Definitions and classifications
RFR in normal and diseased kidney
Epidemiology of AKI in the ICU: Are there any changes?
Year | N ICU | # Patients | RIFLE/AKIN/KDIGO | Creat/UO | Incidence (%) | |
---|---|---|---|---|---|---|
Hoste | 2006 | 7 | 5383 | RIFLE | Creat and UO | 67 |
Ostermann [12] | 2007 | 22 | 41,972 | RIFLE | Creat | 35.8 |
Ostermann [13] | 2008 | 22 | 22,303 | AKIN | Creat | 35.4 |
Bagshaw [14] | 2008 | 57 | 120,123 | RIFLE/AKIN | Creat and UO | 37.1 |
Joannidis [15] | 2009 | 303 | 16,784 | RIFLE/AKIN | Creat and UO | 35.5 |
Mandelbaum [16] | 2011 | 7 | 14,524 | AKIN | Creat and UO | 57 |
Nisula [17] | 2013 | 17 | 2091 | AKIN | Creat and UO | 39.3 |
Liborio [18] | 2014 | 1 | 18,410 | KDIGO | Creat and UO | 55.6 |
Kellum [19] | 2014 | 8 | 32,045 | KDIGO | Creat and UO | 74.5 |
Hoste [2] | 2015 | 97 | 1802 (1032)* | KDIGO | Creat and UO | 57.3 |
Bouchard [9] | 2015 | 9 | 6647 (745)* | AKIN | Creat | 19.2 |
Place of renal biopsy in the ICU
Evaluation of renal blood flow by renal Doppler
Old and new diagnostic tools: how to use these in clinical practice
Introduction
Urine output
Serum creatinine
UO and SCr: the KDIGO criteria
AKI sniffer or electronic alert for KDIGO stages
Kidney function or GFR
Cystatin C
Pre-renal AKI or transient AKI
AKI detection before GFR decrease: damage
Old and new drugs: diuretics
Optimizing arterial pressure in patients with septic shock to prevent acute renal failure in ICU?
Is it possible to determine a low MAP threshold to prevent acute renal failure for resuscitation of shock patients with sepsis?
Is it possible to determine a high MAP threshold to prevent complications related to a higher MAP and higher vasopressor needs for resuscitation of shock patients with sepsis?
Conclusion
Alkaline phosphatase: serendipity and the discovery of its renal-protective properties
Clinical trials with biAP
Human recombinant alkaline phosphatase
RRT in severe AKI: an overview
Introduction
Modality: continuous RRT and intermittent hemodialysis
CRRT | SLED | IHD | |
---|---|---|---|
Modality | CVVH/CVVHDF/CVVHD | SLED/SLED-f | IHD/IHD-f |
Duration per session | 24 h | 6–12 h | 4 h |
Frequency | 24 h/day | 3–6/week | 3/week |
Blood flow (ml/min) | 100–200 | 100–200 | 250–350 |
Dialysate dose | 20–25 ml/kg/h | 100–300 ml/min | 500–800 ml/min |
Hemodynamic status | Stable | Possible stable | Unstable |
Volume control | +++ | ++ | + |
Heparin dose | High | Moderate | Low |
Technique: hemofiltration, hemodialysis and hemodiafiltration
Less common techniques: slow low-efficiency dialysis (SLED)
Peritoneal dialysis
Conclusions
Positive fluid balance as an indication for RRT
IHD for shocked patients
HCO membranes in sepsis
Introduction
HCO membrane characteristics
Cytokine removal via HCO membranes: clinical effects
First author, year |
N
| RRT modality | Qf or Qd (l/h) | Cutoffa (kDa) | Cytokine clearance | Albumin clearance | Clinical effects |
---|---|---|---|---|---|---|---|
Morgera et al. [103] | 24 | CVVH versus CVVHD | Qf 1 versus 2.5 Qd 1 versus 2.5 | 60 | Greater IL-1ra clearance with CVVH. Increased Qf or Qd increased IL-6 and IL-1ra clearance | Highest with CVVH 2.5 l/h | Overall decrease in APACHE II and MODS scores. No difference between groups |
Morgera [235] | 30 | CVVH | Qf 2.5 | 30 versus 60 | Greater IL-6 and IL-1ra clearance with 60 kDa-filter | Plasma albumin levels not affected by filter cutoff | Reduced noradrenaline requirements with 60 kDa-filter |
Haase et al. [104] | 10 | IHD | Qd 18 | 20 versus 60 | Greater IL-6, IL-8 and IL-10 clearance with 60 kDa-filter | Plasma albumin levels not affected by filter cutoff | Trend toward increased mean arterial pressure and reduced vasopressor requirements with 60 kDa-filter |
Conclusion
Vascular access sites for acute renal replacement in ICUs
Refs. | Design | Outcome | Highlights |
---|---|---|---|
[2] | RCT, parallel | Catheter infection | The risk of catheter infection inserted in FEM and JUG is similar |
RCT, parallel | Catheter infection | JUG site may be preferred in obese patients | |
RCT, parallel | Thrombosis | The risk of thrombosis is similar in FEM and JUG is similar | |
RCT, parallel | Severe mechanical injury | Without ultrasound guidance, FEM is safer than JUG | |
[3] | RCT, parallel | Catheter dysfunction | The risk to dysfunction is similar in FEM and JUG is similar |
Cohort | Catheter dysfunction | Right side of the body should be preferred for JUG | |
RCT, cluster | Dialysis quality | Urea Reduction Ratio is similar in FEM and JUG | |
Cohort | Dialysis quality | For blood flow >200 ml/min, jugular is better | |
Cohort | Dialysis quality | Length for FEM catheter should be >25 cm | |
[4] | Cohort | Catheter colonization | The risk of infection does not increase overtime with hemodialysis |
Cohort | Catheter colonization | The risk of infection increases overtime with hemodiafiltration | |
[5] | RCT, crossover | Catheter infection | The risk of catheter infection inserted in FEM and JUG is similar |
RCT, crossover | Dialysis quality | Urea Reduction Ratio is similar in FEM and JUG | |
RCT, crossover | Catheter dysfunction | The risk to dysfunction is similar in FEM and JUG is similar |
Acute renal failure as a witness of systemic diseases
Liver and kidney: a relationship
Definitions
Pathophysiology
Diagnostic difficulties
Management
Outcome
ARF as a witness of cardiac arrest
Acute renal failure as a witness of abdominal hypertension
RRT management: optimal timing
Demand | Capacity | Example | Action |
---|---|---|---|
High | Normal | High catabolic state High nutritional loading Poisoning | Reduce demand if possible Monitor for support renal support |
High | Low | Decreased GFR from AKI | Renal support Reduce demand if possible |
Normal | Low | CKD Non-catabolic AKI | Add renal support if necessary to maintain steady state |
Low | Low | Malnutrition and wasting CKD | Assess for nutritional state and add renal support if necessary |
Dialysis dose in AKI
Introduction
Dialysis dose of RRT in AKI
ATN | RENAL | IVOIRE | |
---|---|---|---|
Design | Multicenter RCT | Multicenter RCT | Multicenter RCT |
Country | USA | Australia and New Zealand | France, Belgium and Netherlands |
Patients | AKI | AKI | AKI with septic shock |
No. of patients | 1124 | 1508 | 140 |
Modality | CVVHDF, SLED, IHD | CVVHDF | CVVH |
Prescribed dose | CVVHDF: 21.5 versus 36.2 ml/kg/h SLED and IHD: 3 versus 6/wk | 25 versus 40 ml/kg/h | 35 versus 70 ml/kg/h |
Delivered dose | CVVHDF: 22 versus 35.8 ml/kg/h SLED: 2.9 versus 6.2/wk IHD: 3 versus 5.4/wk | 22 versus 33.4 ml/kg/h | 33.2 versus 65.6 ml/kg/h |
Mortality | 60 days 51.5 versus 53.6% | 90 days 44.7 versus 44.7% | 90 days 50.7 versus 56.1% |
Intensity of RRT in septic AKI
Potential disadvantages of high intensity
Other aspects of dose
Conclusions
Anticoagulation management in continuous RRT (CRRT)
Benefits | Limitations | Monitoring |
---|---|---|
Compared to heparin Safety ↑ Tolerance ↑ Risk of bleeding ↓ Circuit life ↑ Delivered CRRT dose ↑ Biocompatibility ↑ Cheaper | Accumulation in case of persistent hypoperfusion and decreased mitochondrial capacity Difficult to understand Strict protocol is needed Adherence to the protocol is required | Systemic iCa and acid base balance 6–8 hourly Total calcium and total/iCa ratio once daily or more frequently if the risk of accumulation is high |
Conclusion
SLEDD
How to assess recovery from AKI?
AKI: long-term outcomes
Introduction
AKI survivors’ long-term risk of CKD, ESRD and cardiovascular death
Authors [reference] | AKI severity | Study (n) | Follow-upa (years) | Mortality | CKD | ESRD | |||
---|---|---|---|---|---|---|---|---|---|
% | Relative riskb (95% CI) | % | Relative riskb (95% CI) | % | Relative riskb (95% CI) | ||||
Ishani et al. [6] | AKI only AKI + CKD | 233,803 | 2.0c
| 54.3 64.3 | 2.48 (2.38–2.58) 3.24 (3.08–3.40) | NR | NR | 2.5 | 13.0 (10.6–16.0) 41.2 (34.6–49.1) |
Wu et al. [7] | AKI only Mild AKI Moderate AKI Severe AKI AKI + CKD | 9425 | 4.8c
| 33.3 27.4 39.1 45.0 47.2 | 1.62 (1.45–1.81) 2.41 (2.11–2.75) 3.06 (2.66–3.53) 3.58 (2.91–4.41) | NR | NR | 1.9 0.6 0.7 5.1 30.3 | 2.09 (0.97–4.52) 3.19 (1.27–8.03) 22.35 (11.9–42.1) 122.9 (66.8–253.9) |
Pannu et al. [3] | AKI ± CKD AKI recovery AKI non-recovery | 190,714 | 2.8d
| 30.8 | 1.0 1.26 (1.10, 1.43) | 9.8 | 1.0 4.13 (3.38, 5.04) | 2.1 | NR |
Gammelager et al. [8] | D-AKI ± CKD D-AKI only D-AKI + CKD | 107,937 | 3.1e
| NR | NR | NR | NR | 3.8 | 6.2 (4.7–8.1)c
11.9 (8.5–16.8) 2.8 (1.8–4.3) |
Gallagher et al. [2] | D-AKI ± CKD | 810 | 3.6d
| 31.9 | NR | NR | NR | 5.4 | NR |
Rimes-Stigare et al. [4] | AKI only | 97,782 | 3.2d
| 21.8 | 1.15 (1.09–1.21) | 6.5 | 7.6 (5.5–10.4) | 2.2 | 22.5 (12.9–39.1) |