Quality Assurance in RRT for AKI in critically ill patients

What quality indicators should we use?

Quality indicators need the following

  • Measurable clinical outcomes
  • Technical adherence to standards
  • Assessment of interpersonal relationships as defined by stakeholders

What constitutes quality CRRT? KDIGO says the following:

  • Initiate RRT emergency when life-threatening metabolic changes (Not graded)
  • Consider broader clinical context and conditions which can be modified with RRT rather than absolute values of lab tests when deciding to start RRT (not graded)
  • Discontinue when no longer required (not graded)
  • Avoid subclavian route
  • Use heparin as first line anticoagulant

At the moment there is significant heterogeneity in practicalities of delivering CRRT in critical care.

Potential protocol derived themes

  • Dose delivered
  • Dose prescribed
  • Catheter site
  • Anticoagulant use and monitoring
  • Unplanned circuit loss

Easily measurable but relevant?

Technical outcome measures

  • Filter downtime
  • Unplanned circuit loss
  • Fluid balance target achieved
  • Blood loss
  • Hypotension
  • Metabolic complications

Harder to measure but enable intervention and what is the true clinical standard for these

Patient centred

  • Survival
  • Renal recovery
  • Development of CKD
  • Access complications
  • Measure of health and well-being

Most relevant but hardest to study

We suspect a dose-response relationship exists between RRT and outcome but we don’t know where inflection point is!

3219403_cc9415-1

We can’t even be sure patients get the dose we prescribe; 25% of patients in the RENAL study failed to achieve dose target, even in this tightly moderated environment. How does this compare to real life? It seems like a suitable QI but may be difficult to define what is best practice.

What about fluid balance? A positive fluid balance is associated with poor outcomes but may be limited by how well patients tolerate fluid removal.

Using renal recovery depends on baseline population – what is the underlying pathology? Is it reversible?

Safe practice may not be best quality practice

KDIGO Clinical Practice Guideline

Quality indicators in continuous renal replacement therapy (CRRT) care in critically ill patients: protocol for a systematic review

Intensity of Renal Support in Critically Ill Patients with Acute Kidney Injury

Intensity of Continuous Renal-Replacement Therapy in Critically Ill Patients

Clinical review: Optimal dose of continuous renal replacement therapy in acute kidney injury

Fluid Overload

 

Choice of RRT modality for AKI and effect upon long-term dialysis dependence

KDIGO says CRRT and HD complementary therapies in AKI

CRRT recommended in unstable or acute brain injury. However it is more expensive but costs vary across the globe. What is renal recovery though? There is no international consensus but most define it as freedom from renal replacement therapy.

RRT has been associated with less chronic renal failure than IHD but quality of evidence has been questioned. CRRT is more commonly used in modern ICU. IHD may no longer be cheaper with modern care.

Cost of acute renal replacement therapy in the intensive care unit: results from The Beginning and Ending Supportive Therapy for the Kidney (BEST Kidney) Study

Hemofiltration compared to hemodialysis for acute kidney injury: systematic review and meta-analysis

Continuous renal replacement therapy is associated with less chronic renal failure than intermittent haemodialysis after acute renal failure

Choice of renal replacement therapy modality and dialysis dependence after acute kidney injury: a systematic review and meta-analysis

The association between renal replacement therapy modality and long-term outcomes among critically ill adults with acute kidney injury: a retrospective cohort study