【持续性肾脏替代治疗crrt英文精品课件】cbpnephrology – diseases of the kidneys!(102p)

CBP Nephrology Diseasesofthekidneys CBP Nephrology A48 year oldman otherwisehealthy presentswithsevereunspecificabdominalpainandvomitingof2daysduration Heisastablebipolarpersonalitydisorderonlithium anXsmoker hashistoryofalcoholuse CBP Nephrology Onphysicalexamination restless dehydratedHR130andBP90 60 Supine RR28 T37 4 Chestandheartexamsareunremarkable Abd examrevealedmild moderateepigastricabdominaltendernesswithoutperitonealsigns Restoftheexamisunremarkable Lab WBCis16 500 andtheHCTis49 Cr188 67baseline BUN12 3 K5 5andtherestofelectrolytevaluesarenormal CBP Nephrology IntubatedonadmissionduetoalteredLOCandinabilitytoprotecthisairwayaswellasimpendinghypoxemicrespiratoryfailure remainsonmultiplevasoactiveagents andisinoliguric to anuricrenalfailureAdmittedtoICUandadequatelyresuscitatedPatientremainsanuricdespitetheadequatefluidresuscitation Question1 AnyroleforincreasingdosesofLasixinananuricpatient Anyharm Anybenefit Eric DiureticsinAKI DiureticsinAKI Threepartquestion ElectrolytemanagementFluidmanagementConversionofoligurictonon oliguricRF Electrolytes Fluid PaucityofdataansweringthesespecificquestionsRemainsclinicaldecisionandtherapeuticoption Differentiatefluidmanagementfromurineoutput Conversionofoligurictonon oliguricRF RavindraLMetal Diuretics Mortality andNonrecoveryofRenalFunctioninAcuteRenalFailure JAMA 2002 288 20 2547 2553 Confounders Diureticuseatthetimeofconsultationwassignificantlyassociatedwitholderage presumednephrotoxic ratherthanischemicormultifactorial ARForigin alowerBUNlevel acuterespiratoryfailure andahistoryofcongestiveheartfailure CausevsCorrelate Afteradjustingforcovariatesassociatedwiththeriskofdeath diureticusewassignificantlyassociatedwithin hospitalmortalityannon recoveryofrenalfunction evenafteradjustmentfornonrandomtreatmentassignmentusingpropensityscores DiureticsinAKI Threepartquestion Electrolytemanagement Fluidmanagement Conversionofoligurictonon oliguricRF Question2 DefineAcuteKidneyInjury Eric DefinitionsofAKI Thedilemma Morethan35definitionsofAKIcurrentlyexistintheliterature AKIvsAcute ChronicRF CritCareMed2010 38 261 275 RIFLEvsAKIN Bagshawetal AcomparisonoftheRIFLEandAKINcriteriaforacutekidneyinjuryincriticallyillpatients NephrolDialTransplant 2008 23 1569 1574 BottomLine BoththeRIFLEandAKINcriteriaweredevelopedtofacilitateclinicalinvestigationandcomparisonacrossstudypopulations Todate mostinterventionalstudies e g NAC NaHCO3 etc topreventormitigateAKIhavenotusedthesedefinitions Question3 WhatistheincidenceofAKIintheICUandhowdoesitaffectpatientoutcomes yahya IncidenceofAKIintheICU AKIoccursin 7 ofallhospitalizedpatients whereasitoccursin36 67 ofcriticallyillpatients Onaverage 5 ofICUpatientswithAKIrequirerenalreplacementtherapy DennenP DouglasIS AndersonR Acutekidneyinjuryintheintensivecareunit anupdateandprimerfortheintensivist CritCareMed 2010Jan 38 1 261 75 AKIandmortality Inmoststudies mortalityratesriseproportionallywithseverityofAKI EvensmallincreasesinserumcreatininehavebeenassociatedwithincreasingmortalityinvariousICUpopulationsdespiteadjustingforseverityofillnessandcomorbidities InpatientswithAKIrequiringRRT mortalityratesreach50 to70 DennenP DouglasIS AndersonR Acutekidneyinjuryintheintensivecareunit anupdateandprimerfortheintensivist CritCareMed 2010Jan 38 1 261 75 AKIandotheroutcomes AKIisalsoassociatedwith IncreasedlengthofstayIncreasedincidenceofCKDandend stagekidneydiseaseIncreasedcostForexample anincreaseinSCrof0 5mg dl 38mmol L wasassociatedwitha 6 5 foldincreaseintheoddsofdeath3 5dayincreaseinLOSnearly 7500inexcesshospitalcosts DennenP DouglasIS AndersonR Acutekidneyinjuryintheintensivecareunit anupdateandprimerfortheintensivist CritCareMed 2010Jan 38 1 261 75 ChertowGM BurdickE HonourM BonventreJV BatesDW Acutekidneyinjury mortality lengthofstay andcostsinhospitalizedpatients JAmSocNephrol 2005Nov 16 11 3365 70 Question4 Whatarethemethodsfordetectingacutekidneyinjury yahya TraditionalmethodsfordetectingAKI Currentlyavailablemeasuresdonotdetectactualkidneyinjurythewaytroponindetectsmyocardialinjury CreatinineUreaUrineoutputRathertheyaremarkersofabnormalrenalfunction thatcanbeusedtopresumekidneyinuryhasoccurred BagshawSM BellomoR Earlydiagnosisofacutekidneyinjury CurrOpinCritCare 2007Dec 13 6 638 44 Serumcreatinine UsedtoestimateGFRProsProducedatarelativelyconstantrateFreelyfilteredbyglomerulusNotreabsorbedormetabolizedbythekidney BagshawSM BellomoR Earlydiagnosisofacutekidneyinjury CurrOpinCritCare 2007Dec 13 6 638 44 Serumcreatinine UsedtoestimateGFRCons10 40 issecretedbythetubulesRelativelyinsensitive mayneeda50 reductioninfunctionbeforeadetectableriseinSCrisseen Creatinineproductionvariesbasedonage sex musclemass dietCertaindiseasestatescanincreaseproduction rhabdo Certaindrugscandecreasesecretion cimetidine trimethoprim Certainfactorsmayaffectassay ketoacidosis cefoxitin flucytosine Doesnotreflectreal timechangesinGFR BagshawSM BellomoR Earlydiagnosisofacutekidneyinjury CurrOpinCritCare 2007Dec 13 6 638 44 Urea RateofproductionisnotconstantIncreaseswithproteinintakeIncreasesincriticalillness burns sepsis trauma GIBleedSteroids40 50 ofureaisreabsorbedbythekidney evenmorewhendry BagshawSM BellomoR Earlydiagnosisofacutekidneyinjury CurrOpinCritCare 2007Dec 13 6 638 44 Urineoutput ProsAdynamicgaugeofkidneyfunction MaybeabarometerforchangeinkidneyperfusionConsPoorsensitivityandspecificityCanhavesevereAKIwithnormalorincreasedurineoutput BagshawSM BellomoR Earlydiagnosisofacutekidneyinjury CurrOpinCritCare 2007Dec 13 6 638 44 Summaryofnovelmarkers BagshawSM BellomoR Earlydiagnosisofacutekidneyinjury CurrOpinCritCare13 638 644 CBP Nephrology Patientcontinuestohaveincreasingventilationsupportrequirmentsandisnowon 85FiO2 HisK isnow5 6 HeisgivenroutinehyperK therapy HehasbeenstartedonvasopressorsbecauseofdecliningMAP Question6 WhenshouldRRTbestarted Indicationandtiming Brian Historicalaspects UseofHDinARFstartedintheyearsimmediatelyfollowingWWII 1947 1950 Initialindications advancedsymptomsofrenalfailure clinicaluremia severehyperkalemia pulmonaryedemaReductioninmortalitycouldnotbedemonstrated withhighcomplicationratesTeschanetalreportedimprovedsurvivalwith prophylacticdialysis in1960 Indisputable indications VolumeoverloadHyperkalemiaMetabolicacidosisUremicsignsorsymptomsRefractorytomedicalmanagementNospecificobjectivecriteria OtherIndications Progressiveazotemiaintheabsenceofuremia noconsensus Otherelectrolytedisturbances Na Mg PO4 Uricacid TimingofinitiationofRRT CompetingrisksRiskofdelayintherapyPotentialharmoftherapy includingcomplicationsoftherapyandthepotentialthatdialysismayprolongthecourseofARF Teschanetal Prophylactichemodialysisinthetreatmentofacuterenalfailure AnnIntMed1960 PaulTeschanofUSArmyMedicalCorpsaftertheKoreanWarintroducedtheconceptof prophylacticdialysis appliedbeforeoverturemicsymptomsappearedN 15 uncontrolledtrial initiationofdialysisbeforeserumUreaNitrogenreached100mg dlTwincoilcellulosicdialyzersatBF75 250ml mintomaintainBUNlessthan75mg dlAllcausemortality33 mortalityduetohemorrhageorsepsis20 Nocontrolgroup However investigatorsreportedthattheresultrepresented dramatic increaseinsurvivalcftheirpastexperienceinptinwhomdialysiswasnotinitiateduntil conventional indicationswerepresent Earlystudies Boumanetal CCM2002 2centerRCT n 106 ICUptsonMVwithvasopressordependentcirculationandoliguricARFARF CrCl40mmol l pulmonaryedemawithPaO2 FiO2 150despitePEEP10Manyissues Jiang etal 2005 RCT n 37 inseverepancreatitisWITHOUTdocumentedevidenceofARFEarly CVVHwithin48hoursonsetofabdopainLate within96hoursImprovedhemodynamicsand14dsurvival Gettingsetal ICM1999 Retrospectivenonrandomizedcohortstudy n 100 Traumapatients Timing definedbyBUNlevelEarly RRTstartedatameanBUN15mmol lLate atBUN34mmol LSurvival 39 Early 20 Late Piccinietal ICM2006 Retrospectivestudy n 80 PatientswithsepticshockandoliguricAKIHistoricalcontrolEarly 35mmol lorCr 600Improvedhemodynamics gasexchange 28dsurvival Elahietal 2004 Retrospectivecohortstudy n 80 CardiacsurgerypatientsEarly CVVHwhenUO30mmol l Cr 250 orK 6regardlessofUOSurvival44 early 22 late p 0 05 Demirkilicetal 2004 Retrospectivestudy n 61 ARFfollowingcardiacsurgeryHistoricalcontrolEarly CVVHDFifUO444Hospitalmortality23 5 Early55 latep 0 02 Summary TrendtowardsbetteroutcomewithearliertimingofRRTMethodologypoorNonuniformdefinitionoftimingHeterogeneityofpopulationHeterogeneityofRRT Summary NonuniformandarbitrarydefinitionofARFpreventsdirectcomparisonoftrialsButhowaboutusingRIFLEcriteriaandAKINdefinition Shiaoetal 2009 MulticenterprospectiveobservationalstudyN 98whounderwentRRTaccordingtolocalindicationsforpost majorabdosurgeryAKIEarly sRIFLE 0orRiskLate sRIFLE IorF RIFLE AKIN Results N 98Early 51 0 22 R 29 Late 47 I 27 F 20 ICUmortality Early41 2 Late68 1 Hospitalmortality Early43 1 Late74 5 p 0 002 RRTwean offrate 21 vs41 p 0 050 Conclusions Limitations LatedialysisdefinedbysRIFLE IorsRIFLE FisanindependentpredictorforinhospitalmortalitySupportearlierinitiationofRRTSmallNOnlyGFRcriterionofRIFLEused sRIFLE Question7 DefinedifferentmodesofRRT Brian RRTmodalities Diffusion Convection SCUF CVVH CVVHD CVVHDF IHD Bloodflow200 300ml minDialysateflow500 800ml minSoluteremovalbydiffusion fluidremovalbyultrafiltrationSoluteclearancedependentonbloodflowAdvantages rapidsoluteandfluidremoval rapidelectrolytecorrection certaintoxinremoval noneedforanticoagulationDisadvantages systemichypotension RenalReplacementTherapy AllformsofRRTrelyontheprincipleofallowingwaterandsolutetransportthroughasemipermeablemembraneanddiscardingwasteproductsFluidremoval ultrafiltrationSolutetransport diffusion convection orboth Question8 IHDvsCRRT Brian Dialysismodality 1999NKFsurveyrevealedIHDaspreferredformofRRT 75 whileCRRT PDwaslessthan10 MorerecentsurveyrevealedIHDaspreferredbynephrologists intensivistsin57 whileCRRTwaspreferredin37 inUSInternationally BESTKidneystudy JAMA2005 revealedCRRTastheinitialmodalityofchoiceforRRTinICUusedin80 followedbyIHD 17 So isCRRTbetter PreferenceofCRRT Putativeadvantages ImprovedhemodynamicstabilityMoreeffectivecontrolofacid baseandelectrolytestatusImprovedremovalofuremictoxinsRemovalofinflammatorymediators Disadvantages Needforanticoagulation2 3xmoreexpensivethanIHD Evidence Two2002metaanalysesofearliertrialscomparingsurvivalinICUAKIassignedtoIHDorCRRTandadjustedforseverityofillnessdidnotsupportCRRTSeveralobservationalandprospectiveRCTscomparingIHDvsCRRTfailedtoconfirmexpectedsurvivaladvantageofCRRTLimitations dosedifference highcrossoverrate randomizationfailure nonstandardizationofprotocol CochraneReview2008 Intermittentvs continuousRRTforARFinadults Objectives TocompareCRRTwithIRRTtoestablishifanyofthesetechniquesissuperiortoeachotherinpatientswithAF Methods Typesofstudies RCTsInterventionsIRRTdefinedasanyformofRRT HD HF HDF UF prescribedforperiodof 24hwithinany24hperiodCRRTdefinedasanyRRTintendedtorunonacontinuousbasisuntilrecoveryofrenalfunctionoccurred Methods OutcomemeasuresMortality priortoICU hospitalDC timetoICU hospitaldeath DCRecoveryofrenalfunctionCardiovascularstabilityComplicationsoftherapy bleeding sepsis Results Mortality In hospitalmortality nodifference 7studies N 1245 RR1 01 0 92 1 12 noevidenceofsignificantheterogeneityICUmortality nodifference 5studies N 515 RR1 03 0 90 1 26 Timetohospitaldeathordischarge nodifference 1study N 25 TimetoICUdischargeordeath notassessed Results RecoveryofRF Survivingptnotrequiringdialysis Nodifference 3 N 161 RR0 99 0 92 1 07 noevidenceofsig heterogeneitysCroreGFRathospitaldischarge nodifference 1 N 129 RR1 13 0 94 1 36 Results Cardiovascularstability Hemodynamicinstability nodifference 2 N 205 RR0 48 0 2 2 28 Onestudydidnotspecifydefinition whiletheotherdefineditasavaeragevariabilityb wmaxadmindailyMAP NoheterogeneityHypotension Nodifference 3 N 514 RR0 92 0 72 1 16 VariabledefinitionofhypotensionMAPatendofstudy CRRTsignificantlyhigher 2 N 112 meandif5 35 1 41 9 29 SystolicBP Nodifference 1 N 30 Escalationofpressorrx NodifferencewhenanalysedbyrandomeffectsmodelDoseofinotropicdrugs nodifference Results ComplicationsofRRT Bleeding nodifference 5 N 638 Clottingofdialysisfilter CRRTsignificantlymorelikelytoclotfilter 3 N 149 RR8 5 1 14 63 33 Arrhythmia nodifference 2 N 439 RRTmodalityswitchduetocomplications nodifference 4 N 920 Conclusions CRRToffersnosurvivaladvantagecfIRRTinARFPtsurvivingARFwhoaremanagedwithCRRThassimilarrecoveryofRFasthosetreatedwithIRRTCRRTisassociatedwithsighigherMAPCRRTisassociatedwithsigincreasedfilterclotting Limitations EachRCTsarenotlargeenoughtoprovideanaccurateevaluationofthedifferenceinoutcomeConsiderablevariationsindefinitionofARFandhypotension heterogeneityindialysisx dose membrane andptcharacteristics WhatkindofanticoagulationshouldbeusedwithCRRT UBCAHDNephrologyCBPSamuelKohenNovember18 2010 Introduction CRRTisusedinhemodynamicallyunstablepatientswithrenalfailure ThemostcommonproblemwithCRRTiscircuitclotting Anticoagulationdecreasesthis HeparinandCitratearethetwomostcommonCRRTanticoagulants Untilrecently itwasnotclearwhichwasbetter Heparin IVinfusionadministeredintotheinflowlimboftheextracorporealcircuit IVBolusof500 2000Utheninfusionof300 500U htitratedtoagoalPTT1 5 2xnormal Stopheparinforbleedingorthrombocytopenia Citrate Citrateinhibitsclottingbychelatingcalcium IVcalciumisinfusedpost circuittomaintainnormalserumCalevels Citrateisbasicsotheotherdialysatebuffers bicarbonateorlactate mustbereducedItishepaticallymetabolizedbythepatient Citrateversusheparinforanticoagulationincontinuousvenovenoushemofiltration aprospectiverandomizedstudy Mehranetal IntensiveCareMed 2004 30 260 265 Mehranetal Prospectivetrialrandomizing20patientsreceivingCVVHFtoheparinorcitratebyhemofilter 49hemofiltersused 23heparinand26citrate Patientsrequiringmorethanonehemofilterwerecrossedover Patientswithliverdysfunctionordeemedathighriskofbleedingwereexcluded Mehranetal ThereisnodifferenceinCRRTfunction ureaandcreatinineclearance Themediancircuitlifetimewaslongerwithcitratethanheparin 70vs40hours mostlyduetoclotting 74vs46 Citrateanticoagulationisassociatedlessbleeding Fewersignificantbleedingepisodes 1UGIBvs0 FewerPRBCtransfusions 1U dvs0 2U d CitrateismoreoftenassociatedwithmetabolicderangementsMetabolicalkalosisandhypocalcemia Regionalcitrateversussystemicheparinizationforcontinuousrenalreplacementincriticallyillpatients Demetriosetal Kidneyinternational Vol67 2005 P2361 2367 Demetriosetal 30criticallyilladultpatientswithacuterenalfailureonCRRTwererandomizedtoeitherheparin 16 orcitrate 14 2patientscrossedovertreatmentgroups 79hemofilterswereused Heparin 43 Citrate 36 Demetriosetal Nosignificantdifferenceinsurvivaltohospitaldischarge Citrate14 Heparin29 p 0 69 Filtersusingcitratefunctionedmuchlongerthanthosewithheparin 124 5vs38 3hours Conclusions Citrateisbetter Nodifferenceincreatinineclearanceor60daymortality Citratetreatedcircuitsclotlessfrequentlyandlastlonger Citrateanticoagulationisassociatedwithfewerbleedingepisodes Metabolicalkalosisandhypocalcemiaarethemostcommoncomplicationsofcitrate treatedcircuitsbutareeasilydetectedandusuallyharmless WhatarewedoingatVGH Primethecircuitwith5000Uhep