Renalreplacementtherapy

MarliesOstermann

Guy’s&StThomasHospitalLondon

Disclosures

Speakerhonoraria:Fresenius MitsubishiTanabePharma Biomerieux Baxter

Advisoryrole: Gilead

Gambro-Baxter Fresenius Nxstage

Researchfunding: FreseniusMedicalCare

LaJollaPharma Baxter

RRT-officialguidelines

NospecificrecommendationregardingRRT

RRT-officialguidelines

NocommentregardingRRT

RRT-officialguidelines

RRToptions

ContinuousextracorporealRRTCVVHF,CVVHDF,CVVHD,(CAVH)IntermittentRRTstandardintermittentHDsustainedlowefficiencydialysis(SLED)prolongedintermittentRRT(usingstandardHDorCRRTmachine)PeritonealdialysisCAPDautomatedPD

IHD SLEDPIRRT PD CRRT

intermittentcontinuous

Clearance++++++perhourFluidstatusFluctuationsinurea/NH3/Na+

RRToptions

RRToptionsinCOVID-19patients

RRToptionsinCOVID-19patients

Idealsituation Reality

CRRT limitedresources

initiationbeforeonsetoflifethreateningcomplications

needforrationingandapplicationofstrictercriteria

prescriptionofdosecompensatesforunplanned‘downtime’

limitedfluids

optimalanticoagulationtomaintainfilterpatency

highriskoffilterclogging/clotting

highlyqualifiedstaff lessqualifiedstaff/surgestaff

ICUenvironment non-criticalcareareaprovisionaccordingtohighstandardsandbenchmarks

needtolowerstandards

RRToptionsinCOVID-19patients

Idealsituation Reality

CRRT limitedresources/supplies

initiationbeforeonsetoflifethreateningcomplications

needtoapplystrictercriteria

prescriptionofdosecompensatesforunplanned‘downtime’

limitedfluids

optimalanticoagulationtomaintainfilterpatency

highriskoffilterclogging/clotting

highlyqualifiedstaff lessqualifiedstaff/surgestaff

ICUenvironment non-criticalcareareaprovisionaccordingtohighstandardsandbenchmarks

needtolowerstandards

RRToptionsinCOVID-19patients

Alternative:IntermittentRRTStandardhaemodialysis(4hr)

prolongedintermittentRRT(6-8hr)

needforHDmachine standardHDorCRRTmachine

requiressufficientwateranddrainresourcesandROsystemtogeneratedialysateorfluidsinbags(mobileunit)

waterviaROsystem(HD)orfluidsinbags(mobilecarts,CRRT)

noabsoluteneedforanticoagulation

usuallyneedforanticoagulation

trainedstaff/extrastaff trainedstaff/extrastaff

potentialtotreat4-5pts/day potentialtotreatupto3pts/day

RRToptionsinCOVID-19patients

Alternative:IntermittentRRTStandardhaemodialysis(4hr)

prolongedintermittentRRT(6-8hr)

needforHDmachine standardHDorCRRTmachine

requiressufficientwateranddrainresourcesandROsystemtogeneratedialysateorfluidsinbags(mobileunit)

waterviaROsystem(HD)orfluidsinbags(mobilecarts,CRRT)

noabsoluteneedforanticoagulation

usuallyneedforanticoagulation

trainedstaff/extrastaff trainedstaff/extrastaff

potentialtotreat4-5pts/day potentialtotreatupto3pts/day

RRToptionsinCOVID-19patients

Alternative:IntermittentRRTStandardhaemodialysis(4hr)

prolongedintermittentRRT(6-8hr)

needforHDmachine standardHDorCRRTmachine

requiressufficientwateranddrainresourcesandROsystemtogeneratedialysateorfluidsinbags(mobileunit)

waterviaROsystem(HD)orfluidsinbags(mobilecarts,CRRT)

noabsoluteneedforanticoagulation

usuallyneedforanticoagulation

trainedstaff/extrastaff trainedstaff/extrastaff

potentialtotreat4-5pts/day potentialtotreatupto3pts/day

RRToptionsinCOVID-19patients

Alternative:IntermittentRRTStandardhaemodialysis(4hr)

prolongedintermittentRRT(6-8hr)

needforHDmachine standardHDorCRRTmachine

requiressufficientwateranddrainresourcesandROsystemtogeneratedialysateorfluidsinbags(mobileunit)

waterviaROsystem(HD)orfluidsinbags(mobilecarts,CRRT)

noabsoluteneedforanticoagulation

usuallyneedforanticoagulation

trainedstaff/extrastaff trainedstaff/extrastaff

potentialtotreat4-5pts/day potentialtotreatupto3pts/day

RRToptionsinCOVID-19patients

Alternative:IntermittentRRTStandardhaemodialysis(4hr)

prolongedintermittentRRT(6-8hr)

needforHDmachine standardHDorCRRTmachine

requiressufficientwateranddrainresourcesandROsystemtogeneratedialysateorfluidsinbags(mobileunit)

waterviaROsystem(HD)orfluidsinbags(mobilecarts,CRRT)

noabsoluteneedforanticoagulation

usuallyneedforanticoagulation

trainedstaff/extrastaff trainedstaff/extrastaff

potentialtotreat4-5pts/day potentialtotreatupto3pts/day

RRToptionsinCOVID-19patients

Alternative:IntermittentRRTStandardhaemodialysis(4hr)

prolongedintermittentRRT(6-8hr)

needforHDmachine standardHDorCRRTmachine

requiressufficientwateranddrainresourcesandROsystemtogeneratedialysateorfluidsinbags(mobileunit)

waterviaROsystem(HD)orfluidsinbags(mobilecarts,CRRT)

noabsoluteneedforanticoagulation

usuallyneedforanticoagulation

trainedstaff/extrastaff trainedstaff/extrastaff

potentialtotreat4-5pts/day potentialtotreatupto3pts/day

Principle:Useofperitonealmembranetoremovesolutesandwater

RRToptionsinCOVID-19patients

Alternative:acuteperitonealdialysis

peritonealcavity

hyperosmolarfluid

watersmallmolecules

PDinCOVID-19patients

PD exchange

PDinCOVID-19patients

PD exchange

PDinCOVID-19patients

Vou

CAPDVolume:2–2.5LDwelltime:4–6hrs

Clearancecanbeincreasedbyusingfluidwithhigherglucoseconcentrationoradditionofotherosmoticallyactivesubstances

PDinCOVID-19patients

CAPD continuousambulatoryperitonealdialysis: 4manualexchangesadaywithfluidleftin peritonealcavityinbetween

APD automatedperitonealdialysis:

usingamachinethatmovesfluidinandout oftheabdomenwhilstpatientisasleep

PDinCOVID-19patients

PDinCOVID-19patients

Acuteperitonealdialysis

Advantages Disadvantages

continuousRRT needforperitonealcatheter

noneedforHD/CRRTmachine needfor’kit’noneedforanticoagulation limitedcontroloffluidremoval

establishedtechniqueincriticallyillpatientsinsomecountries(ieprotocolsavailable)

needfortraining/education

noneedforvascularaccess riskofacuteleak(espinproneposition)riskofperitonitis

PDinCOVID-19patients

Acuteperitonealdialysis

Advantages Disadvantages

continuousRRT needforperitonealcatheter

noneedforHD/CRRTmachine needfor’kit’noneedforanticoagulation limitedcontroloffluidremoval

establishedtechniqueincriticallyillpatientsinsomecountries(ieprotocolsavailable)

needfortraining/education

noneedforvascularaccess riskofacuteleak(espinproneposition)riskofperitonitis

RRTduringCOVID-19pandemic

Challenges•  ChallengesrelatedtoacuteCOVID-19disease(hyperinflammation,

pro-coagulantstate)

•  Limitedresources-->potentialneedtoadaptRRTplans(environment,machines,consumables,staff)

•  Adoptionofunfamiliartechniques•  Urgentneedforcontinuouseducation/audit/researchduringbusy

times•  Increasedlevelof‘stress’atthebedside(physical,emotional,moral,

PPE,lessexperiencedstaff)•  Preparednesstochangeplansquickly

RRTduringCOVID-19pandemic

Challenges•  ChallengesrelatedtoacuteCOVID-19disease(hyperinflammation,

pro-coagulantstate)

•  Limitedresources-->potentialneedtoadaptRRTplans(environment,machines,consumables,staff)

•  Adoptionofunfamiliartechniques•  Urgentneedforcontinuouseducation/audit/researchduringbusy

times•  Increasedlevelof‘stress’atthebedside(physical,emotional,moral,

PPE,lessexperiencedstaff)•  Preparednesstochangeplansquickly

RRTduringCOVID-19pandemic

Challenges•  ChallengesrelatedtoacuteCOVID-19disease(hyperinflammation,

pro-coagulantstate)

•  Limitedresources-->potentialneedtoadaptRRTplans(environment,machines,consumables,staff)

•  Adoptionofunfamiliartechniques•  Urgentneedforcontinuouseducation/audit/researchduringbusy

times•  Increasedlevelof‘stress’atthebedside(physical,emotional,moral,

PPE,lessexperiencedstaff)•  Preparednesstochangeplansquickly

RRTduringCOVID-19pandemic

Challenges•  ChallengesrelatedtoacuteCOVID-19disease(hyperinflammation,

pro-coagulantstate)

•  Limitedresources-->potentialneedtoadaptRRTplans(environment,machines,consumables,staff)

•  Adoptionofunfamiliartechniques•  Increasedlevelof‘stress’atthebedside(physical,emotional,moral,

PPE,lessexperiencedstaff)•  Preparednesstochangeplansquickly•  Urgentneedforcontinuouseducation/audit/researchduringbusy

times

RRTduringCOVID-19pandemic

Challenges•  ChallengesrelatedtoacuteCOVID-19disease(hyperinflammation,

pro-coagulantstate)

•  Limitedresources-->potentialneedtoadaptRRTplans(environment,machines,consumables,staff)

•  Adoptionofunfamiliartechniques•  Increasedlevelof‘stress’atthebedside(physical,emotional,moral,

PPE,lessexperiencedstaff)•  Preparednesstochangeplansquickly•  Urgentneedforcontinuouseducation/audit/researchduringbusy

times

RRTduringCOVID-19pandemic

Challenges•  ChallengesrelatedtoacuteCOVID-19disease(hyperinflammation,

pro-coagulantstate)

•  Limitedresources-->potentialneedtoadaptRRTplans(environment,machines,consumables,staff)

•  Adoptionofunfamiliartechniques•  Increasedlevelof‘stress’atthebedside(physical,emotional,moral,

PPE,lessexperiencedstaff)•  Preparednesstochangeplansquickly•  Urgentneedforrapideducation/audit/researchduringbusytimes

RRTduringCOVID-19pandemic

Teamworkidentificationofskillmix

collaborationwithotherteams(renal,paeds)

Equipment/consumables•  machines(CRRT,mobileHD,PDmachines)

•  consumables

•  compatibilityofkit

•  accesstoROunits/mobileROunits

•  alternativestocommercialfluids

RRTduringCOVID-19pandemic

Patientselection•  absolutecriteriaforinitiationofRRT•  identificationofpatientssuitableforintermittentRRT(HD,PIRRT)

Preservationofequipment/consumables/staff•  intermittenttherapiesversusCRRT

•  HDvia“plumbedwatersystem”ormobileRO

•  useof“home-made”dialysisfluid(usualpracticeinmanycountries)

•  optimisationoftechniquestomaintainfilterpatency

•  criteriaforweaning/discontinuationofRRT•  identificationofpatientssuitablefortransfertorenalunit

Filterpatency

190-215µm

35-50µm

Ahumanhairhasathicknessofabout0.09mm=90µm

Blood

ultrafiltrate

Hkt

Filterpatency

Innersurfaceofdialyzermembraneduringhemodialysistherapy:densefibrinnetworkwithlargeamountsofaggregatederythrocytesdespiteheparin

HofbauerRetal,KI1999;56,1578–1583Effectofanticoagulationonbloodmembraneinteractions

Filterpatency-clotting

IbaTetal,2020

Hyperinflammationandclotting

Protein

Filterpatency-clogging

Protein

Filterpatency-clogging

protein“cake”

Bloodcomponentsaccumulateinsidetheporesofthemembraneandblockthepores

Permeabilityandultrafiltrationareimpaired

Membraneclogging Clotsformandblockthelumenofthefilter

Flowisimpaired

Membraneclotting

Filterpatency–cloggingvsclotting

HighprevalenceofcloggingandclottinginCOVID-19Prevention:anticoagulation

reductionofUFrate switchfromHFtoHD

Strategiestokeepfilterpatent•  Haemodilution(pre-dilution/regularsalineflushes)•  Anticoagulation

Heparin(systemicvsviacircuit,unfractionatedvsLMWH)

Epoprostenol

Regionalanticoagulation(citrate)

Others(argatroban,hirudin,fondaparinux)

Combinations:citrate&heparin heparin&epoprostenol

•  Goodvascularaccess!

Vascularaccess

CVVHDLowerbloodflowrate(100-150ml/min):12Fr

CVVHFHigherbloodflowrates(~200-250ml/min):12Fr

IntermittentHDHighbloodflowrate(≥200-350ml/min): 12-14Fr

Mrozek et al. Annals of Intensive Care 2012

Vascularaccess

OtherstrategiestopreventRRT

OtherstrategiestopreventRRT

•  preventionofAKI

•  loopdiureticsforfluidoverload

•  minimisationoffluidintakeinbetweenRRTsessions

•  lowKfeed

•  K-binders

•  NaHCO3formetabolicacidosis

Roleofbloodpurification

IbaTetal,2020

Roleofbloodpurification

Roleofbloodpurification

COVID-19

Cytokine removal

Crosstalk Interventions

Pore density

Cytokine Removal

Organ Crosstalk

Cytokine storm

Albumin 66 kDa

MCO

Myoglobin 17 kDa β2MG 12 kDa

Pore

den

sity

Roleofbloodpurification

AKI

RRT

Otheressentials

Mostimportantweapons:teamworkknowledgeresilience

Thereisnouniversalplan!CircumstanceschangequicklyPreparednessandflexibilityareessential

Conclusions

•  Officialguidelinessuggest”standardRRT”

•  Challengesdueto: frequentclotting/clogging limitedresources adoptionofalternativemethods

•  Roleofbloodpurificationunknown

Thankyou