SCCM Pod-495: Renal Resurgence: Exploring CRRT's Impact on Critical Illness and AKI

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Join host Pamela M. Peeke, MD, MPH, FACP, FACSM, as she delves into the critical topic of acute kidney injury (AKI) and its significant impact on critically ill patients. Guest Javier Neyra, MD, MSCS, offers a comprehensive overview of renal replacement therapy (RRT) in AKI, exploring the preferred modalities and technical considerations. With a focus on the benefits of continuous therapy versus hemodialysis, the discussion sheds light on indications for continuous RRT (CRRT), emphasizing the importance of early intervention and nephrology consultation. This podcast is sponsored by Baxter Healthcare Corporation.

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Transcript:

This podcast is sponsored by Baxter Healthcare Corporation. When you choose Baxter for your CRRT program, you’re not only choosing true patient-focused treatment with industry-leading CRRT technology, you’re also selecting a partner dedicated to optimizing your clinical success in treating patients with acute kidney injury. Our commitment to you starts with a program individualized to your facility needs and provides complete support every step of the way. For more information, visit us at www.renalacute.com.

Dr. Peeke: Hello and welcome to the Society of Critical Care Medicine Podcast. I’m your host, Dr. Pam Peeke. Today, we will be talking about continuous renal replacement therapy in acute kidney injury. I’m joined by Dr. Javier Neyra, who is associate professor, University of Alabama at Birmingham School of Medicine, Nephrology Department. Welcome, Dr. Neyra.

Dr. Neyra: Thank you, Dr. Peeke. It’s a pleasure to be here.

Dr. Peeke: Before we start, do you have any disclosures to report?

Dr. Neyra: Yes. As a critical care nephrologist, I provide consultation to some of the dialysis companies that provide treatments in the ICU, like Baxter, Outset Medical, and others.

Dr. Peeke: Thank you, Dr. Neyra. I’m going to review the learning objectives. Acute kidney injury is a common complication of critical illness and is associated with substantial morbidity and risk of death. Overview of the therapy indications for continuous renal replacement therapy, modality, and other technical and clinical considerations will be discussed.

Why is this podcast needed? To provide a review for critical care clinicians on the impact of acute kidney injury on their patients, the indications for renal replacement therapy, what modality is preferred, and when to consult nephrology for acute kidney injury and continuous renal replacement therapy. The knowledge gaps that this podcast will address include the true impact of acute kidney injury on critically ill patients, the indications of when renal replacement therapy can be performed and, finally, when to ask for a consult from nephrology, also, the benefits of continuous renal replacement therapy versus hemodialysis. Dr. Neyra, what is the true challenge of acute kidney injury in the ICU?

Dr. Neyra: Acute kidney injury is a very common condition that occurs during critical illness. The incidence of this complication is up to 50%. Depending on the severity of the acute illness, this incidence can even increase further. It’s a frequent problem we face in the ICU and it’s associated with the degree of multiorgan dysfunction that the patient has during acute illness. For that reason, there is a lot of emphasis on developing better ways to identify acute kidney injury earlier and, once identified, to intervene as soon as possible to try to promote kidney and other organ recovery. Among all those interventions, one of the support therapies we have is providing renal replacement therapy to these patients.

Dr. Peeke: Excellent. Thank you, Dr. Neyra. When is RRT an option for patients? What are the clinical considerations here?

Dr. Neyra: Renal replacement therapy is a support treatment, right? We need to institute this treatment according to various specific goals. It could be a solute-control goal. This means when we have severe electrolyte acid-base abnormalities that we can control, mitigate, with the provision of renal replacement therapy, or it could be, and frequently is, related to fluid management on these patients. Because the patients who are critically ill, most of the time during the early phases of resuscitation are exposed to a significant amount of fluids. A lot of times, if their kidneys are failing, they will accumulate these fluids. One of the common indications in the ICU for renal replacement therapy is fluid management. So we need to recognize that, to institute renal replacement therapy, we need to have clear goals of treatment for solute management or fluid management and that will guide our decision as to when is the right time for a particular patient to be initiated on renal replacement therapy.

Dr. Peeke: Thank you. When should clinicians consult or think about using continuous renal replacement therapy on patients?

Dr. Neyra: Among the options we have to support the kidneys in a patient who is critically ill, we have a myriad of therapies including continuous renal replacement therapy, including hemodialysis, and also intermittent modalities such as prolonged intermittent renal replacement therapy, also called SLEDD. With these treatments, we should be able to support the kidneys for both goals of solute and fluid management. The indications are very patient-specific according to these two categories of solute control and fluid removal. At the same time, we should recognize that patients may have different levels of hemodynamic stability at the time we are evaluating renal replacement therapy options.

For patients who are hemodynamically unstable, requiring a significant amount of pressor support, we favor more continuous modalities such as CRRT versus patients who are more hemodynamically stable. Or in patients for whom we have a very specific goal of solute control, we select hemodialysis because, remember, hemodialysis will have a more effective and rapid clearance than CRRT. CRRT, the clearance will be lower, and to reach a very specific solute control target, it may take longer hours.

I’m going to give a specific example. We have an acute intoxication with a substance that can be dialyzable. Certainly, if the patient can tolerate, based on hemodynamic stability, we prefer hemodialysis. If a patient, for example, is critically ill with significant pressor requirements, we need to have solute and fluid control, certainly we will select CRRT for that patient. Now, hospitals sometimes don’t have the availability of devices that can provide either CRRT or hemodialysis, then you have intermittent forms of renal replacement therapy, such as SLEDD, that can be delivered with both CRRT or HD devices in the ICU. So we have variable options, and that’s why it’s very important to discuss these options with the treating teams and also with the family members of the patient who is critically ill to identify what is the best option for each patient.

Dr. Peeke: What are the benefits of CRRT over hemodialysis in the critical care setting?

Dr. Neyra: CRRT, again, will be reserved most of the time for patients who are hemodynamically unstable, if we have the resources available. This is because, with CRRT, we’ll provide 24-hour treatment continuously compared to a short treatment of three or four hours with hemodialysis. The amount of hemodynamic stress that the hemodialysis device produces in a patient is much higher than the stress that the CRRT device will produce in terms of hemodynamic stability. For that reason, treatment with CRRT is preferred in patients who are acutely ill who are hemodynamically unstable and requiring pressor support.

Dr. Peeke: Do most institutions have the availability of CRRT?

Dr. Neyra: That’s a very important question and the answer is no if you talk about worldwide distribution of CRRT therapies. If you talk about developed countries, there are more resources and there is an expansion in ICU practice to deliver CRRT. But if we talk about low- or low-middle-income countries, we are facing problems in availability of CRRT in these ICUs.

Most of the time, the most available device is a hemodialysis machine in these low-resource settings. That’s very important. The context in which our ICU is providing treatment will determine, a lot of the time, the availability of these resources. That being said, it’s very clear that intensivists will favor having more continuous modalities in settings where they treat and deal with higher-level-acuity patients.

Dr. Peeke: If an institution is interested in integrating CRRT, what are the resources they need, looking at the team, looking at the equipment, etc.? How do they begin this entire process?

Dr. Neyra: This is very important. To develop a CRRT program, you need to first be sure you have enough logistical resources to support the program. It’s not only just having a budget to purchase devices that provide CCRT. In addition to a budget that can support the operations, you need to have a human team to deliver the treatment and, not only a human team to deliver the treatment, but to sustain the treatment and be able to educate all the members of this team that are going to be involved directly in the care of these patients during the provision of CRRT.

Just to give some concrete examples, ideally you need to have clinician and nurse champions who will be delivering the treatment from the prescriber side and also from the execution at the bedside, setting up the device, monitoring the treatment during the duration of CRRT, and also identifying some key performance indicators to try to see what are areas that the program can do better compared to more standard references of centers that have more experience. It’s very important, the logistical budget component and also the humanistic component in developing this infrastructure, of course, all under the umbrella of institutional support. The institution has to support this implementation to be able to successfully do it.

Once the program is initiated, key frequent tips that we provide the community is try to create a protocol, a protocol that is standardized across your ICUs, a protocol that is supported by all the clinicians who are going to be prescribing the treatment, they understand the protocol, they are in favor of the protocol. That will create some homogeneous practice and will minimize errors on the execution side, that is, the nursing staff delivering the treatment to patients at the bedside.

That’s very important, to have a protocol. These days, there are many hospitals, at least in North America, that have available protocols that they are always willing to share, so you can have some references about which protocols you can consider for implementation at your center. After that, maintain that team-based approach with individuals who are motivated, who like to continue to be self-educated, and also to be very cognizant of the evolving evidence in the field to be able to adapt your practice to the most-value, evidence-based care.

Dr. Peeke: You’re speaking to continuous education as absolutely critical here because it is a rapidly evolving field as well as quality assurance once the actual program is implemented, correct?

Dr. Neyra: Absolutely. Those are the key words for the program. The good thing about CRRT is that there are many programs that are well skilled in the provision of CRRT that can always be reference centers. Also, there are many programs that are evolving and they are developing these CRRT deliverables locally. It’s an evolving practice, a growing group.

At the same time, there is a lot of heterogeneity in practice. It’s not fully standardized and there are gaps in evidence. There are some things in CRRT that we understand based on robust evidence, for example, the dose of CRRT. With the dose trials that were done several years ago, we now understand that we recognize what is the average total effluent dose of the treatment that we should prescribe and deliver to our patients. That being said, we also recognize that, depending on the individual need of a particular patient, we may prescribe either a higher or a lower dose, depending on the clinical context, but we have very solid evidence about what should be an initial prescription if you don’t have outside-of-range indications.

On the other side, you should also recognize that there are still gaps in evidence. For example, one that I want to mention is fluid management during CRRT. What are the metrics we should be monitoring continuously to assess patient tolerance to fluid removal? For example, when we do this extracorporeal removal of fluid, it’s still not very well standardized. There is evolving evidence, for example, about a metric that is the net ultrafiltration rate that we use to prescribe fluid removal in these patients. But more evidence is in the process of being developed, including clinical trials. That’s still a very heterogeneous area of practice that hopefully, in the coming years, will be more standardized than it is right now, the prescription of dose during CRRT.

Dr. Peeke: Thank you, Dr. Neyra. As we wrap this up, what are some other key dynamics of continuous renal replacement therapy to keep in mind for clinicians?

Dr. Neyra: I think during this discussion I commented on very important aspects, right? But just to summarize, we can say the logistical portion of the program is very key, not only to have a budget, but to have a way to collect numbers about how are your operations, what are the projected number of patients to whom we potentially can deliver the therapy? Then, do we have enough capacity, both from the infrastructure side and the humanistic side, to provide? Do we have enough ICU nurses who are trained in the use of CRRT who can deliver the treatment? Do we have enough pharmacists who will support the solutions that we use during the treatment? Do we have enough chain of supply for all the logistics and the materials that are involved during the provision?

This is what I call the back end of the treatment. When we are training as fellows, we typically are taught about how to prescribe it, how to monitor, how to recognize indications, when to stop the treatment. But we are not taught, a lot of times, about how to run a program on the back end. This not only includes what we said, but includes also the technical support you have on these devices. These devices sometimes will require technical support that needs to be in house. These people typically will have some type of turnover and you need to understand the logistics of how that works to be able to integrally monitor the program. That’s one aspect, right? All the logistics.

The other aspect is the recognition of quality assurance and that there is a continuous search for best practices around CRRT. For that reason, we should create this motivation in our team that we always can find a way to do it better. That is just the recognition of what we’re doing now, how we can better serve our patients, and how we integrate evolving evidence around the capacity we have to enhance our deliverables. That is an important concept.

The most important concept, in my mind, is just the human team that is around the program. Having adequate leadership in the program and a team that is motivated with complementary expertise is vital. There are a lot of debates in the field about who prescribes CRRT. Is it the intensivist? Is it the nephrologist? It doesn’t matter at the end if you have a quality program where you communicate with each other because independently of who prescribed the treatment, a constant and optimal communication between the intensivist and the nephrologist needs to occur because there needs to be coordination of care for this dynamic therapy that is adjusted continuously during the day.

There are some times that we prescribe a specific CRRT prescription in the morning but later on, we need to make adjustments because a new event occurs, let’s say this patient starts having an acute bleeding scenario, that all the prescriptions need to be adjusted according to that. This is a constant communication exercise between the intensivist and the nephrologist, at the time of initiation or deciding on initiating a patient on CRRT, during the treatment, and also at the time of de-escalation. Because a lot of the time, patients still require some degree of support with renal replacement therapy, perhaps not CRRT, but there needs to be coordination of how to de-escalate renal replacement therapy when the patient has not fully recovered kidney function or enough kidney function to be independent of renal replacement therapy. So, a lot of things.

Just remember, working with another human can be a little bit complex sometimes, but we need to learn the process how to communicate effectively, how to learn from each other, and how to recognize the value in each other to be able to have a cohesive and outstanding team that always is trying to improve bedside care.

Dr. Peeke: What an excellent message to end this episode. We thank you very much, Dr. Javier Neyra, for your wisdom and your thoughts. This concludes another episode of the Society of Critical Care Medicine Podcast. I’m your host, Dr. Pam Peeke. Thank you.

This podcast is sponsored by Baxter Healthcare Corporation. When you choose Baxter for your CRRT program, you’re not only choosing true patient-focused treatment with industry-leading CRRT technology, you’re also selecting a partner dedicated to optimizing your clinical success in treating patients with acute kidney injury. Our commitment to you starts with a program individualized to your facility needs and provides complete support every step of the way. For more information, visit us at www.renalacute.com.

Pamela M. Peeke, MD, MPH, FACP, FACSM is a nationally renowned physician scientist, expert and thought leader in the field of medicine. Dr. Peeke is a Pew Foundation Scholar in Nutrition and Metabolism and Assistant Professor of Medicine at the University of Maryland. She holds dual master’s degrees in Public Health and Policy, and is a fellow of both the American College of Physicians and American College of Sports Medicine. Dr. Peeke has been named one of America’s top physicians by the Consumers Research Council of America. She is a regular in-studio medical commentator for the National Networks and an acclaimed TEDx presenter and national keynote speaker. Dr. Peeke is a three-time New York Times bestselling author and is a science and health advisor for Apple.

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