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/