Category Archives: Renal

From theory to practice – ARDS: An old syndrome, new organ interactions #EuAsia18

The lung and the kidneys (Ostermann)

When kidney function lost, –> reduced clearance , fluid overload, acidosis BUT also inflammation, cytokine release and cell death

The distant organ effects of acute kidney injury

AKI causes a higher degree of capillary leakage within the lungs

Ventilator induced kidney injury

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Bench-to-bedside review: Ventilation-induced renal injury through systemic mediator release – just theory or a causal relationship?
Mechanical ventilation as a mediator of multisystem organ failure in acute respiratory distress syndrome.

Fluid management with a simplified conservative protocol for the acute respiratory distress syndrome

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Lung brain interactions (Oddo)

ARDS in the brain-injured patient: what’s different?

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Issues to consider

  • Oxygenation
  • PEEP
  • CO2/TV

Hyperoxia in intensive care, emergency, and peri-operative medicine: Dr. Jekyll or Mr. Hyde? A 2015 update
Cerebro-pulmonary interactions during the application of low levels of positive end-expiratory pressure.

Effect of hyperventilation on cerebral blood flow in traumatic head injury: clinical relevance and monitoring correlates.
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Heart lung interactions (Cecconi)

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Is tidal volume challenge the new PLR? Use of ‘tidal volume challenge’ to improve the reliability of pulse pressure variation

Or end-expiratory hold?
Predicting volume responsiveness by using the end-expiratory occlusion in mechanically ventilated intensive care unit patients.

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Master Class: AKI and RRT #EuAsia18

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Diagnostic workout of AKI

KDIGO guidelines http://kdigo.org/guidelines/

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Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study.

https://www.ncbi.nlm.nih.gov/pubmed/26162677

Basic investigation for all AKI

  • Renal ultrasound
  • Ca
  • Biochemistry
  • Urinalysis – microscopy and electrolytes

The subsequent tests are guided by the clinical picture and history

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A prospective evaluation of urine microscopy in septic and non-septic acute kidney injury.

https://www.ncbi.nlm.nih.gov/pubmed/21669886

Renal biopsy can be diagnostic and can provide information about background histology. 85% of pts develop peri-renal haematoma.

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Future – renal biomarkers

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Summary

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When to start and when to stop RRT

Does this patient with AKI need RRT? https://www.ncbi.nlm.nih.gov/pubmed/26690077 

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Strategies for the optimal timing to start renal replacement therapy in critically ill patients with acute kidney injury. https://www.ncbi.nlm.nih.gov/pubmed/28222898

Renal replacement therapy in critically ill patients with acute kidney injury–when to start.

https://www.ncbi.nlm.nih.gov/pubmed/22231034

The optimal time of initiation of renal replacement therapy in acute kidney injury: A meta-analysis https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5620297/

Effect of Early vs Delayed Initiation of Renal Replacement Therapy on Mortality in Critically Ill Patients With Acute Kidney Injury: The ELAIN Randomized Clinical Trial.

https://www.ncbi.nlm.nih.gov/pubmed/27209269

Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit http://www.nejm.org/doi/full/10.1056/NEJMoa1603017

 

When to stop –

  1. Has the original precipitant for the AKI resolved?
  2. Is there evidence of some degree of recovery of kidney function?
  3. Has any fluid overload been resolved?

Can this patient be safely weaned from RRT?

https://link.springer.com/content/pdf/10.1007/s00134-017-4948-0

 

The terms ‘early’ and ‘late’ RRT should be replaced with TIMELY RRT

Furosemide stress test/challenge test – 0.5-1mg/kg.

 

How to select mode of RRT

Depends on resources, where you work

Acute Renal Failure in Critically Ill Patients: A Multinational, Multicenter Study

https://jamanetwork.com/journals/jama/fullarticle/201386

Intermittent versus continuous renal replacement therapy for acute renal failure in adults: cochrane review

http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD003773.pub3/full

 

Modality on mortality – no strong data to support continuous or intermittent RRT

 

Intensity of Continuous Renal-Replacement Therapy in Critically Ill Patients

http://www.nejm.org/doi/full/10.1056/NEJMoa0902413

Nice comparison of IHD vs CRRT vs SLED https://lifeinthefastlane.com/ccc/ihd-vs-crrt-vs-sled/

 

The dose of RRT

No benefits to higher intensity RRT

Target 25ml/kg/hr

 

Drug dosing during RRT

Does anyone adjust drug dosing when pt is on SLEDD? If so, how? Even the pharmacist disagree on what to do – Survey of pharmacists’ antibiotic dosing recommendations for sustained low-efficiency dialysis. https://www.ncbi.nlm.nih.gov/pubmed/26499505

SaMpling Antibiotics in Renal Replacement Therapy (SMARRT): an observational pharmacokinetic study in critically ill patients

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4773999/

 

 

 

EuAsia Day 3: Metabolic issues

Hyponatraemia: European guidelines (E Hoste)

Proportion of ICU pts with hypoNa (<135) – 14 to 27%

Acute hypoNa – < 48hrs

Symptoms variable

Guideline recommends treating for severe symptomatic hypoNa with 150mls of 3%NaCl over 20 minutes, aim for Na increase of 5mmol/L

Aim to correct severe hypoNa by 10mmol/L in D1 (8mmol/L D2) until pt asymptomatic or Na >130

IF corrected too quickly – add in 5% dextrose and/or consider desmopressin 2mcg (per 8hr)

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References:

Clinical practice guideline on diagnosis and treatment of hyponatraemia

 

Nutrition in ICU (Ostermann)

Malnutrition is associated with poor outcome

Critically ill patients lose 10-20% of body protein within a week

Resting energy expenditure – Estimation/Harris and Benedikt/Indirect calorimetry

TICACOS trial – enteral feeding with energy target determined by estimation (control) vs indirect calorimetry

  • Improved survival in pts where targets were met
  • Better outcomes in control group (estimation 25kcal/kg/day)

CALORIES Trial (TPN)

  • No significant difference in groups

ESICM Guidelines (2017)

  • Early enteral nutrition as a default
  • Delay enteral nutrition in specific cases e.g. uncontrolled shock, bowel ischaemia, life threatening hypoxaemia/hypercapnia/acidosis
  • Not to delay EN in prone position

ASPEN (2016)

  • PN initiated ASAP in high risk groups if EN not feasible
  • PN can be considered in low risk pts after 7-10 days if unable to meet >60% energy goal
  • Immune0modulating enteral formulation should be considered in pts with severe trauma or TBI or post-operatively

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References:

The tight calorie control study (TICACOS): a prospective, randomized, controlled pilot study of nutritional support in critically ill patients.

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient

Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines

 

Liver failure: how to support (Gruber)

Liver dysfunction common but acute liver failure is rarer

Liver dysfunction post immunotherapy (as part of cancer treatment) is not uncommon

  • Supportive care
  • Steroids 1-2mg/kg/day

Commonest cause on ICU – sepsis

Cirrhotic pts have vascular hypo-reactivity due to increase NO levels

Relative adrenal insufficiency is common

Septic liver pts

  • Supportive
  • Prophylaxis – encephalopathy, GI bleeds, infection
  • High risk of fungal infection

Acute variceal haemorrhage

  • oesophageal varices common
  • Peak re-bleed day 5
  • Endoscopic and interventional radiology interventions
  • Reduction of portal pressure – octreotide, somastatin etc

AKI common but majority is NOT hepato-renal syndrome (HRS)

  • 2 types of HRS: type 1 rapid and poorer outcomes
  • Specifically for HRS: albumin/terlipressin
  • RRT as a bridge (consider citrate)

Liver support systems

  • MARS, RELIEF, PROMETHIUS
  • Failed to show mortality benefits

References:

Acute-on-chronic liver failure definitions

Acute esophageal variceal bleeding: Current strategies and new perspectives

EuAsia Day 2: AKI

Epidemiology of AKI and outcome (YS Guh)

AKI characterised by rapid decrease in renal excretory function

Continuum of injury as it develops which corresponds to worsening prognosis

Multiple definitions with limitations e.g. all depend on urine output and creatinine

Most common cause of AKI – SEPSIS

Increase mortality and morbidity in AKI

CKD is a major risk factor for AKI

The quicker pts recover from the AKI, the better the outcome

2017-04-07 10.57.13 2017-04-07 10.56.51 2017-04-07 11.09.29

References

RIFLE criteria for AKI

AKIN criteria for AKI 

KDIGO definitions

Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study.

Recovery after Acute Kidney Injury (2017)

 

Biomarkers for AKI: what, why, how (@erichoste)

Multiple biomarkers available and indicate different things

May be improve the diagnosis of AKI

Not a single delegate in the room uses biomarkers in clinical practice

Interesting but how does it translate to clinical outcomes/management is currently unknown

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Interactions of AKI with other organs (K Chan)

Affects all organ systems

5 types of cardiorenal syndromes

Relationship with AKI and brain is 2 way

2017-04-07 11.31.47 2017-04-07 11.44.21

 

References:

Acute kidney injury: short-term and long-term effects 

Cardiorenal syndromes

Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit 

 

Contrast-associated AKI: an issue? (M Ostermann)

Incidence depends on pt groups and criteria for AKI

Most of work done in cardiac patients

Most contrast agents have iodine, high isomolarity compared to plasma and have high viscosity

Impact of contrast – contrast-induced AKI associated with poor short and long term outcomes after PCI for STEMI (HORIZONS-AMI) BUT significant limitations

Newer evidence suggest the risk is for pts who had poor renal function prior OR no risk at all

2017-04-07 12.01.05 2017-04-07 12.13.19 2017-04-07 12.14.31

 

References

Contrast-induced acute kidney injury after primary percutaneous coronary intervention: results from the HORIZONS-AMI substudy.

Acute kidney injury in the critically ill: is iodinated contrast medium really harmful?

Post-contrast acute kidney injury in intensive care unit patients: a propensity score-adjusted study.

Contrast-associated acute kidney injury in the critically ill: systematic review and Bayesian meta-analysis.

Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospective, randomised, phase 3, controlled, open-label, non-inferiority trial