CRRT-f
- 1. AKI and CRRT 신장내과 안신영
- 2. CRRT, IHD, SLED, PD SLED : slow low efficiency dialysis
- 3. • CRRT (Continuous renal replacement therapy) – Who ? • Hemodynamic instability • Intermittent hemodialysis could not control volume or metabolic derangements – Slower solute clearance and removal of fluid → better hemodynamic tolerance – Venovenous circuit
- 4. 1. Intractable hyperthermia 2. Overdose of dialysable drugs or toxin (heparin, myoglobin, vancomycin) 3. Radiocontrast nephropathy
- 5. Optimal timing for initiation of RRT in AKI • The optimal indication and timing of initiation of RRT in critically ill patients with AKI in not known • Absence of robust predictive biomarkers • Traditional indications (based on fluid, electrolytes, and metabolic status) are late complication of AKI • RRT is usually started preemptively before the development of overt complications of AKI. According to clinical state of the patient includings age, the severity, other organ dysfunctions, and the degree of renal dysfunctions.
- 27. 1. Vascular assess • Short term uncuffed nontunneled dialysis catheter • Use 12-15 cm (Rt JV) > 20-25 cm (femoral vein) > 15-20 cm (Lt JV) >> subclavian vein (for dominant side) • Ultrasound guidance for catheter insertion • CRX after placement of IJV catheter/ before first use
- 28. 2. BFR (blood flow rate) • 최소한 혈류 속도를 체중 (Kg) x 2ml/min 이상 유지할 것. – Ex> 50kg : 100 ml/min, 70kg : 140 ml/min • 혈류 속도를 높일 수록 solute clearance 가 높아지고 filter clot 의 가능성이 낮아지므로, 환자의 상태에 따라서 증/감 시도가 가능 – 비교 > intermittent HD의 BFR > 200 – 350 ml/min
- 29. 3. Dose of CRRT in AKI • No evidence for superiority of higher CRRT dose Dose threshold below which mortality may increase - 35 mL/kg/hr is a reasonable target for prescription - > 25 mL/kg/hr should be effectively delivered • KDIGO Clinical Practice Guidelines for AKI, 2012 Delivering an effluent volume of 20-25 mL/kg/h for CRRT in AKI
- 32. • Dialysate flow rate – Small molecular toxin 또는 electrolyte 제거 효율이 증가 (diffusion 증가) – Hypokalemia, hypophosphatemia 가 조장될 수 있음 • Replacement flow rate – Middle molecular toxin 제거에 용이 (convection 증가) – Predilutional replacement flow rate or pre-blood pump (PBP) • Filter clot 의 위험성은 감소 • 그러나 대개 10-20% 정도의 clearance는 감소 – Postdilutional replacement flow rate • Clearance는 증가 • Filter clot 위험성이 증가
- 34. 4. Total I/O (patients removal) • Rationale of fluid therapy – Increasing preload and stroke volume – Restoration right ventricular end-diastolic volume – Restoration of cardiac output – Restoration of systemic blood pressure – Reversal of renal ischemia – Dilution of nephrotoxin
- 35. 1B 5. Anticoagulation (1C) Unfractionated/ LMWH Unfractionated/ LMWH Regional citrate in CRRT Cix: Heparin in CRRT Heparin in intermittent RRT Potential risk vs. benefits from anticoagulation Not increasing bleeding risk/ not systemic AC Use AC during RRT in AKI (NG) (1B) Avoid regional heparin in CRRT (2B) (2C) (2C) Heparin-induced thrombocytopenia Argatroban (direct thrombin inhibitor) Danaparoid/fondaparinux (fXa inhibitors) rather than no AC during RRT (1A)
- 36. Citrate anticoagulation protocol Systemic iCa Ca gluconate@ infusion < 0.75 + 4 mL/hr (Ca-gluconate 10mEq in N/S 50cc for 1hr) 0.75 ~ 1.13 + 2 mL/hr 1.13 ~ 1.32 No change > 1.32 - 4 mL/hr Post-filter iCa Citrate infusion (ACD solution*) < 0.25 - 10 mL/hr 0.25 ~ 0.35 No change 0.35 ~ 0.45 + 10 mL/hr > 0.45 + 20 mL/hr @ Calcium gluconate solution: Normal saline 600cc + Ca gluconate 20 amp * ACD solution: dextrose 2.45 g/dL, sodium citrate 2.2 g/dL, citric acid 730 mg/dL (원내 물품 코드: 441ASO50)
- 37. Nafamostat Protocol in CRRT 0.3 mg/kg/hr 현재 용량 유지 동맥측 Filter clot time < 6시간 이내 ACT 측정장소 이전 시작용량 + 5mg/hr 로 재시작 고려 ※ 상기 표는 산술적인 추정치이고, 환자의 상태 및 CRRT 처방량에 따라 달라질수있으므로 신중히 판 단하시기 바랍니다. 유지용량이 <10mg/hr 혹은 >50mg/hr 인 경우 신장내과와 반드시 상의합니다 시작 용량 모니터링 유지 용량 20 mg/hr ACT F/U q 6 hours: (Target ACT: 150±20 sec) Filter survival > 24 hr 혹은 target ACT 도달 ACT F/U q 12-24 hours 측정한 ACT 값 (sec) Futhan 증량시 추정되는 ACT 값 (sec) +5mg/hr +10mg/hr 80 85 102 90 95 115 100 106 128 110 117 141 120 127 154 130 138 166 측정한 ACT 값 (sec) Futhan 감량시 추정되는 ACT 값 (sec) -5mg/hr -10mg/hr 170 160 122 180 169 130 190 179 137 200 188 144 210 197 151 220 207 158 Filter clot time 6-24시간 사이 Target ACT 벗어난 경우 5 또는 10mg/hr 단위 증량 소아 (만 12세 미만) 성인 Filter clot time >24시간 이상
- 38. CRRT – Adverse effects • Complications of vascular access – Infection / Vascular injury – 5 to 19% – Arterial puncture, hematoma, hemothorax, pneumothorax – AV fistula, aneurysm, thrombus formation, pericardial tamponade, retroperitoneal hemorrhage • During therapy – Hypotension, arrhythmia, fluid-balance, elecrolyte disturbance, nutrient loss, hypothermia, bleeding complications from anticoagulation
- 39. Stopping renal replacememt therapy • One of the following reasons – Improvement in renal function adequate to meet patient needs • Minimun creatinine clearance > 15 ml/min – RRT is no longer consistent with the goals of care • ATN study : creatinine clearance – < 12 mL/min : continue RRT – > 20 mL/min : discontinue RRT – 12-20 mL/min : decisions were left to the clinician • Develop a strategy based on – Hemodynamic stability, adequate fluid balance, nutritional delivery switch to IHD
Editor's Notes
- #5: Classic indication -> little debate Potential indication -> 많은 수의 전문가들이 이 상황에서 CRRT 적절하다고 생각
- #36: 5.3.1.1: We recommend using anticoagulation during RRT in AKI if a patient does not have an increased bleeding risk or impaired coagulation and is not already receiving systemic anticoagulation. (1B) 5.3.2.1: For anticoagulation in intermittent RRT, we recommend using either unfractionated or low-molecular-weight heparin, rather than other anticoagulants. (1C) 5.3.2.2: For anticoagulation in CRRT, we suggest using regional citrate anticoagulation rather than heparin in patients who do not have contraindications for citrate. (2B) 5.3.2.3: For anticoagulation during CRRT in patients who have contraindications for citrate, we suggest using either unfractionated or low-molecular-weight heparin, rather than other anticoagulants.(2C 5.3.3.1: We suggest using regional citrate anticoagulation, rather than no anticoagulation, during CRRT in a patient without contraindications for citrate. (2C) 5.3.3.2: We suggest avoiding regional heparinization during CRRT in a patient with increased risk of bleeding. (2C)