RRT IN AKI

MODERATOR: Dr. Manoj C

PRESENTER: Dr. Prasad SM
DEFINITION OF AKI
 RRT IN AKI

• Despite temporizing measures, some with severe AKI will require RRT.

• Issues to consider :
1. Timing
2. Modality
3. Prescription
4. Discontinuation of RRT
URGENT INDICATIONS — Accepted urgent indications for RRT in patients with AKI generally
include:

●Refractory fluid overload

●Severe hyperkalemia (plasma potassium concentration >6.5 mEq/L) or rapidly rising potassium levels

●Signs of uremia, such as pericarditis, encephalopathy, or an otherwise unexplained decline in mental

status

●Severe metabolic acidosis (pH <7.1)

●Certain alcohol and drug intoxications (e.g., salicylates,

ethylene glycol, methanol, metformin)
 TIMING

• Though the optimal timing of dialysis for AKI is not clear.

• The risk associated with vascular access placement, anticoagulant administration, hypotension,
arrhythmia, and risk for RRT dependence are the most common factors responsible for the
decision to delay.

• The concern of performing an unnecessary procedure in patients who may recover kidney
function is another major reason to delay.
 • A strategy focusing on RRT as renal support instead of renal replacement, aiming to maintain normal
acidbase, electrolyte, and fluid status along with liberal nutritional support.

• KDIGO RECOMMENDATIONS (2012):

1. Initiate RRT emergently when life-threatening changes in fluid, electrolyte, and acid-base balance exist.
(Not Graded)

2. Consider the broader clinical context, the presence of conditions that can be modified with RRT, and
trends of laboratory tests—rather than single BUN and creatinine thresholds alone—when making the
decision to start RRT. (Not Graded)

Kidney International Supplements (2012) 2, 89–115

Factors to Consider for RRT Initiation
Kidney International Supplements (2012) 2, 89–115
Kidney International Reports (2017) 2, 559–578
• The ELAIN (Early Versus Late Initiation of Renal Replacement Therapy in Critically Ill Patients
With Acute Kidney Injury) trial found that 90-day mortality was significantly lower in patients
randomly assigned to earlier RRT.

• However, this study has been criticized as a single center trial that included many post–cardiac
surgery patients and enrolled patients with early AKI (KDIGO stage 2 AKI and elevated plasma
NGAL).

• In contrast, the AKIKI (Artificial Kidney Initiation in Kidney Injury) Study was a multicenter
trial that randomly assigned patients with more severe (KDIGO stage 3) AKI and did not find a
difference in mortality between early and delayed RRT.
A
K
I
• Multicenter randomized trial
• Patients with severe acute kidney injury KDIGO stage 3
• With the early strategy, RRT was started immediately
• With the delayed strategy, RRT was initiated if at least one of the following criteria

K was met: severe hyperkalemia, metabolic acidosis, pulmonary edema, BUN > 112
mg/dL, or oliguria for more than 72 hours after randomization.
• The primary outcome was overall survival at day 60.

I N Engl J Med 2016; 375:122-133

• No significant difference with regard to mortality between an early and a delayed strategy for the
initiation of RRT.

• A delayed strategy averted the need for renal-replacement therapy in an appreciable number of
patients.
 MODALITY AND PRESCRIPTION

• With regard to modality, the most widely used are CRRT and IHD.

• Prolonged intermittent renal replacement therapies (PIRRTs), such as sustained low-efficiency dialysis
(SLED) and extended-duration dialysis (EDD)

• Peritoneal dialysis can be used in the acute setting as well and can be of particular use in resource-
limited settings.
Kidney International Reports (2017) 2, 559–578
• These modalities are distinguished by their underlying mechanism of solute removal.

• CVVH utilizes convection. Replacement fluid is administered to maintain euvolemia and dilute the
plasma concentration of solutes not present in the replacement fluid (i.e. urea nitrogen, creatinine).

• CVVHD utilizes diffusion and convection. Replacement fluid is not used in CVVHD.

• CVVHDF uses a combination of convection and diffusion. Replacement fluid is also used to maintain
euvolemia as in CVVH.
CRRT
Kidney International Reports (2017) 2, 559–578
• To date, small RCTs and meta-analyses have found no association between modality and outcome
(mortality or renal recovery).

• The KDIGO recommends, CRRT and IHD are complementary therapies; treatment considerations include
the patient’s hemodynamic status and the treating facility’s availability/ experience. Suggests using CRRT,
rather than standard intermittent RRT, for hemodynamically unstable patients and with acute brain injury or
other causes of increased intracranial pressure or generalized brain edema. (2B)
Kidney International Reports (2017) 2, 559–578
• Twenty-one studies were eligible.

• RRT modality was not associated with

In-hospital mortality :
CRRT vs IHD: RR 1.00 [95% CI, 0.92-1.09],

CRRT vs SLED: RR 1.23 [95% CI, 1.00-1.51]) or

Dialysis Dependence:
CRRT vs IHD: RR 0.90 [95% CI, 0.59-1.38],

CRRT vs SLED: RR 1.15 [95% CI, 0.67-1.99]).

 Vascular access

• We suggest initiating RRT in patients with AKI via an uncuffed nontunneled dialysis catheter, rather
than a tunneled catheter.
• When choosing a vein for insertion of a dialysis catheter in patients with AKI, consider these
preferences (Not Graded):

1. First choice: right jugular vein;

2. Second choice: femoral vein;
3. Third choice: left jugular vein;
4. Last choice: subclavian vein with preference for the dominant side
Short-term central venous catheters (CVCs): single- and double-lumen CVC.
A, Double-lumen polyurethane catheter in action. B, Silicone dual catheter in action.
Seldinger method of insertion of a double-lumen polyurethane catheter.
Long-term central venous catheters (CVC): different varieties of double-lumen CVC.
Long-term central venous catheters (CVC): examples of tips configuration.
Long-term central venous catheters (CVCs): dual catheter (independent cannula with splittable extension)
and split catheter
(double-lumen cannula in one body).
Comparison of overall design of various
CVC for acute hemodialysis shows
direction of flow and side hole location.

Spaces indicate side holes.

(A) Shaldon catheters.

(B) Uldall concentric catheter.

(C) Mahurkar DD catheter.

 CATHETER PERFORMANCE

• CVC performance is critically dependent on the manufacturer and the cannula engineering Design

• Judged CVC performance based on four criteria: blood flow delivery, flow resistance, recirculation, and
dialysis dose delivery.
Blood flow

• First, the mean effective flow over time (total amount of blood cleared per session) is more important
than the instantaneous maximum flow achieved during a session.

• Second, the solute clearance of small solutes is not proportional to blood flow above a threshold value
of 200 to 300 milliliters per minute (mL/min).

• Third, the clearance of middle- and large-molecular-weight uremic toxins depends on solute
membrane permeability (low, high, or super-flux) and on solute fluxes (diffusive, convective).

• Fourth, the use of two catheters (independent or split) provides better effective and reliable flow rate
than a double-lumen catheter. In other words, the duration of session and the average blood flow are
essential to deliver adequate dialysis dose based on urea, whereas membrane permeability and solute
fluxes are crucial to the removal of large-molecular-weight solutes.
Flow resistance (R)

• Flow resistance (R) is proportional to the pressure (ΔP) generated by the blood pump and inversely
proportional to the blood flow (QB); this translates into the following equation in which R = ΔP/QB.

• the major objective of manufacturers has been to design catheters with a low resistance profile.

• In laminar flow conditions, the resistance to flow R can be obtained by rearranging the Poiseuille
equation as follows:

• R = P QB = 8μL r4
• where μ is the viscosity, L the length of catheter, and
• r the radius, a surrogate, of the inner lumen diameter.
• Schematically, shortening the catheter by 50% reduces the resistance by half, whereas doubling the
diameter of the catheter increases the flow 16-fold.
Recirculation

• Recirculation is more important with the femoral vein than with subclavian and jugular veins.

• Femoral catheters, particularly short ones, exhibit a high recirculation rate, averaging 20% (5%–38%).

• Internal jugular and subclavian catheters have much lower recirculation rates, averaging 10% (5%–
15%).

• Reversing the bloodline positions during a hemodialysis session, which is sometimes indicated to
correct flow difficulties,70 significantly increases blood recirculation. In this case, the recirculation
value may rise up to 20% or 30%.
• KDIGO recommend using ultrasound guidance for dialysis catheter insertion. (1A)

• KDIGO recommend obtaining a chest radiograph promptly after placement and before first use of an
internal jugular or subclavian dialysis catheter. (1B).

• KDIGO suggest not using antibiotic locks for prevention of catheter-related infections of nontunneled
dialysis catheters in AKI requiring RRT. (2C)
 Dialysate

• The KDIGO suggests using bicarbonate instead of lactate as a buffer in dialysate and substitution
fluid for RRT in patients with AKI (2C), in patients with AKI and circulatory shock (1B), and in
patients with AKI and liver failure and/or lactic acidemia (2B).
 NUTRITION

• The KDIGO guideline recommends up to 1.7 g/kg/d of protein in patients receiving CRRT (2D).
Carbohydrates should be given at 5 to 7 g/kg/d, and lipids, at 1.2 to 1.5 g/kg/d.

• Water-soluble vitamins, micronutrients, and trace elements are also lost during CRRT and should be
replaced during prolonged therapy.
 DOSING
• 2 multicenter randomized controlled trials, the VA/NIH ATN (Veterans Affairs/National Institutes of
Health Acute Renal Failure Trial Network) and

• ANZICS RENAL (Australian and New Zealand Intensive Care Society Randomised Evaluation of
Normal Versus Augmented Level of Renal Replacement Therapy in ICU) studies, found that there was
no difference in mortality or renal recovery when comparing high to low-intensity RRT.
Intermittent Hemodialysis - Dosing

• The 2012 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines for AKI recommend
delivering a Kt/Vof 3.9 per week for patients undergoing intermittent therapy [13].

• While these results are loosely based on the results of the ATN study, several caveats need to be considered.
In the ATN study, the targeted dose of IHD in both treatment arms was a Kt/V of 1.2 to 1.4 per treatment,
with a median delivered Kt/V of 1.3 per treatment

• There is no evidence that more frequent hemodialysis is associated with improved outcomes, unless
necessitated for specific acute indications (eg, hyperkalemia).

• The Hanover Dialysis Outcome (HAND-OUT) study compared extended-duration dialysis (EDD),
provided for approximately eight hours per day, with a more intensive regimen where additional eight-hour
treatment sessions were provided to maintain the blood urea nitrogen (BUN) <42 mg/dL [56]. No
difference in survival or recovery of kidney function was observed with more intensive treatment.
CRRT- Dosing
• Mortality was similar between the two groups at 28 days [769/1884
(40.8%) and 744/1798 (41.4%), respectively; P= 0.40] after
randomization.

• However, more participants assigned to higher intensity therapy

remained RRT dependent at the most common key study point of 28
days [e.g. 292/983 (29.7%) versus 235/943 (24.9%); relative risk 1.15
(95% confidence interval 1.00–1.33); P= 0.05].

• Time to cessation of RRT through 28 days was longer in patients

receiving higher intensity RRT (log-rank test P= 0.02) and when
continuous renal replacement therapy was used as the initial modality
of RRT (log-rank test P=0.03).
Anticoagulation
ACUTE PD

Blood Purif 2017;43:173–178

ISPD RECOMMENDATIONS

• Peritoneal dialysis should be considered as a suitable method of continuous renal replacement

therapy in patients with acute kidney injury (1B).

• PD is relatively contraindicated in patients with recent abdominal surgery, adynamic ileus, intra-
abdominal adhesions, peritoneal fibrosis, or peritonitis.

Perit Dial Int 2014; 34(5):494–517

Daugirdas JT, Blake PG, Ing TS. Handbook of Dialysis. Lippincott Williams & Wilkins; 2014.
• Flexible peritoneal catheters should be used for acute PD where resources and expertise exist
(1C) (Optimal). It may be necessary to use rigid stylet catheters or improvised catheters in
resource-poor environments where they may still be lifesaving (2D) (Minimum standard).

Perit Dial Int 2014; 34(5):494–517

• Catheters should be tunneled in order to reduce peritonitis and peri-catheter leaks (1D).

• No method of insertion of PD catheter is superior to any other overall. We recommend that the
method of implantation should be based on patient factors and local availability of skills,
equipment, and consumables (1D).

• Recommend the use of prophylactic antibiotics prior to insertion of the Tenckhoff Catheter (1C).

• A closed fluid delivery system with a Y connection should be used (1A) (Optimal). In resource-
poor areas spiking of bags and makeshift connections may be necessary (2D) (Minimum
standard). It is imperative that strict asepsis be maintained throughout.
FLUID
• In patients with shock or liver failure, bicarbonate-containing solutions should be used (1B)
(Optimal). Where these solutions are not available, the use of lactate-containing solutions is an
alternative (1D).
• Once potassium levels in the serum fall below 4 mmol/L, potassium should be added to dialysate
using sterile technique(1D).(4-5mmol/L)
Prescription of Acute PD

• Where resources permit, targeting a weekly Kt/V urea of 3.5 provides outcomes comparable to those
of daily HD.

• This dose may not be necessary for many AKI patients and targeting a weekly Kt/V of 2.1 may be
acceptable.

• Short cycle times (every 1–2 hours) in the first 24 hours to correct hyperkalemia, fluid overload,
and/or metabolic acidosis. Thereafter, the cycle time may be increased to 4 – 6 hours depending on
the clinical circumstances (1D).

• Ultrafiltration can be increased by raising the concentration of dextrose and/or shortening the cycle
duration. When the patient is euvolemic, the dextrose concentration and cycle time should be
adjusted to ensure a neutral fluid balance (1B).
Complications

• Peritonitis: It is reasonable to perform a leukocyte count daily for peritonitis surveillance in patients on
acute PD.
• Mechanical complications
• Protein loss
• Hyperglycemia
 Discontinuation of RRT

• The decision to discontinue RRT in patients with AKI is made based on 1 of 3 clinical scenarios:
intrinsic kidney function has adequately improved to meet demands, the disorder that prompted
renal support has improved, or continued RRT is no longer consistent with goals of care.

• In one study of patients on CRRT, 24-hour urine output > 400 mL/d in patients not using diuretics
or >2,300 mL/d in patients using diuretics had >80% chance of successful RRT discontinuation.
• Other studies have suggested that quantitation of timed urinary creatinine and urea excretion (either as
total excretion per 24-hour period or calculation of creatinine and urea clearance) may be helpful.
Prospective studies are needed to help guide clinicians on when to attempt RRT discontinuation.
DISCONTINUING RENAL
REPLACEMENT THERAPY

• There is very little literature to guide the decision to discontinue

• RRT in patients recovering from AKI. The underlying
• insult must have resolved, the patient must have enough
• urine output to avoid volume overload, and RRT usually is
• continued until the patient manifests evidence of recovery
THANK YOU