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

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Presentation on theme: "©2011 MFMER | slide-1 Continuous Renal-Replacement Therapy CRRT Kianoush Kashani 5 th Anesthesia and Critical Care Conference Kuwait 2013."— Presentation transcript:

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

2 ©2011 MFMER | slide-2 RRT indications (traditional) Gibney et al. cJASN 3: , 2008.

3 ©2011 MFMER | slide-3 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

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

5 ©2011 MFMER | slide-5 Heart

6 ©2011 MFMER | slide-6 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

7 ©2011 MFMER | slide-7 Liver

8 ©2011 MFMER | slide-8 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 DialysisVol 24, No –202

9 ©2011 MFMER | slide-9 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 DialysisVol 24, No –202

10 ©2011 MFMER | slide-10 Sepsis

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

12 ©2011 MFMER | slide-12 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

13 ©2011 MFMER | slide-13 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.

14 ©2011 MFMER | slide-14 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): Ding et al. ASAIO Journal 2011; 57:426 – 432.

15 ©2011 MFMER | slide-15 Lung

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

17 ©2011 MFMER | slide-17 RRT modalities

18 ©2011 MFMER | slide-18 Modalities of RRT Hemodyalisis IRRT CRRT Peritoneal dialysis Transplant

19 ©2011 MFMER | slide-19 RRT modality and mortality Bagshaw et al. Crit Care Med 2008 Vol. 36, No. 2

20 ©2011 MFMER | slide-20 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

21 ©2011 MFMER | slide-21 Cost Mayo Clinic study N= 161, retrospective observational study Mean adjusted total costs through hospital discharge $ for IHD $140,733 for CRRT (P<.001). Rauf et al. J Intensive Care Med May-Jun;23(3):

22 ©2011 MFMER | slide-22 Anticoagulation

23 ©2011 MFMER | slide-23 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?

24 ©2011 MFMER | slide-24 CVVH -predilution Partial loss of delivered RF by HF need for anticoagulation AccessReturn UF Flow Replacement fluid

25 ©2011 MFMER | slide-25 CVVH -postdilution Higher clearance chance of clotting AccessReturn UF Flow Replacement fluid

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

27 ©2011 MFMER | slide-27 Case Filtration fraction = [ Q uf (ml/min) / Q b (ml/min)] X 100 Q uf = 4500 ml/hour = 4500/60 = 75 ml/min Q b = 200 ml/min Current FF = (75/200) X 100 = 37.5% 1.Decrease Q uf to 3000 ml/hour (50 ml/min) 2.Increase Q b to 300 ml/min FF = 50/200 X 100 = 25% FF = 75/300 X 100 = 25%

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

29 ©2011 MFMER | slide-29 No Heparin Systemically Heparinized Gail Annich, University of Michigan Citrate

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

31 ©2011 MFMER | slide-31 CRRT dosing

32 ©2011 MFMER | slide-32 Meta-analysis Mortality Jun et al. Clin J Am Soc Nephrol 5: 956–963, 2010.

33 ©2011 MFMER | slide-33 Meta-analysis Renal recovery Jun et al. Clin J Am Soc Nephrol 5: 956–963, 2010.

34 ©2011 MFMER | slide-34 CRRT Timing

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

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

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

38 ©2011 MFMER | slide-38 شكراً The best interest of the patient is the only interest to be considered

39 ©2011 MFMER | slide-39 Questions & Discussion


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