RRT in ICU - Renal Replacement Therapy in ICU Dr. Sunil...

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Renal Replacement Therapy in ICU Dr. Sunil Sharma Senior Resident Dept of Pulmonary Medicine
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Introduction Need for RRT in patients with ARF is a common & increasing problem in ICUs Leading cause of ARF is sepsis (as a part of MODS) Mortality rates of ARF quite high The in-hospital mortality rate ~30% in patients with drug induced ARF up to 90% in ARF with severe MODS Nephrol Dial Transplant 1996;11:293–299
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In experimental ARF isolated renal ischemia & reperfusion injury causes injury and dysfunction of distant organs Precise effects of ‘uremic’ toxins is not known in ARF except for severe hyperkalemia CRRT in its current form is only a partial solution to the multisystem problems caused by ARF
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For many years, IHD was the only treatment option for patients with ARF Still the most frequently used modality Am J Nephrol 1999; 19:377–382 Standard IHD could not be used in patients with severe hemodynamic instability Led to development of CRRT which was first described by Kramer et al in 1977 Continuous venovenous hemofiltration (CVVH) was used as an alternative to IHD better tolerated by hypotensive patients continuous regulation of fluid and nutritional support avoided cycles of volume overload and depletion
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In ICU patients AKI is caused by prerenal azotemia (reversible renal insufficiency due to renal hypoperfusion) ATN ATN results from combined effect of Critical Care 2004; 8:R204–R212 Renal hypoperfusion & injury caused by systemic hypoperfusion effects of mechanical ventilation renal vasoconstriction in patients with cirrhosis and sepsis increased intra-abdominal pressure endogenous and exogenous nephrotoxins
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RIFLE criteria (the Risk, Injury, Failure, Loss, and End-stage Kidney) stratified patients into 3 categories of severity (risk, injury, and failure) and 2 outcomes (loss of renal fxn. after receipt of RRT for 4 weeks and permanent kidney failure) J Am Soc Nephrol . 2003;14(8):2178-2187 criteria have been simplified to focus only on change in levels of serum creatinine (0.3 mg/dL or a 50% increase) urine output (0.5 mL/kg per hour for longer than 6 hours) Crit Care . 2007; 11(2):R31
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Indications AKI requires RRT when there is an acute fall in glomerular filtration rate Developed / at risk of developing clinically significant solute imbalance/toxicity volume overload The precise timing of RRT initiation is based on clinical judgment The classic indications for dialysis are diuretic resistant pulmonary edema hyperkalemia - refractory to medical therapy metabolic acidosis - refractory to medical therapy uremic complications - pericarditis, encephalopathy, bleeding dialyzable intoxications - lithium, toxic alcohols, and salicylates
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Principles Water and solute transport through a semi-permeable membrane → discarding the waste products
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This note was uploaded on 12/03/2011 for the course MEDICINE 350 taught by Professor Dr.aslam during the Winter '07 term at Medical College.

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RRT in ICU - Renal Replacement Therapy in ICU Dr. Sunil...

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