nutritional implications of renal replacement therapy in icu therapy … · 2013-09-08 ·...
TRANSCRIPT
ESPEN Congress Vienna 2009
Nutritional implications of renal replacement therapy in ICU
Why and how renal replacement therapy is used
M. Joannidis (Austria)
WHY and HOWrenal replacement therapy is
used?
M. JoannidisICU, Dept Internal Medicine IMedical University Innsbruck
„Critical illness“
Acute Stress Response
Trauma/Infection
Immunological
Response
Neuroendocrine Response
Metabolic Response
Iatrogenic Factors
ESPEN Congress Vienna 2009
Normoglycaemia in the acute patient not so crucial - and potentially
Hazardous
F. Brunkhorst (Germany)
WHY
should we use RRT?
Correct answer
„To replace the function of the most important organ of the body“
(Single) Organ Dysfunction and Hospital LOS
Liangos et al. CJASN 2006
Are we doing a good job..….by replacing renal function?
Do patients survive with this treatment?
End Stage Renal Disease
• 30% patients die within the first 12 months after starting dialysis
Mortality of AKI in ICU patients requiring RRT and not requiring RRT
Clermont G,Kidney Int. 2002
Loss of Renal Function
Consequences
• Uremia• Acid-base disorders
->Metabolic Acidosis• Electrolyte disorders (K+)• Endocrine disorders
(Vit D3, EPO, GH)• Metabolic disorder• Hypervolemia ( ↓ fluid excretion)• Inflammation
Chronic
++
++
++/--
Acute
+/-+/-
+/--
-++
Loss of Renal Function
Consequences
• Uremia• Acid-base disorders
->Metabolic Acidosis• Electrolyte disorders (K+)• Endocrine disorders
(Vit D3, EPO, GH)• Metabolic disorder
• Hypervolemia (↓ fluid excretion)
• Inflammation
Chronic
++
++
++/--
Acute
+/-+/-
+/--
-++
RRT
Why RRT….
Based on which criterion?
• GFR (eGFR)?• UO?• Acid-base?• Electrolytes?
CKD
AKI
Early vs late start of RRT
Liu et al, CJASN 2006
Initiation of CRRT A worldwide practice survey (B.E.S.T kidney)
• Oliguria/anuria 70.2%
• High urea/creatinine 53.0%
• Metabolic acidosis 43.6%
• Fluid overload 36.7%
Uchino et al, Intensive Care Med 2007
• Intubation
Start of CRRT in SEPSIS
• vasopressors
Death
• IRV
• AKI
Clinical trials -CRRT in Sepsis
• randomized trial with 24 pt. in early septic shock
• 48 h isovolemic CVVH 2L/h vs. stand. med. treatment
• 72 h observation period• primary parameters:
– C3a + C5a, interleukins 6, 8 + 10, TNF
– MODS
• No significant changes in cytokines or C3a + C5a by CVVH
• MODS – no difference between both groups.
• CVVH does not result in improvement of oxygenation or hemodynamics
Cole L et al., Crit Care Med 2002
Initiation of CRRT:Early isovolumetric CVVH in septic schock
Survival
Piccinni, Intensive Care Med 2005
40 postoperative pats.•septic shock•acute lung injury
Intitation-criterion:•oliguria >12h
•Modality:•CVVH
•45 ml/kg/h 8h•20 ml/kg/h 16h•daily filter change
HOW?Intermittent RRT (IRRT)
HOW?Continuous RRT (CRRT)
CVVHF
CVVHDFSLED
Which modality of RRT in (critically ill) patients?
IHDCVVHD
PD
CVVHDF vs IHD for acute kidney injury in patients with MODS
• RCT• N=360 (175 HDF/189 IHD)• Sepsis 56% /69% • SAPS II 64 /65• Katechol 89% /86%
Vinsonneau C, Lancet 2006
The VA/NIH Acute Renal Failure Trial Network.Patients
Enrollment, Randomization, and Follow-up of Study
N Engl J Med 2008;359:7-20
IHD daily or SLED orCVVHDF 35 ml/kg/h
IHD every other day or SLED or
CVVHDF 20 ml/kg/h
Recommendation:
-> use the cheapest modality-> use the lowest intensity possible
n=1124
General considerations
• Dose delivery – Physicochemical differences: convection
vs. diffusion• Hemodynamic stability• Fluid removal• Costs
QB= 150-250 ml/minQF = 20 - 50 ml/minConvection +++Diffusion -Adsorption +
-> Urea Clearance ~ 20 - 50 ml/min
Continuous
0
TMP
Ultrafiltrate
Substitutionfluid
TMP
Dialysate
QB= 100-150 ml/minQD = 20 - 50 ml/minConvection +Diffusion +++Adsorption +
Hemofiltration (HF) Hemodialyis (HD)
0
0,25
0,5
0,75
1
10 100 1000 10.000 100.000
HFHD
Sieving-coefficient and Treatment modality
Molekülgröße (D)
Sie
bkoe
ffizi
ent
urea
CVVHF
CVVHDFSLED
Why should we need ….
IHDCVVHD
QB= 100 - 250 ml/minQD= 10 - 35 ml/minQF = 10 - 50 ml/minQD+ QF = 20 - 85 ml/min
Convektion +++Diffusion +++Adsorption +Urea. Cl. ~ 20 - 85 ml/min
Hemodiafiltration (HDF)
0
TMP
dialysateultrafiltrat(+dialysate)
substitutionfluid
Additional small molecular clearance by CVVHDF
Kindgen-Milles et al 2000
Is increased middle molecule clearance clinically relevant??
Impact of added dialysis dose on survival in ARF
Saudan P., Kidney Int 2006
(UF~25 ml/kg/h)
(UF+D~42ml/kg/h)
p=0.03
28 day mortality: 61% vs 41%, p= 0.0390 day mortality: 66% vs 41%, p =0.0005
N=206 , Apache II ~ 26, 60% patients with sepsis
weekly Kt/V~ 11
~ 7
Requirement of CVVHDF mainly resulted from technical limitaions of some older CRRT machines ….
QB= 200 - 350 ml/minQD= 500 (- 800) ml/minConvection +Diffusion +++Adsorption +
-> Urea Cl. ~ 200 - 300 ml/min
Intermittent Hemodialysis (IHD)
0
TMP =400
Dialysate
/treatment time!!!
Hybrid Techniquese.g. Sustained Low Efficiency Dialysis (SLED)
• F60S, 1.3 m²• QB=200 ml/min• QD=100 ml/min• duration of a single
session 8-12 h
Kielstein JT, AJKD 2004
Effects of different modalities of RRT on BUN
Time (day)0 1 2 3 4 5 6 7
BU
N (m
g/dL
)
0
20
40
60
80
100
120
CVVHIHDSLED
Liao Z., Artif.Organs 2003
Effects of different modalities of RRT on middle molecules (ß2-MG)
Liao Z., Artif.Organs 2003
Time (day)0 1 2 3 4 5 6 7
b2M
(mg/
dL)
0
1
2
3
4
5
6
CVVHIHDSLED
Effects of different modalities of RRT on Phosphate Removal
CRRT > SLED > IHD
Extended Daily Dialysis versus CVVH: Effect on Acid-base Balance
Baldwin I, Intensive Care Med 2007
Bicarbonate Base Excess
SLED: Qd=280 ml/min, 8h/dCVVH: UF=2L/hN=16
General considerations
• Dose delivery – Physicochemical differences: convection
vs. diffusion• Hemodynamic stability• Fluid removal• Costs
CVVH vs. IHD in Septic Shock
John S. (2001), NDT 16: 320IHD (n=10) CVVHF (n= 20)
Hemodynamic EffectsSLED vs CVVH
Kielstein J, AJKD 2003
MAP HR
CO SVR
RCT, n=19/20, ICU pat. + ARF + mechanical ventilation
Choice of Modality Initiation
Continuation
UnstableStable
N Engl J Med 2008;359:7-20
Fluid removal-Example:patient with ARF, 70 kg BW,average daily fluid intake 4L
Daily IHD: 3 h23 ml/min
0.4 ml/min/kg
CVVH: 24 h2.5 ml/min
0.03 ml/min/kg
SLEDD: 12 h 5.5 ml/min
0.09 ml/min/kg
Required ultrafiltration
4000 ml/24 h
Frequency of Hypotensive Episodes
Ronco et al, Int. J. Artif. Organs 1988
SLED IHDCVVH
…..Costs
Comparison of costs of RRT
Manns B, Crit Care Med 2003
Berbece AN , Kidney Int 2006
Comparison of costs of RRT
Summary
CVVH(DF) IHD (daily) SLED
Middle molecules ++ - -
Hemodynamic tol. ++ +/- ++
Fluid removal ++ +/- +
Dose ++ +/- +
Costs - + ++
Renal Recovery ++ - ?
Anticoagulation - + +/-
The Principle of Peritoneal Dialysis
CAPD
High volume peritoneal dialysis vs daily hemodialysis:
A randomized, controlled trial in patients with acutekidney injury
N=60/60
Gabriel DP, Kidney Int 2008
High volume peritoneal dialysis vs daily hemodialysis:
A randomized, controlled trial in patients with acutekidney injury
• Peritonitis 18% (HVPD)• Catheter Infection 13% (DHD)
• weekly Kt/V 3.6 (HVPD)• weekly Kt/V 4.7 (DHD)
Gabriel DP, Kidney Int 2008
CRRT, SLED ….CVVHF
CVVH
DF
SLED
IHD
CVVHD
PD
Take Home Messages
• Dose:
• Inititation:
1) „Individualised“ dose!2) Minimal dose:
>20-22ml/kg/h CRRT>1.3 Kt/V (4h) IHD
early:• Oliguria/Acidosis (?)• BUN >50-70 mg% (?)