Category Archives: Renal

Renske chats with Jim Watchorn and Sam Hutchings about the kidney! At #LIVES2019

 

ABSTRACT

All adult intubated patients in critical care were eligible for inclusion using an emergency waiver of consent. A minimum of four standardized video clips were taken by an investigator using an incident dark field (IDF) video-microscope (Cytocam, Braedius Medical, NL) who subsequently calculated a POEM score and recorded the time taken. On completion a second investigator blinded to the results of the first repeated this process. At a later stage (>1 month) investigators re-scored their own and their co-investigators images. Scores were analysed using Cohens weighted Kappa score to provide intra-user, inter-user and test-retest reliability. A kappa statistic was also calculated for test-retest reliability for POEM score 1-3 against POEM score 4-5 which is the threshold for fluid administration used in an ongoing interventional study (Clinical Trials.gov  ID).

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

IMG_3154

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

IMG_3155IMG_3154

Lung brain interactions (Oddo)

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

IMG_3158 IMG_3157

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.
Screen Shot 2018-04-14 at 11.30.11

Heart lung interactions (Cecconi)

IMG_3159

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.

 IMG_3162

Master Class: AKI and RRT #EuAsia18

Screen Shot 2018-04-12 at 12.03.43

Diagnostic workout of AKI

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

IMG_3069

 

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

IMG_3075

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.

IMG_3073

Future – renal biomarkers

IMG_3074

Summary

IMG_3075

 

When to start and when to stop RRT

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

IMG_3077

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)

Screen Shot 2017-04-08 at 09.07.08

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

C82tGuTU0AAzQVA
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