DEPARTMENT OF INTENSIVE CARE MEDICINE, GHENT UNIVERSITY HOSPITAL

WHEN TO USE HYBRID

THERAPY
Eric Hoste
CONFLICT OF INTEREST
̶ Intensivist

̶ Employee of Ghent University Hospital and Research Foundation-Flanders

̶ Academic research grants for biomarker research (CHI3L1)

̶ Participated in Astute Medical sponsored research on TIMP2/IGFBP7

̶ I received material for a study on ECCO2R from Bellco

̶ I received a speakers fee from Alexion, Bioporto/Sopachem

̶ I received a travel grant for AKI & CRRT 2017 from AM Pharma
HYBRID & ACRONYMS
̶ Sustained Low-Efficiency Dialysis (SLED)
̶ Sustained Low-Efficiency Daily Dialysis (SLEDD)
̶ Sustained Low-Efficiency Diafiltration (SLED-f)
̶ Sustained Low-Efficiency Daily Diafiltration (SLEDD-f)
̶ Extended Dialysis (ED)
̶ Extended Daily Dialysis (EDD)
̶ Prolonged Intermittent Renal Replacement Therapy (PIRRT)
̶ Prolonged Daily Intermittent Renal Replacement Therapy (PDIRRT)
̶ Slow continuous Dialysis (SCD)
̶ “Go Slow Dialysis”
WHAT IS HYBRID
Standard Hemodialysis equipment
̶ Machine Efficiency Duration
̶ Filter Intensivist ++ -
̶ Blood circuit Nephrologist - ++

̶ (online production) dialysate

Diffusion
Time: 6-12h
HYBRID: THE BEST OF CRRT & IHD?
HYBRID COMPARED TO IHD & CRRT
Intermittent HD Hybrid CRRT
Duration 3-4 6-12 24/7
Solute transport Diffusion Diffusion a/o Convection Diffusion a/o Convection
Blood flow (mL/min) 200-350 100-300 100-250
Dialysate flow (mL/min) 300-800 100-300 0-50
Urea clearance (mL/min) 150-180 90-140 20-45
Fluctuations of osmolites ++ +
Fluctuations of fluid ++ +
Effect on ICP Increase Potential increase -
Effect on Antibiotics Major Some Minor

Mobilisation ++ ++ -
Cost + + ++

Bagshaw et al Intensive Care Med 2017

7
HYBRID, IHD & CRRT: C HYBRID = C IHD
Intermittent HD Hybrid CRRT
Duration 3-4 6-12 24/7
Solute transport Diffusion Diffusion a/o Convection Diffusion a/o Convection
Blood flow (mL/min) 200-350 100-300 100-250
Dialysate flow (mL/min) 300-800 100-300 0-50
Urea clearance (mL/min) 150-180 90-140 20-45
Fluctuations of osmolites ++ +
Fluctuations of fluid ++ +
Effect on ICP Increase Potential increase -
Effect on Antibiotics Major Some Minor

Mobilisation ++ ++ -
Cost + + ++

Bagshaw et al Intensive Care Med 2017

8
HYBRID, IHD & CRRT: FLUCTUATIONS
Intermittent HD Hybrid CRRT
Duration 3-4 6-12 24/7
Solute transport Diffusion Diffusion a/o Convection Diffusion a/o Convection
Blood flow (mL/min) 200-350 100-300 100-250
Dialysate flow (mL/min) 300-800 100-300 0-50
Urea clearance (mL/min) 150-180 90-140 20-45
Fluctuations of osmolites ++ +
Fluctuations of fluid ++ +
Effect on ICP Increase Potential increase -
Effect on Antibiotics Major Some Minor

Mobilisation ++ ++ -
Cost + + ++

Bagshaw et al Intensive Care Med 2017

9
HYBRID, IHD & CRRT: MOBILISATION!
Intermittent HD Hybrid CRRT
Duration 3-4 6-12 24/7
Solute transport Diffusion Diffusion a/o Convection Diffusion a/o Convection
Blood flow (mL/min) 200-350 100-300 100-250
Dialysate flow (mL/min) 300-800 100-300 0-50
Urea clearance (mL/min) 150-180 90-140 20-45
Fluctuations of osmolites ++ +
Fluctuations of fluid ++ +
Effect on ICP Increase Potential increase -
Effect on Antibiotics Major Some Minor

Mobilisation ++ ++ -
Cost + + ++

Bagshaw et al Intensive Care Med 2017

10
CRRT TO HYBRID SWITCH: SAME OUTCOMES

Marshall et al NDT 2011

META-ANALYSIS: CRRT VS. HYBRID

N= 1,291patients

Zhang et al Am J Kidney Dis 2015

SAME MORTALITY RISK

Zhang et al Am J Kidney Dis 2015

SIMILAR EFFECT ON KIDNEY RECOVERY

Zhang et al Am J Kidney Dis 2015

SIMILAR AMOUNT OF FLUID REMOVED

Zhang et al Am J Kidney Dis 2015

CRRT VS. HYBRID OTHER OUTCOMES
Outcome Measure Difference
LOS ICU (d) Mean difference -1.55 d (-7.84, 4.3)
SCr (mg/dL) Mean difference 0.37 (-0.43, 1.17)
Urea (mg/dL) Mean difference -8.56 (-37.17, 20.04)
P (mg/dL) Mean difference -0.31 (-1.50, 0.89)
Heparin (kU/D) Mean difference -4.49 (-12.9, 3.10)
less in observational studies
Vasopressor escalation P = 0.8
Cost EDD<CRRT

Zhang et al Am J Kidney Dis 2015

COST: LOWER

Berbece & Richardson Kidney Int 2006

HYPOTENSION CAN OCCUR WHEN UF

Albino et al Artif Organs 2015

TIPS & TRICS FOR RRT-HYPOTENSION

Bagshaw et al Intensive Care Med 2017

CHALLENGE: AB DOSING

Removal of AB

SLEDD
 DEPARTMENT OF INTENSIVE CARE MEDICINE, GHENT UNIVERSITY HOSPITAL

WHEN NOT TO USE HYBRID

THERAPY
Eric Hoste
WHEN NOT TO USE HYBRID THERAPY
When “off” periods are not desired and 24/7 solute and
fluid removal is probably better
̶ Acute – very severely ill
̶ Acidosis +++
̶ low effective arterial blood volume
̶ Heart failure
̶ High dose of vasoactive drugs
Thank You Very Much!

Eric.Hoste@UGent.be
@erichoste