Disclaimer2: 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 are 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 Pam Peeke (Host): 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 Javier Neyra: Thank you, Dr. Peeke. It's a pleasure to be here.

Host: Before we start, do you have any disclosures to report?

Dr Javier Neyra: Yeah. 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.

Host: 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 Javier Neyra: Acute kidney injury is a very common condition that occurs during critical illness. The incidence of this complication, it's up to 50%. And depending on the severity of the acute illness, these incidence can even increase further. So, it's a frequent problem we face in the ICU. And it's associated to the degree of multiorgan dysfunction that the patient has during acute illness. For that reason, there is a lot of emphasis in 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.

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

Dr Javier Neyra: So, 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 that 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. And 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 to when is the right time for a particular patient to be initiated on renal replacement therapy.

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

Dr Javier Neyra: Among the options we have to support the kidneys in a patient that 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 SLED. 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. And 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. So for patients that are hemodynamically unstable, requiring a significant amount of pressor support, we favor more continuous modalities such as CRRT versus patients that are more hemodynamically stable. Or in patients that 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. So, I'm going to put a specific example. We have an acute intoxication with a substance that can be dialyzed. So 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 in that patient.

Now, hospitals that 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 SLED 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 that is critically ill to identify what is the best option for each patient.

Host: So, what are the benefits of CRRT over hemodialysis in the critical care setting?

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

Host: Do most institutions have the availability of CRRT?

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

Most of the time, the most available device is a hemodialysis machine in these low resource settings. So, that's very important to if the context in which our ICU is providing treatment will determine a lot of the time the availability of these resources. Now, that being said, it's very clear that the intensivist will favor to have more continuous modalities in settings where they treat and deal with higher level of acuity of patients.

Host: If an institution is interested in integrating CRRT, what are the resources they need, looking at the team, looking at the equipment, et cetera? How do they begin this entire process?

Dr Javier Neyra: This is very important. So 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.

And just to put concrete examples, ideally, you need to have clinician and nurse champions that 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 comparing to more standard references of centers that have more experience. So, 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 is 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 that are going to be prescribing the treatment, they understand the protocol, they are in favor of the protocol, and that will create some homogeneous practice and will minimize errors on the execution side, that is the nursing staff delivering the treatment to the patients at the bedside. That's very important, to have a protocol. And 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. And after that, maintain that team-based approach with individuals that are motivated, that they 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 care, evidence-based care that it's erasing continuously.

Host: So, you're speaking to continuous education is absolutely critical here because it is a rapidly evolving field as well as quality assurance once the actual program is implemented. Correct?

Dr Javier 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 be always reference centers. And also, there are many programs that are evolving and they are developing this CRRT deliverables locally. So, it's an evolving practice, a growing group. At the same time, there is a lot of heterogeneity in the 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 on the treatment that we should prescribe and deliver in 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 a very solid evidence about how 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. So, that's still a very heterogeneous area of practice that hopefully in the coming years will be more standardized as it is right now, the prescription of dose during CRRT.

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

Dr Javier Neyra: Yeah. 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 that we potentially can deliver the therapy? And then, do we have enough capacity both from the infrastructure side and the humanistic side to provide? Do we have enough ICU nurses that are trained in the use of CRRT that can deliver the treatment? Do we have enough pharmacies that will support the solutions that we use during the treatment? And do we have enough chain of supply for all the logistics and the materials that are involved during the provision?

So, this is what I call the backend 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 backend. And 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. And these people typically will have some type of turnover and you need to understand the logistics of how that works to be able to monitor integrally 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. And for that reason, we should create this motivation in our team that we always can find a way to do it better. And 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. So, that is an important concept.

And 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 a complementary expertise is vital. There are 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 intensivists and the nephrologist need 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 the patient, a new event occurs, let's say this patient starts having some acute bleeding scenario, that all the prescription needs to be adjusted according to that. So, this is a constant communication exercise between the intensivist and the nephrologist and at the time of initiation or deciding on initiating a patient on CRRT, during the treatment and also at the time of deescalation. 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 a coordination how to deescalate 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.

So, 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.

Host: What an excellent message to end this episode. And 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.

Disclaimer2: 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 are 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

disclaimer: 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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