3. What is the ? advantages of RIFLE Criteria
Applying the RIFLE criteria revealed new
insights.
Firstly,the RIFLE classification is feasible
and fairly straightforward.
Secondly, the patients categorized as
RIFLE-F had a far higher mortality than
RIFLE-I and -R patients.
Max Bell et al; Nephrol Dial Transplant 2005 20:354 –
360
4. Stage-based management
General Principles
(Stage 1 (RRiisskk
Risk for more severe AKI
Monitor (prevent
(progression
(Stage 2 (IInnjjuurryy
Risk of AKI-related
mortality/morbidity
high
(Conservative therapy
(Stage 3 (FFaaiilluurree
Highest risk of death
Consider RRT
AKI Stage
1 2 3
Discontinue all nephrotoxic agents when possible
Ensure volume status and perfusion pressure
Consider functional hemodynamic monitoring
Monitoring Serum creatinine and urine output
Avoid hyperglycemia
Consider alternatives to radiocontrast procedures
Non-invasive diagnostic workup
Consider invasive diagnostic workup
Check for changes in drug dosing
Consider Renal Replacement Therapy
Consider ICU admission
Avoid subclavian catheters if possible
Risk
Injury
Failure
High Risk
6. Indications for RRT in critically ill AKI patients
Renal Indications
Life-threatening indications
Hyperkalemia
Metabolic Acidosis
Pulmonary edema
Uremic omplications
Gibney et al, Clin J Am Soc Nephrol 2008
7. Indications aarree ooppeenn ttoo iinntteerrpprreettaattiioonnss
How volume overloaded?
What is the definition of diuretic resistance?
What should potassium level be?
How severe for metabolic acidosis?
8. DDiiaallyyssiiss IInntteerrvveennttiioonnss ffoorr TTrreeaattmmeenntt ooff AKI
55..11..11: IInniittiiaattee RRRRTT eemmeerrggeennttllyy when life-threatening
changes in fluid, electrolyte, and
acid-base balance exist.(Not Graded)
55..11..22: Consider the bbrrooaaddeerr cclliinniiccaall ccoonntteexxtt, the
presence of conditions that can be modified with
RRT, and ttrreennddss ooff llaabboorraattoorryy tests—rather
than single BUN and creatinine thresholds alone
—when making the decision to start RRT. (Not
Graded)
KDIGO® AKI Guideline March 2012
9. ??WWhheenn ttoo ssttaarrtt RRRRTT
Crit Care Med 2008, Vol. 36, No 4 (suppl.(
Higher mortality in the early HD group
10. ??WWhheenn ttoo ssttaarrtt RRRRTT
Crit Care Med 2008, Vol. 36, No 4 (suppl.(
Early start CRRT in Post-Traumatic ARF has better survival
11. ??WWhheenn ttoo ssttaarrtt RRRRTT
Crit Care Med 2008, Vol. 36, No 4 (suppl.(
No significant differences in survival were observed
12. ??WWhheenn ttoo ssttaarrtt RRRRTT
Crit Care Med 2008, Vol. 36, No 4 (suppl.)
The sooner the ARF after surgery is recognized and CVVHDF is performed,
the higher the likelihood of the reduction of the hospital mortality
13. ??WWhheenn ttoo ssttaarrtt RRRRTT
Crit Care Med 2008, Vol. 36, No 4 (suppl.)
EEaarrllyy RRRRTT sseeeemmss bbeetttteerr
16. Peritoneal Dialysis (PD) In AkI
Advantages
Hemodynamic stability
Slow correction
Easy access placement
No Anticoagulation
Tolerated in children
Disadvantages
Risk of infections
Difficulty to use with abdominals
surgery
Logestics
17. Potential Advantages of CCRRRRTT
Homodynamic stability
Recovery of renal function
Brain edema
Biocompatibility
Removal of cytokines
Nutritional support
Correction of metabolic acidosis
20. Dialysis Interventions for Treatment of AKI
55..66..22:: We suggest using CRRT, rather than
standard intermittent RRT, for hemodynamically
unstable patients. (2B)
55..66..11: Use continuous and intermittent RRT as
complementary therapies in AKI patients. (Not
Graded
KDIGO® AKI Guideline March 2012
21. Study Modality recovering renal function%
SUPPORT *IHD **67%
.Morgera et al CRRT 90%
.Ronco et al CRRT 90%
.Mehta et al
IHD
CRRT
59%
92%
†BEST Kidney
IHD
CRRT
65%
89%
22. Role of CCRRRRTT in management of IICCPP
DDaavveennppoorrtt,, AA SSeemm DDiiaallyyssiiss,, 22000099
55..66..33: We suggest using CRRT, rather than intermittent RRT, for AKI
patients with acute brain injury or other causes of increased intracranial
pressure or generalized brain edema. (2B)
KDIGO® AKI Guideline March 2012
23. removal of Cytokine
The elimination of
inflamatory mediator occurs
only during the 1st hour after
application of new filter.
Cytokines removal capacity
of curently available
membranes hardly matches
the productin observed in
severly affected septic
patients.
De Vriese AAss--JJAAMM SSoocc NNeepphhrrooll 1100--884466--885533 11999999
24. Is their an aalltteerrnnaattiivvee ttoo CCRRRRTT ??
Slow Low-Efficiency Daily Dialysis (SSLLEEDD)
Typically performed over 6-12 hours
Can be performed with a conventional
dialysis machine
– A little less labor intensive
– Requires less training/startup
Fliser D and Kielstei JT Nat Clin Pract Nephrol, 2006
25. Slow Low-Efficiency ) Daily Dialysis (SSLLEEDD
Major advantages: flexibility, reduced costs,
low or absent anticoagulation
Similar adequacy and hemodynamics
One small study (16 pts) showed slightly higher
acidosis and lower BP (Baldwin 2007)
VA trial (Palevsky NEJM 2008) suggests similar
outcomes as CRRT and IRRT.
Vanholder et al. Critical Care 2011, 15:204
26. Mode of
therapy
Principle method of
solute clearance
CVVH Convection
CVVHD Diffusion
CVVHDF Convection & Diffusion
SCUF (Ultrafiltration (fluids
27. ? HHooww wwee ccaann ddoo iitt
Processes of care, more pertinent to
Nephrologists:-
Vascular Access
Membrane characteristics
Solution
Anticoagulation
Dose
28. Vascular access
55..44..11: We suggest initiating RRT in patients with AKI via an
uncuffed nontunneled dialysis catheter, rather than a
tunneled catheter. (2D)
55..44..22: When choosing a vein for insertion of a dialysis
catheter in patients with AKI, consider these preferences (Not
Graded):
First choice: right jugular vein;
Second choice: femoral vein;
Third choice: left jugular vein;
Last choice: subclavian vein with preference for the dominant side.
KDIGO® AKI Guideline March 2012
29. SSoolluuttiioonnss ffoorr CCRRRRTT
Lactate buffer solution
Commonly used in RRT
Under physiologic conditions, lactate is converted to
bicarbonate
Limitations :
Impairment of lactate metabolism ( liver failure(
Enhanced lactate production (severe hypoxia, sepsis(
Lactate accumulation leads to lactic acidosis (decreased
myocardial performance and hemodynamic instability)
30. SSoolluuttiioonnss ffoorr CCRRRRTT
Bicarbonate buffer solution
Instability in the presence of calcium and magnesium
Pharmacy-made in hospitals
Recently solutions containing
bicarbonate have became available in
separated solutions that are mixed just
before use
31. SSoolluuttiioonnss ffoorr CCRRRRTT
Bicarbonate- versus lactate-based fluid replacement in CVVH
Prospective, randomized study
Results :
Serum lactate concentration was
significantly higher and the
bicarbonate was lower in patients
treated with lactate-based
solutions
Increased incidence of CVS
events in pts ttt with lactate
solution
Hypotension
Increased dose of inotropic
support
barenborck and colleague
Barenbrock M et al; Kidney Int (2000
32. Dialysis Interventions for Treatment of AKI
55..77..33: We suggest using bicarbonate, rather than
lactate, as a buffer in dialysate and replacement
fluid for RRT in patients with AKI and liver
failure and/or lactic acidemia. (2B)
KDIGO® AKI Guideline March 2012
33. TThhee MMeemmbbrraannee
High Flux membrane , synthetic , biocompatable ,
acting by providing both methods of detoxications:
a)Diffusion : for low molecular weight toxins.
b)Convection : for large molecules.
55..55..11: We suggest to use dialyzers with a biocompatible
membrane for IHD and CRRT in patients with AKI. (2C)
KDIGO® AKI Guideline March 2012
34. Modality Advantages Disadvantages
Heparin Good anticoagulation Thrombocytopenia bleeding
LMWH Less thrombocytopenia bleeding
Citrate Lowest risk of bleeding Metabolic alkalosis,
hypocalcemia special dialysate
Regional Heparin Reduced bleeding Complex management
Saline flushes No bleeding risk Poor efficacy
Prostacycline Reduced bleeding risk Hypotension poor efficacy
35. 55..33..22..11: For anticoagulation in intermittent RRT, we
recommend using either unfractionated or
low-molecular weight heparin, rather than
other anticoagulants. (1C)
55..33..22..22: For anticoagulation in CRRT, we suggest using
regional citrate anticoagulation rather than
heparin in patients who do not have
contraindications for citrate. (2B)
KDIGO® AKI Guideline March 2012
36. DDoossee
Optimal intensity of RRT is controversial
RCT of 1124 critically ill pts with AKI and sepsis or at
least one organ failure to intensive or less intensive
renal-replacement therapy
Hemodynamically unstable pts received CRRT or
SLEDD, stable pts IRRT
Intensive RRT= IRRT or SLEDD 6x/wk or CRRT at 35
ml/kg/hr
Less intensive RRT= IRRT or SLED 3x/wk or CRRT at 20
ml/kg/hr
VA/NIH Acute Renal Failure Trial Network. (NEJM 2008;359:7):
37. No difference in mortality
VA/NIH Acute Renal Failure Trial Network. (NEJM 2008;359:7):
38. The RENAL Replacement Therapy Study
1508 Critically ill patients with ARF on CVVHF were
randomized to:-
llooww (25 mL/kg/hr – 747 patients)
hhiigghh intensity (40 mL/kg/hr – 761 patients) effluent rates.
There was no
difference in 90 day
mortality rate
(44.7%) or the need
for RRT at 90 day
between the two
treatment groups.
N Engl J Med. 2009 Oct 22;361(17):1627-38
39. 55..88..11: The dose of RRT to be delivered should be prescribed
before starting each session of RRT. (Not Graded)
We recommend frequent assessment of the actual delivered
dose in order to adjust the prescription. (1B)
55..88..22: Provide RRT to achieve the goals of electrolyte,
acid-base, solute, and fluid balance that will meet
the patient’s needs. (Not Graded)
KDIGO® AKI Guideline March 2012
40. CCCCoooonnnncccclllluuuussssiiiioooonnnnssss
Data from high quality RCTs are lacking
The current trend is to provide RRT earlier
There may be a recovery advantage to using CRRT
vs. HD for initial management of AKI but no
difference on mrtalitaty
Dose: No benefit to “intensive” therapy
DDiiaallyyttiicc SSuuppppoorrtt ooff AAKKII ==
IInnddiivviidduuaalliizzaattiioonn
