Dialysis in aki

Prof Yasser M. Abdelhamid MD
Professor of Nephrology
Cairo University

• A) Initiation
• C) Dosing
• D) Termination
Prof. Yasser Abdelhamid

• Modality: The main mechanism with which
clearance is achieved.

Ideal Treatment Modality
• Preserves homeostasis
• Does not increase co-morbidity
• Does not worsen patient’s underlying
condition
• Inexpensive
• Simple to manage
• Not burdensome to the ICU staff

• 80% of patients with AKI in the ICU were
treated with continuous therapies,
• 17% with intermittent Therapies
• 3% with peritoneal dialysis or slow continuous
ultrafiltration
(Uchino et al, Intensive Care Med, 2007)

Modalities
IHD
PD
PIRT
EDD
SLEDD
SLEDD-f
CRRT

• Convection is used for higher than 1000 kDa
up to several thousand kDa
Principles

Membrane Characteristics (SC)
Prof. Yasser Abdelhamid Neri et al, Critical Care , 2016

• Adsorption:
Principles

Modality Choice
o IHD # CRRT
o SLEDD # CRRT
o IHD # PD
o SLEDD # PD
o CRRT # PD

CRRT: Advantages
 Hemodynamic Stability
 Recovery of Renal Functions
 Correction of Metabolic Acidosis
 Biocompatibility
 Correction of Malnutrition
 Removal of Cytokines
 Solute Removal

Disadvantages
• Continuous??!!!
• Anticoagulation
• Bed rest
• Higher cost
• Lower efficiency than IHD
• Risk of hypothermia

• Gradual removal of solutes and metabolic
waste helps to clear inflammatory mediators
and ensure adequate nutrition for patients

Intermittent Hemodialysis
 Short duration
 less anticoagulation
 Higher efficiency
 Less bed rest
 Flexible
 Bags cost saving
 Dialysate
 Infrastructure
 Rebound
 Hemodynamic
instability
 Residual renal
functions

CRRT ……Gradual
Deepa and Muralidhar, J Anaesthiology clin Pharmcol,2012,386-396Prof. Yasser Abdelhamid

Why
• Maintenance of intravascular compartment volume
• Prolonged treatments permit lower fluid removal rates
– IHD: 3 L in 3 hours = 1 L/h UF rate
– CRRT: 3 L in 24 hrs = 0.125 ml/h UF rate
• Urea diffusion is faster with IHD than CRRT
– IHD: Urea clearance ~160 ml/min
– CRRT: Urea clearance ~15-30 ml/min
• Convective sodium removal rate
[hemofiltration/hemodiafiltration] is less than diffusive
removal rate [hemodialysis]
• Decreased core temperature.
• Convective removal of inflammatory mediators could
contribute to hemodynamic stability.

• Cardiac failure.
• Large amount of IV intake.
• Hyperthermia (core temperature >39.5°C) or
hypothermia (core temperature <37°C)
• Overdose with a dialyzable toxin (e.g. Lithium)
Non Renal Indications (ICU)

• Combined acute renal and hepatic failure
• Acute brain injury: Decreases cerebral edema
– Autoregulation is lost!
– Sudden changes in systemic or intra-abdominal
pressure change intracranial pressure
– Slow correction of azotemia
• Na disorders
• Abdominal compartment syndrome
Non Renal Indications

Special Circumstances
• Acute fulminant liver failure:
– Brain edema.
– Hyponatremia is common, causes brain edema

CRRT Modalities
(Cerda´ and Ronco, Seminars in Dialysis, 2009)

• Many intensivists and nephrologists prefer to
use CVVH in the belief that pure convection
will remove a greater number of larger
molecules than diffusion-base CVVHD.
• CVVHDF in a safe combination
(Ricci et al, Crit Care, 2006)

• Initially, high volume hemofiltration offered
benefit over conventional hemodialysis.
• Meta-analysis (IVOIRE) suggested no
benefit (Borthwick et al, Cochrane Database Syst Rev. 2013, Joannes-Boyau et
al Intensive Care Med. 2013)
• High dose 80ml/kg/h was found to decrease level
of IL 1B, 6, 8 and 10 with no effect on mortality
than conventional dos of 40ml/kg/h
(Park et al, Am J Kidney Dis, 2016)
CRRT and Sepsis

 Slower (QD,QB).
 Prolonged >5 h.
 Hemodynamic tolerance.
• 6–12 hours over night treatment.
• Patient mobility
 Anticoagulation.
 Superior clearance than CRRT,
 Removal of toxins (higher flows)
Advantages

Disadvantages
• Same as IHD
• Hypophosphatemia.
• Hypothermia.
• Low efficiency.

Hybrid Methods
• Operational characteristics
• Fluid removal: ultrafiltration volumes vary
between zero and 6 L /d
• Electrolyte control and nutritional
considerations: maintained within normal limits.
• Protein should be augmented by 0.2 gm/kg per
day during hybrid treatment.
• Drug clearance: intermediate between that of
IHD and CRRT.

Ultrapure Water

Hybrid Methods (PIRTT)
Reported experiences suggest patients
outcomes are similar to those reported with
other acute therapies.
Outcome
s

• Conclusion:
• SLEDD is a viable modality of renal
replacement therapy in patients with septic
shock as the hemodynamic effects are similar
to CRRT.

Sepsis associated AKI
Use of Norepinephrin
194 pt , 531 sessions
No difference in mortality
or renal recovery

Advantages

Limitations

Acute Kidney Injury in Critically Ill Patients: A Prospective Randomized Study of Tidal Peritoneal Dialysis Versus Continuous R
Replacement Therapy
Acute Kidney Injury in Critically Ill Patients: A Prospective Randomized Study of Tidal Peritoneal Dialysis Versus Continuous Renal Replacement Therapy, Volume: 22, Issue:
4, Pages: 371-379, First published: 25 March 2018, DOI: (10.1111/1744-9987.12660)

Acute Kidney Injury in Critically Ill Patients: A Prospective Randomized Study of Tidal Peritoneal Dialysis Versus Continuous Renal Replacement Therapy, Volume: 22, Issue:
4, Pages: 371-379, First published: 25 March 2018, DOI: (10.1111/1744-9987.12660)

• Comparison of
metabolic and fluid
control in daily
extended hemodialysis
(EHD) and high volume
peritoneal dialysis
(Researchgate)
BUN
Creat
Bicab
K
UF Kt/V

• CONCLUSIONS:
• Based on moderate (mortality, recovery of kidney
function), low (infectious complications), or very
low certainty evidence (correction of acidosis)
there is probably little or no difference between
PD and extracorporeal therapy for treating AKI.
Fluid removal (low certainty) and weekly
delivered Kt/V (very low certainty) may be higher
with extracorporeal therapy.

• Hemodynamic stability of the critically ill
patient is the main determinant of the choice
of dialysis modality
(Palevsky et al, N Engl J Med, 2008)

Criteria of Different Therapies
(Cerda´ and Ronco, Seminars in Dialysis, 2009)Prof. Yasser Abdelhamid

Modalities and Clinical Outcome

Fluid Overload

Figure 2

Figure 3

Figure 4

Renal Recovery
• Forty-nine studies were included
• Conclusion: Findings of the conducted
assessment show that initial CRRT is
associated with higher rates of renal recovery.

RRT and Recovery
• Decision to initiation:
• No clear effect on short and long term
recovery
• (Clec’h C, et al, Crit Care, 2011)
• (Elseviers et al, Crit Care, 2010)
• (Bagshaw et al, J Crit Care, 2013) BEST

Initial therapy, at least with CRRT, may confer
a higher likelihood of recovery to dialysis
independence
(Wald et al, Crit Care Med. 2014)
(Glassford et al, Curr OpinCrit Care 2011)
(Schneider et al, Intensive Care Med 2013)
 RENAL and ATN (the reverse)
RRT and Recovery

Impact on Modality on Recovery
(Schneider and Bagshaw, Nephron Clin Pract 2014)Prof. Yasser Abdelhamid
Definition
of
Recovery

Do You Trust?
• IRRT: Lower illness severity
• IRRT: Greater hemodynamic stability
• Impact of original disease.
• Other treatments.

End Point of Recovery
• 30 d survival
• 90 d survival
• ICU stay
• RRT dependence
• 6m, 12 m survival
• RIFLE improvement

• Retrospective cohort
• 2000 to 2008 who received RRT for AKI and
survived to hospital discharge or 90 days
• 4738 pt AKI KDIGO 3
• 638 (47.7%) survived to hospital discharge
• Renal recovery (alive and not requiring RRT
• 90 and 365 days.

• No significant difference in hazards for non-
recovery or reasons for non-recovery
(mortality or ESRD) with intermittent
hemodialysis versus continuous RRT

Truche et al, Intensive Care Med (2016)

• CRRT did not appear to improve 30-day and 6-
month patient outcomes. It seems beneficial
for patients with fluid overload, but might be
deleterious in the absence of hemodynamic
failure. (Truche et al ,Intensive Care Medicine, 2016)

 Conclusion

• Hemodynamic stability is the main determinant
of modality choice.
• Clearance is better achieved by combination of
diffusion and convection.
• Specific indications for CRRT.
• Volume overload and renal recovery.
• CRRT and recovery ???

Egyptian Nephrology Guidelines ( Part 1 )
Dialysis in AKI

Dialysis in aki

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