1. Dr. Andrew Ferguson Consultant in Anaesthesia & Intensive Care Medicine Craigavon Area Hospital Renal Replacement Therapies in Critical Care

3. Overview

4. AKI classification systems 1: RIFLE

5. AKI classification systems 2: AKIN Patients receiving RRT are Stage 3 regardless of creatinine or urine output Stage Creatinine criteria Urine output criteria 1 1.5 - 2 x baseline (or rise > 26.4 mmol/L) < 0.5 ml/kg/hour for > 6 hours 2 >2 - 3 x baseline < 0.5 ml/kg/hour for > 12 hours 3 > 3 x baseline (or > 354 mmol/L with acute rise > 44 mmol/L) < 0.3 ml/kg/hour for 24 hours or anuria for 12 hours

7. Mortality by AKI Severity (1) Clermont, G et al . Kidney International 2002; 62: 986-996

8. Mortality by AKI Severity (2) Bagshaw, S et al. Am J Kidney Dis 2006; 48: 402-409

10. Therapy Dose in IRRT p = 0.01 p = 0.001 Schiffl, H et al . NEJM 2002; 346: 305-310

11. Therapy Dose in CVVH 25 ml/kg/hr 35 ml/kg/hr 45 ml/kg/hr Ronco, C et al . Lancet 2000; 355: 26-30

14. Outcome with IRRT vs CRRT (3) Vinsonneau, S et al . Lancet 2006; 368: 379-385

16. Implications of the available data

20. Major Renal Replacement Techniques Intermittent Continuous Hybrid IHD Intermittent haemodialysis IUF Isolated Ultrafiltration SLEDD Sustained (or slow) low efficiency daily dialysis SLEDD-F Sustained (or slow) low efficiency daily dialysis with filtration CVVH Continuous veno-venous haemofiltration CVVHD Continuous veno-venous haemodialysis CVVHDF Continuous veno-venous haemodiafiltration SCUF Slow continuous ultrafiltration

21. Intermittent Therapies - PRO

22. Intermittent Therapies - CON

25. Continuous Therapies - PRO

26. Continuous Therapies - CON

32. Kinetic Modelling of Solute Clearance TAC = time-averaged concentration (from area under concentration-time curve) EKR = equivalent renal clearance Inulin represents middle molecule and  2 microglobulin large molecule. CVVH has marked effects on middle and large molecule clearance not seen with IHD/SLED SLED and CVVH have equivalent small molecule clearance Daily IHD has acceptable small molecule clearance Liao, Z et al . Artificial Organs 2003; 27: 802-807 CVVH (predilution) Daily IHD SLED Urea TAC (mg/ml) 40.3 64.6 43.4 Urea EKR (ml/min) 33.8 21.1 31.3 Inulin TAC (mg/L) 25.4 55.5 99.4 Inulin EKR (ml/min) 11.8 5.4 3.0  2 microglobulin TAC (mg/L) 9.4 24.2 40.3  2 microglobulin EKR (ml/min) 18.2 7.0 4.2

33. Uraemia Control Liao, Z et al . Artificial Organs 2003; 27: 802-807

34. Large molecule clearance Liao, Z et al . Artificial Organs 2003; 27: 802-807

35. Comparison of IHD and CVVH John, S & Eckardt K-U. Seminars in Dialysis 2006; 19: 455-464

36. Beyond renal replacement… RRT as blood purification therapy

37. Extracorporeal Blood Purification Therapy (EBT) Intermittent Continuous TPE Therapeutic plasma exchange HVHF High volume haemofiltration UHVHF Ultra-high volume haemofiltration PHVHF Pulsed high volume haemofiltration CPFA Coupled plasma filtration and adsorption

43. Common Antibiotics and CRRT These effects will be even more dramatic with HVHF Honore, PM et al . Int J Artif Organs 2006; 29: 649-659

44. Towards Targeted Therapy Non-septic ARF Septic ARF Cathecholamine resistant septic shock Daily IHD Daily SLEDD CVVHD/F ? dose CVVH > 35ml/kg/hour ? 50-70 ml/kg/hour CVVH @ 35ml/kg/hour Daily IHD? Daily SLEDD? HVHF 60-120 ml/kg/hour for 96 hours PHVHF 60-120 ml/kg/hour for 6-8 hours then CVVH > 35 ml/kg/hour EBT Honore, PM et al . Int J Artif Organs 206; 29: 649-659 Cerebral oedema

45. Marge Simpson “ You should listen to your heart, and not the voices in your head”

46. Questions?