatment of Multiple Organ Dysfunction and Sepsis with CRRT Eicosanoids, cytokines (tumor necrosis factor and interleukins such as IL-1, IL-6, and IL-8), endothelin, and platelet-activating factor may all contribute to the reduction of renal blood flow and GFR during sepsis ARF cannot be treated effectively unless the underlying problems are resolved CVVH using the high-permeability membranes allows extraction of significant quantities of circulating macromolecules (MW 30 kDa) CRRT of AKI in Burns Patients CRRT may maintain a good uremic control for severely catabolic burns patients with multiorgan dysfunction Treatment is possible despite cardiovascular instability and total parenteral nutrition can be given CAVHD appears to give somewhat better uremic control, but the difference in mortality is not significant Large burns, pulmonary burns and septicemia seems to be bad prognostic signs (Leblanc et al. 1999) Advantage of CRRT for Nutritional Support Fluid restrictions are removed Electrolyte overload is avoided Hyperosmolar nutrition solutions are safe CRRT result in a cumulative Kt/V or small solute removal rate equivalent or superior to conventional intermittent 4 hours HD IHD daily X 4 hr: Kt/V weekly 7.5 IHD X three sessions /week: Kt/V weekly 3.2 CAVHD: Kt/V weekly 6.2 CVVHD: Kt/V weekly 8.0 (Leblanc M. et al. Semin Dial 1995) CRRT provide adequate clearance of nitrogenous compounds with the avoidance of repeatedly high peak serum nitrogen values (Clark WR et al. JASN 1994) Regional Chemotherapy plus Hemofiltration vs. Hemoperfusion Regional intra-arterial chemotherapy: drug delivery 1.5~2 x systemic dose Regional chemotherapy plus hemofiltration: drug delivery 3~4 x systemic dose Regional chemotherapy plus hemoperfusion: drug delivery 5~8 x systemic dose Ability to overcome drug delivery problems and resistance Improves survival for HCC, pancreatic cancers, and hepatic metastasis colorectal cancer (Muchmore et al. 1999) CRRT in Liver Support Requirements for liver support Detoxification Fluid regulation Acid-Base and electrolyte homeostasis Indications of CRRT support Combines renal and liver failure Liver transplant Mx of complications of decompensated liver disease – Ascites – Encephalopathy Post Cardiac Surgery AKI Intra-operative support and post-operative problems Oxygenator membranes and cytokine generation Blood tubing and extraction of plasticizers (DEHP) Prolonged bypass time and hemodynamic consequences Application of aggressive ultrafiltration in the cardiac support of children and outcome improvement Dialysis variants added to extracorporeal cardiac support system VAD and support ECMO and support IABP and support (Lin CY, Chen YC, Fang JT et al. JN 2008) Evidence Based Medicine (1) Optimal way to deliver CRRT does not exist Acute Dialysis Quality Initiative (ADQI) aims at establishing an evidence-based appraisal and set of consensus recommendations to standardize care and direct further research http://www.ADQI.net Evidence Based Medicine (2) Levels of Evidence Level I: Randomized trials with low false positive () and low false negative () error (i.e. high power) Level II: Randomized trials with high error or low power Level III: Non-randomized concurrent cohort studies Level IV: Non-randomized historic cohort studies Level V: Case series, case reports, expert opinion Evidence Based Medicine (3) Grades of Recommendations Grade A: Supported by at least 2 level I studies Grade B: Supported by only 1 level I study Grade C: Supported level II studies Grade D: Supported by at least 1 level III study Grade E: Supported by only level IV or V studies Evidence Based Medicine (4) CRRT use in a variety of non-ARF conditions including intoxication with dialyzable/filterable drugs or toxins, cardiac failure, ARDS, and pediatric cardiac surgery or sepsis and systemic inflammation Insufficient evidence to recommend the use of CRRT for nonARF indications outside clinical investigation (Grade E) CRRT use may be advantageous in the management of ICU patients with ARF (Grade E) CRRT is recommended over IHD for patients with AKI who have, or are at risk for, cerebral edema (Grade C) CVVH Dose (1) (Ronco C et al. Lancet 2000) CVVH Dose (2) CVVH Dose (3) Intensive vs. Less-Intensive Strategy (1) (Palevsky PM et al. NEJM 2008) Intensive vs. Less-Intensive Strategy (2) Intensive vs. Less-Intensive Strategy (3) CVVHDF vs. CVVH (1) (Saudan P et al. KI 2006) CVVHDF vs. CVVH (2) CVVHDF vs. CVVH (3) p=0.0005 CRRT vs. IHD (1) (Tonelli M et al. AJKD 2002) CRRT vs. IHD (2) (Vinsonneau C et al. Lancet 2006) CRRT vs. IHD (3) CRRT vs. IHD (4) CRRT vs. IHD (5) B.E.S.T. Kidney Investigators (Uchino S et al. ICM 2007) Less Chronic Kidney Disease in CRRT (Bell M et al. ICM 2007) Conclusions CRRT are safe, simple, effective, and well tolerated in the management of patients with multiple organ failure and acute renal failure Maintenance of water, and electrolyte balance Removal of metabolic waste products Removal of inflammatory mediators of MOSF Facilitate full nutrition support The treatment of choice in critically ill patients with acute renal failure No particular form of CRRT has yet shown to be superior of survival Scheme for Selection of a Renal Replacement Therapy in ICUs: Patient-Center Approaching Renal Failure requiring renal replacement therapy Uni-organ failure Intermittent hemodialysis Main problems: biochemical/uremia Multi-organ failure Hemodynamically stable Main problems: CRRT fluid overload or cytokines Intermittent Hemodialysis Intolerance Hemodynamically unstable CRRT (EDD, SLED) IHD