AKI and CRRT: Progress over the last 2 decades!
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AKI and CRRT: Progress over the last 2 decades! Timothy E Bunchman MD Professor Director Pediatric Nephrology tbunchmanmcvh-vcu.edu pedscrrtgmail.com www.pcrrt.com Terminology change ARF Acute renal failure AKD Acute kidney disease
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01
AKI and CRRT: Progress over the last 2 decades! Timothy E Bunchman MD
Professor & Director
Pediatric Nephrology
tbunchman@mcvh-vcu.edu
pedscrrt@gmail.com
www.pcrrt.com<br>
Professor & Director
Pediatric Nephrology
tbunchman@mcvh-vcu.edu
pedscrrt@gmail.com
www.pcrrt.com<br>
02
Terminology change * ARF
Acute renal failure
AKD
Acute kidney disease
AKI
Acute kidney Insufficiency (* No matter the name they are still sick)<br>
Acute renal failure
AKD
Acute kidney disease
AKI
Acute kidney Insufficiency (* No matter the name they are still sick)<br>
03
Creatinine Changes and AKI in Children 390 pediatric cardiac surgery patients
Cr rise at 25-50% above baseline within first 24 hours of surgery
Increase LOS
Increase ventilator days
Zappitelli et al, Kid Int 2009 76:885-892<br>
Cr rise at 25-50% above baseline within first 24 hours of surgery
Increase LOS
Increase ventilator days
Zappitelli et al, Kid Int 2009 76:885-892<br>
04
Pediatric ARF - Incidence of cases requiring RRT 227 cases in the years 84-91. Yorkshire UK
Incidence: 0.8/yr/100.000 total population
neonate-infant: 19.7/yr/100.000 age related population
1-4 years: 5.9/yr/100.000 age related population
5-15 years: 1.5/yr/100.000 age related population
children: 3.9/yr/100.000 age related population
1/5 of the adult incidence
ICU was needed for half the children
ARF is often a secondary event (eg sepsis)<br>
Incidence: 0.8/yr/100.000 total population
neonate-infant: 19.7/yr/100.000 age related population
1-4 years: 5.9/yr/100.000 age related population
5-15 years: 1.5/yr/100.000 age related population
children: 3.9/yr/100.000 age related population
1/5 of the adult incidence
ICU was needed for half the children
ARF is often a secondary event (eg sepsis)<br>
05
Etiology of Pediatric ARF(Andreoli SP, Curr Opin in Pediatr, 14:183-188, 2002) HUS
Moghal et al, Clin Nephro 49:91-95, 1998
ARF with MOSF
Secondary to underlying disease
Surgery for congenital heart disease
Bone marrow tx
Solid organ tx<br>
Moghal et al, Clin Nephro 49:91-95, 1998
ARF with MOSF
Secondary to underlying disease
Surgery for congenital heart disease
Bone marrow tx
Solid organ tx<br>
06
Causes of ARF in Children Current Opinion in Pediatrics, April 1998<br>
07
The etiology of acute renal failure- Nigeria
( Anochie & Eke Peds Neph 2005:20 1610-1614)<br>
( Anochie & Eke Peds Neph 2005:20 1610-1614)<br>
08
Pediatric ARF: Disease and Survival Ped Neph 16:1067-1071, 2001<br>
09
Williams et al, Arch Ped Adolesc Med, 2002 Changes with Era's HUS: >25% to ~15%
Heme-Onc: 8 to ~18%
Sepsis:No change (~1/5)<br>
Heme-Onc: 8 to ~18%
Sepsis:No change (~1/5)<br>
10
Characteristics, patterns<br>
11
SPECIAL FIBERS AND FILTERS HAVE BEEN DESIGNED FOR SPECIAL CONDITIONS AND PATIENTS Minifilters Ronco C, et al Treatment of acute renal failure in newborns by Continuous Arterio-Venous Hemofiltration. Kidney International, 1984<br>
12
1980s Following Ronco’s paper little was published except for a descriptive paper by Leone et al describing CAVH in children
Early experience with continuous arteriovenous hemofiltration in critically ill pediatric patients. Crit Care Med. 1986 Dec;14(12):1058-63.
Neonatal work by Zobel
Continuous arteriovenous hemofiltration in premature infants. Crit Care Med. 1989 Jun;17(6):534-6.<br>
Early experience with continuous arteriovenous hemofiltration in critically ill pediatric patients. Crit Care Med. 1986 Dec;14(12):1058-63.
Neonatal work by Zobel
Continuous arteriovenous hemofiltration in premature infants. Crit Care Med. 1989 Jun;17(6):534-6.<br>
13
1990s Equipment during this era was “adaptive”
Solutions for convection or diffusion was pharmacy made or lactate based
Latter part of 1990s industry began to market machines that did not take momentum until turn of the decade<br>
Solutions for convection or diffusion was pharmacy made or lactate based
Latter part of 1990s industry began to market machines that did not take momentum until turn of the decade<br>
14
1990s Important work on Access was presented by John Gardner RN describing the MAHURKAR™ Catheter that is now marked by Covidien
“how to do it papers”
Continuous arterial-venous diahemofiltration and continuous veno-venous diahemofiltration in infants and children. Pediatr Nephrol. 1994 Feb;8(1):96-102.
Continuous venovenous hemodiafiltration in infants and children. Am J Kidney Dis. 1995 Jan;25(1):17-21.
Out come paper by Smoyer et al on
Determinants of survival in pediatric continuous hemofiltration. J Am Soc Neph 1995 Nov;6(5):1401-9.
Comparison paper on CAVH vs CVVH by our group in Am J Kid Dis 1995
Maxvold and colleagues began comparison of modalities
Management of acute renal failure in the pediatric patient: hemofiltration versus hemodialysis. Am J Kidney Dis. 1997 Nov;30(5 Suppl 4):S84-8.<br>
“how to do it papers”
Continuous arterial-venous diahemofiltration and continuous veno-venous diahemofiltration in infants and children. Pediatr Nephrol. 1994 Feb;8(1):96-102.
Continuous venovenous hemodiafiltration in infants and children. Am J Kidney Dis. 1995 Jan;25(1):17-21.
Out come paper by Smoyer et al on
Determinants of survival in pediatric continuous hemofiltration. J Am Soc Neph 1995 Nov;6(5):1401-9.
Comparison paper on CAVH vs CVVH by our group in Am J Kid Dis 1995
Maxvold and colleagues began comparison of modalities
Management of acute renal failure in the pediatric patient: hemofiltration versus hemodialysis. Am J Kidney Dis. 1997 Nov;30(5 Suppl 4):S84-8.<br>
15
1990s Evaluation of PICU needs and RRT beyond AKI began
Parekh RS et al
Dialysis support in the pediatric intensive care unit. Adv Renal Replac Therapy 1996 Oct;3(4):326-36.
Quigley and associates on use of HD and hemofiltration in TLS
Hyperphosphatemia in tumor lysis syndrome: the role of hemodialysis and continuous veno-venous hemofiltration. Peds Nephrol 1994, 8: 351-3<br>
Parekh RS et al
Dialysis support in the pediatric intensive care unit. Adv Renal Replac Therapy 1996 Oct;3(4):326-36.
Quigley and associates on use of HD and hemofiltration in TLS
Hyperphosphatemia in tumor lysis syndrome: the role of hemodialysis and continuous veno-venous hemofiltration. Peds Nephrol 1994, 8: 351-3<br>
16
2000s This era exploded with advancements in
Equipment
FDA approval of bicarbonate based Solutions
Nutrition in AKI/CRRT
Avoidance of complications
Anticoagulation protocols<br>
Equipment
FDA approval of bicarbonate based Solutions
Nutrition in AKI/CRRT
Avoidance of complications
Anticoagulation protocols<br>
17
2000s Gambro and B Braun (and soon to follow Baxter) came out with machines with commonality of warmer, accurate fluid control as well as blood flow and solutions controllers<br>
18
2000s FDA approval of bicarbonate based Solutions by Dialysis Solution Inc and Walter O’Rourke
Pediatric hemofiltration: Normocarb dialysate solution with citrate anticoagulation. Pediatr Nephrol 2002 17:150-4
Maxvold et al described Nutrition needs and losses in AKI/CRRT
Amino acid loss and nitrogen balance in critically ill children with acute renal failure: a prospective comparison between classic hemofiltration and hemofiltration with dialysis. Crit Care Med 2000 28:1161-5<br>
Pediatric hemofiltration: Normocarb dialysate solution with citrate anticoagulation. Pediatr Nephrol 2002 17:150-4
Maxvold et al described Nutrition needs and losses in AKI/CRRT
Amino acid loss and nitrogen balance in critically ill children with acute renal failure: a prospective comparison between classic hemofiltration and hemofiltration with dialysis. Crit Care Med 2000 28:1161-5<br>
19
2000s Additional data on outcome
Pediatric acute renal failure: outcome by modality and disease. Pediatr Nephrol 2001, 16:1067-71
Maxvold et al
Renal failure and renal replacement therapy. Crit Care Clin 2003 19:563-75
Barletta et al
Acute renal failure in children and infants. Curr Opin Crit Care 2004: 10: 499-504<br>
Pediatric acute renal failure: outcome by modality and disease. Pediatr Nephrol 2001, 16:1067-71
Maxvold et al
Renal failure and renal replacement therapy. Crit Care Clin 2003 19:563-75
Barletta et al
Acute renal failure in children and infants. Curr Opin Crit Care 2004: 10: 499-504<br>
20
2000s Anticoagulation Protocols
Pediatric acute renal failure: outcome by modality and disease. Pediatr Nephrol 2001, 16:1067-71
Pediatric convective hemofiltration: Normocarb replacement fluid and citrate anticoagulation. Am J Kid Dis 2003 42: 1248-52
Brophy et al
Multi-centre evaluation of anticoagulation in patients receiving continuous renal replacement therapy (CRRT). NDT 2005 20:1416-21<br>
Pediatric acute renal failure: outcome by modality and disease. Pediatr Nephrol 2001, 16:1067-71
Pediatric convective hemofiltration: Normocarb replacement fluid and citrate anticoagulation. Am J Kid Dis 2003 42: 1248-52
Brophy et al
Multi-centre evaluation of anticoagulation in patients receiving continuous renal replacement therapy (CRRT). NDT 2005 20:1416-21<br>
21
Indications Ronco et al
CRRT at initiation results in improved survival
Lancet. 2000 Jul 1;356(9223):26-30.
Fluid overload
Lane et al
Bone Marrow Transplant. 1994 May;13(5):613-7.
Goldstein et al
Pediatrics. 2001 Jun;107(6):1309-12.
Paden et al
Crit Care Med. 2004 Aug;32(8):1771-6.
Symons et al
Pediatr Nephrol. 2004 Dec;19(12):1394-9.<br>
CRRT at initiation results in improved survival
Lancet. 2000 Jul 1;356(9223):26-30.
Fluid overload
Lane et al
Bone Marrow Transplant. 1994 May;13(5):613-7.
Goldstein et al
Pediatrics. 2001 Jun;107(6):1309-12.
Paden et al
Crit Care Med. 2004 Aug;32(8):1771-6.
Symons et al
Pediatr Nephrol. 2004 Dec;19(12):1394-9.<br>
22
Infants AKI and IBEM Symons et al
Am J Kidney Dis. 2003 May;41(5):984-9.
Askenazi DJ et al
J Pediatr. 2013 Mar;162(3):587-592.
Picca et al
Leader in the field of in born error of metabolism and RRT
Extracorporeal dialysis in neonatal hyperammonemia: modalities and prognostic indicators. Pediatr Nephrol. 2001 Nov;16(11):862-7.<br>
Am J Kidney Dis. 2003 May;41(5):984-9.
Askenazi DJ et al
J Pediatr. 2013 Mar;162(3):587-592.
Picca et al
Leader in the field of in born error of metabolism and RRT
Extracorporeal dialysis in neonatal hyperammonemia: modalities and prognostic indicators. Pediatr Nephrol. 2001 Nov;16(11):862-7.<br>
23
Complications Brophy et al
AN-69 membrane reactions are pH-dependent and preventable. Am J Kid Dis 2001 38:173-8
Barletta et al
Medication errors and patient complications with continuous renal replacement therapy. Pediatr Nephrol 2006 21:842-5
Johnson P et al
Thermic control and heat loss in CRRT
presented at the CRRT meeting in San Diego abst only<br>
AN-69 membrane reactions are pH-dependent and preventable. Am J Kid Dis 2001 38:173-8
Barletta et al
Medication errors and patient complications with continuous renal replacement therapy. Pediatr Nephrol 2006 21:842-5
Johnson P et al
Thermic control and heat loss in CRRT
presented at the CRRT meeting in San Diego abst only<br>
24
Beginning of the meetings and cooperative studies CRRT San Diego began in 1996
PCRRT meetings began in 2000
PCRRT meetings arose from a discussion with Christian Schlaeper (Fresenius)
ppCRRT registry began is 2006<br>
PCRRT meetings began in 2000
PCRRT meetings arose from a discussion with Christian Schlaeper (Fresenius)
ppCRRT registry began is 2006<br>
25
ppCRRT Registry An Idea of Stu Goldstein that brought together 13 + programs to pool data based upon local standard of care
The ppCRRT registry was responsible for 15 manuscripts from multiple authors<br>
The ppCRRT registry was responsible for 15 manuscripts from multiple authors<br>
26
ppCRRT representative papers Flores FX et al Continuous renal replacement therapy (CRRT) after stem cell transplantation. A report from the prospective pediatric CRRT Registry Group. Pediatr Nephrol. 2008 Apr;23(4):625-30.
Hackbarth R et al The effect of vascular access location and size on circuit survival in pediatric continuous renal replacement therapy: a report from the PPCRRT registry. Int J Artif Organs. 2007 Dec;30(12):1116-21.<br>
Hackbarth R et al The effect of vascular access location and size on circuit survival in pediatric continuous renal replacement therapy: a report from the PPCRRT registry. Int J Artif Organs. 2007 Dec;30(12):1116-21.<br>
27
Tandem therapies Meyer RJ et al Hemodialysis followed by continuous hemofiltration for treatment of lithium intoxication in children. Am J Kidney Dis. 2001 May;37(5):1044-7.
Phenylacetate and benzoate clearance in a hyperammonemic infant on sequential hemodialysis and hemofiltration. Pediatr Nephrol. 2007 Jul;22(7):1062-5. Epub 2007 Feb 3.<br>
Phenylacetate and benzoate clearance in a hyperammonemic infant on sequential hemodialysis and hemofiltration. Pediatr Nephrol. 2007 Jul;22(7):1062-5. Epub 2007 Feb 3.<br>
28
Use of RRT in Intoxications EXTRIP.org
Ferris et al Management of toxic ingestions with the use of renal replacement therapy. Pediatr Nephrol. 2011 Apr;26(4):535-41<br>
Ferris et al Management of toxic ingestions with the use of renal replacement therapy. Pediatr Nephrol. 2011 Apr;26(4):535-41<br>
29
RRT and ECMO Meyer RJ Survival and renal function in pediatric patients following extracorporeal life support with hemofiltration. Pediatr Crit Care Med. 2001 Jul;2(3):238-242.
Hoover NG Enhanced fluid management with continuous venovenous hemofiltration in pediatric respiratory failure patients receiving extracorporeal membrane oxygenation support. Intensive Care Med. 2008 Dec;34(12):2241-7<br>
Hoover NG Enhanced fluid management with continuous venovenous hemofiltration in pediatric respiratory failure patients receiving extracorporeal membrane oxygenation support. Intensive Care Med. 2008 Dec;34(12):2241-7<br>
30
RRT and ECMO Askenazi DJ Acute kidney injury and renal replacement therapy independently predict mortality in neonatal and pediatric noncardiac patients on extracorporeal membrane oxygenation. Pediatr Crit Care Med. 2011 Jan;12(1):e1-6.<br>
31
Liver Disease and CRRT Deep A et al Factors affecting circuit life during continuous renal replacement therapy in children with liver failure. Ther Apher Dial. 2015 Feb;19(1):16-22
Deep A and colleagues Prostacyclin (epoprostenol) As An Anticoagulant In Continuous Renal Replacement Therapy (CRRT) In Paediatric Acute Liver Failure (PALF) ( Abstract) Arch Dis Child 2014;99:Suppl 2 A100-A101<br>
Deep A and colleagues Prostacyclin (epoprostenol) As An Anticoagulant In Continuous Renal Replacement Therapy (CRRT) In Paediatric Acute Liver Failure (PALF) ( Abstract) Arch Dis Child 2014;99:Suppl 2 A100-A101<br>
32
Definitions RIFLE
pRIFLE
AKIN
KDIGO
Urine out put
Changes in Creatinine
Cystatin C<br>
pRIFLE
AKIN
KDIGO
Urine out put
Changes in Creatinine
Cystatin C<br>
33
Urine NGAL as an Early AKI Biomarker after Cardiopulmonary Bypass AKI = 50% or greater increase in serum creatinine from baseline Mishra et al, Lancet 2005, 365:1231-1238<br>
34
Advancement in Equipment CARPEDIUM (Ronco)
Nidus (Coulthard)
Aquadex (Askenazi)
Japanese small circuit (Ishikawa)<br>
Nidus (Coulthard)
Aquadex (Askenazi)
Japanese small circuit (Ishikawa)<br>
35
Where is research needed Over incidence of AKI
AWARE study recently published
Timing of intervention
Optimal nutritional dosing
Optimal drug dosing<br>
AWARE study recently published
Timing of intervention
Optimal nutritional dosing
Optimal drug dosing<br>
36
I have worked with Giants(by no means is this list inclusive) Maxvold
Brophy
Barletta
McBryde
Goldstein
Askenazi
Zappitelli
Picca
Parekh
McCulloch Deep
Hackbarth
Flores
Quigley
Ronco
Symons
Flores
Ferris
Fortenberry
Raina<br>
Brophy
Barletta
McBryde
Goldstein
Askenazi
Zappitelli
Picca
Parekh
McCulloch Deep
Hackbarth
Flores
Quigley
Ronco
Symons
Flores
Ferris
Fortenberry
Raina<br>