Early VS Late

Renal Replacement Therapy

Adhrie Sugiarto
FK Universitas Indonesia – RS Cipto Mangunkusumo
Jakarta
 AKI STAGE
High Risk 1 2 3
Discontinue all nephrotoxic agents when possible
Ensure volume status and perfusion pressure
Consider functional hemodynamic monitoring
Monitor Serum creatinine and urine output
Avoid hyperglycemia
Consider alternatives to radiocontrast procedures
Non-invasive diagnostic workup
Consider invasive diagnostic workup
Check for changes in drug dosing
Consider Renal Replacement Therapy
Consider ICU admission
Avoid subclavian catheters if possible
 Renal Replacement Therapy Indication
Renal
• Rapid increase of serum ureum
and creatinin or presence of
uremic complications
• Hyperkalemia unresponsive to
medication
• Severe metabolic acidosis
• Diuretic resistant pulmonary
oedema
• Oliguria or anuria
Non Renal
• Management of fluid balance in
heart failure
• Clearing of ingested toxins
• Severe electrolyte imbalance
• Temperature control
• Mediators removal in sepsis
 Modalities of RRT
• Intermittent Therapies :
– Intermittent Hemodialysis (IHD), Extended Daily Dialysis (EDD),
Sustained Low-efficiency Dialysis (SLED)
• Peritoneal Dialysis (PD)
• Continuous Renal Replacement Therapy (CRRT):
– SCUF, CAVH, CAVHD, CAVHDF, CVVH, CVVHD, CVVHDF
 Complications of RRT
TECHNICAL COMPLICATIONS
• Vascular Access Problems
• Infection
• Access Recirculation
• Air Embolism
• Hemolysis
• Electrolyte and Acid-Base Disorders
CLINICAL COMPLICATIONS
• Bleeding and Thrombosis
• Hypoxemia
• Hypotension
• Biocompatibility
• Hypersensitivity Reactions
• Cardiac Arrhythmias
• Febrile Reactions
• Dialysis Dysequilibrium Syndrome
The Evidence of RRT timing
Long term outcome
• Extended the follow-up of patients in the ELAIN Trial from 90 days to
1 year after randomization for 230 (99.6%) patients
• In conclusion, early initiation of RRT in these critically ill patients with
AKI significantly reduced the occurrence of major adverse kidney
events, reduced mortality, and enhanced renal recovery at 1 year
IDEAL – ICU Trial
Factors affecting decision to initiate RRT
• Anticipation of worsening kidney function
• Worsening nonrenal organ dysfunction
• Expected high solute burden (e.g. tumor lysis syndrome)
• Facilitate other supportive measures (nutrition, drugs, other fluids)
• Availability of facility and resources
Summary
• No strong evidence that early RRT will improve outcomes
• Decision to initiate RRT not only based on single criteria
• Timing based on patient characteristics, illness severity and
progression