CRRT ROLE IN SEPSIS

Putu andrika
 outline

AKI SEPSIS
Overview CRRT
CRRT in sepsis
Timing, dose, intensity
Summary
Acute kidney injury consensus definitions
Conceptual model of damage and function
in AKI. Modified

KDIGO clinical practice guideline for acute

kidney injury. Kidney Int Suppl. 2012; 2: 1138
Mortality in AKI patients admitted to the
intensive care unit.

the SHARF Study Group

Clin J Am Soc Nephrol 5: 17551762,
2010.
 Septic shock remains the main cause of death in
intensive care units, and despite improved
treatments, mortality ranges from 30 to 70%
(Angus et al. 2001; Mori et al. 2010).

Sepsis and septic shock are the most important

causes of acute kidney injury (AKI) in critically ill
patients, and account for 50% or more of cases
of AKI in intensive care units (Bagshaw et al.
2008).

and mortality remains high despite

improvements in our ability to support vital
organs.
Mortality AKI (septic dan non-
septic)

Bagshaw SM et al; Early acute kidney injury and

sepsis: a multicentre evaluation. Critical Care
2008
 Pathophysiology
The kidneys receive around 20% of the cardiac
output, and renal oxygen extraction is low
(approximately 10-15%), yet they are very
susceptible to tissue hypoxia, especially during
an acute illness.

AKI develops due to a global decrease in renal

perfusion associated with a state of shock.

In sepsis, animal models demonstrated that

renal blood flow (RBF) may be reduced,
increased, or unchanged, which implies that
factors other than RBF play an important role.

???????
 mechanisms contribute, including regional
variations in perfusion and oxygen consumption,
impaired autoregulation, distortion of peritubular
and glomerular microcirculation, tubular cell
injury, endothelial injury, microvascular
thrombosis, and arteriovenous shunting,
resulting in the activation of inflammatory
processes.

AKI is now considered a pro-inflammatory

condition.
 TREATMENT
Supportive focus on the optimisation of fluid and
haemodynamic status

Treatment of the underlying illness

Avoidance of Nephrotoxic Agents
Exclusion of Obstruction
AKI Care Bundles
Prevention of Contrast-Induced Nephropathy
Renal Replacement Therapy (Continuous RRT)
 Renal replacement therapy in critically ill
patients with acute kidney injury
when to start
Renal replacement therapy (RRT) is a key
component of modern critical care.

remain uncertain, including optimal

indication and timing.

RRT is generally viewed as a organ support

aimed at achieving metabolic homeostasis
and preventing fluid overload and new organ
failure.

risks related to central venous access,

infections and anticoagulation
Indications and Contraindications for Continuous Renal-
Replacement Therapy in Critically Ill Patients with Acute
Kidney Injury.

Ashita Tolwani, CRRT

N Engl J Med 2012;367:2505-
14.
Mehtha.WCN Berlin 2003
 SCUF Ultra filtration

CVVH Ultra filtration + Convection

CVVHD Ultra filtration + Diffusion

CVVHDF - Ultra filtration + Diffusion + Convection

 Dellepiane et al. Critical Care (2016) 20:61
 CRRT in Sepsis
Tradisional indication : uremia, metabolic
disturbances, fluid overload and electrolyte
derangements.

Several authors : To remove inflammatory

mediators potentially involved in AKI and distant
organ damage.

Early initiation of RRT and the use of continuous

and not intermittent strategies are associated
with a better hemodynamic profile and outcome.
 Differences between AKIKI and ELAIN studies

we still have to investigate

when would be the best timing of RRT
initiation for every single AKI patient.
J Thorac Dis 2016;8(9):E1006-E1009
 The timing initiation remains heterogeneous in
clinical practice.

Excessive delays in RRT initiation have been

associated with higher mortality rates and with
worsening of renal function.

Another relevant issue, which dose of 35 ml/kg/h

was associated with a better survival of AKI
patient, in particular of sepsis.

Optimal dose of dialysis ???

 CRRT ..better
outcome save live.
 summary

RRT is generally viewed as a organ support

aimed at achieving metabolic homeostasis and
preventing fluid overload and new organ failure.

Early initiation and the use of continuous and

not intermittent strategies are associated with a
better hemodynamic profile and outcome.

CRRT in septic patients for renal support and

immunomodulation.