I trattamenti extracorporei nelle terapie intensive del Piemonte

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1 I trattamenti extracorporei nelle terapie intensive del Piemonte Filippo MARIANO (per conto del Gruppo di Lavoro "Trattamenti Sostitutivi in Area Critica", Sezione Piemonte e Valle d'aosta, SIN) Dipartimento di Area Medica, SCDO di Nefrologia e Dialisi, Ospedale CTO - Torino

2 Piedmont and Aosta s Valley Survey on December 31, 2007: Habitants 4,526,078 ( ,812) Source ISTAT

3 Key points della discussione:! Analisi dei dati della survey 2007! Incidenza! Cause, tipi di trattamento! Gestione e prescrizione della dialisi! Dose di dialisi! Anticoagulazione! Accesso vascolare! Confronto con dati del 2009

4 Survey year 2007 Distribution of ICUs beds numbers according to Dialysis Center - year Beds numbers (total 606 beds in 79 ICUs) beds numbers A B C D E F G H I J K L M N O P Q R S T U V X Y 0 Statistiche Descrittive mean incidence (Consensus_Acuti_no_zeri.sta) of patients needing RRT/year: / 100,000 habitants Critici_Trattati_ totali N Validi Somma Media Dev.Std. Minimo Massimo ,00 46,58 53,3478 8,00 247,00 Days_Totali ,00 326,75 438,81 22, ,00 STATISTICA, versione 6.1 Ita, Stasoft, Tulsa OK

5 Table I: Demographic data as to Nephrology and Dialysis Centres, numbers of patients receiving RRT and days of RRT in the Piedmont and Aosta Valley. Data are given as the sum of absolute numbers (1st column ) and the median value per centre* (2nd column) n. median (interquartiles)* Respondents Dialysis Centres 24/24 -- Number of patients receiving RRT 1, (16 52) Total days of RRT 7, ( ) Median duration of RRT (days/patient) ( ) 2009 Respondents Dialysis Centres 25/25 -- Number of patients receiving RRT 1, (20 50) Total days of RRT 8, ( ) Median duration of RRT (days/patient) ( ) * Median of Centres

6 Causes of RRT year 2007 Table II: Distribution of 1,128 patients according to RRT aetiology n. patients (%) average % in each Centre (range) Acute kidney injury 780 (69.9) 69.9 (30-100) RDT patients admitted in ICUs 249 (24.9) 23.6 (0-70) Extrarenal indications* 37 (4.2) 6.5 (0 46) * Extrarenal indications include congestive cardiac failure, hepatic failure or septic shock 249 / 3,192 a x 100 = 7.8 % (from literature 1.62% and 8.6% of the RDT population is admitted to an ICU a 3192 = chronic dialytic patients cared for in Nephrology and Dialysis centres in ) Uchino S, Morimatsu H, Bellomo R, Silvester W, Cole L. End-stage renal failure patients requiring renal replacement therapy in the intensive care unit: incidence, clinical features, and outcome. Blood Purif 2003; 21: ) Manhes G, Heng AE, Aublet-Cuvelier B, Gazuy N, Deteix P, Souweine B. Clinical features and outcome of chronic dialysis patients admitted to an intensive care unit. Nephrol Dial Transplant 2005; 20: ) Bagshaw SM, Mortis G, Doig CJ, Godinez-Luna T, Fick GH, Laupland KB. One-year mortality in critically ill patients by severity of kidney dysfunction: a population-based assessment. Am J Kidney Dis 2006; 48:

7 Distribution of patients in years 2007 and 2009 according to RRT etiology (1118 patients) (1253 patients) % of patients AKI RDT in ICUs Extrarenal Figure 1

8 Distribution of patients according to duration of treatment year 2007 CRRT 39.4% Peritoneal dialysis 1.6% RRT<6 hours 20.6% SLED 38.5% - Several dialysis centres chose not to apply CRRT, but rather to extend SLED to 6-14 hours. - The choice of RRT duration might reflect: - the therapeutic necessity in patients with unstable hemodynamics, - a logistical organization necessity of the dialysis centre Mariano f et al, J Nephrol 2011; 24:

9 Distribution of patients in years 2007 and 2009 according to RRT duration 75 % of patients (1118 patients) 2009 (1253 patients) 0 CRRT PIRRT RRT<6 h PD 8 9 Figure 2

10 Distribution of patients according to type of treatment - year 2007 CPFA 1.6% SCUF+other 1.0% - Dialysis centres are able to provide various types of treatment: - convective/diffusive modality - peritoneal dialysis (mostly in pediatric patients) Mixed (HDF) 39.4% Convective (HF) 49.2% High Volume HF 2.4% Diffusive(HD) 6.4% - Almost all the patients (about 90%) were treated with high permeability membrane (HF 49% or HDF 39.4%), a rate similar to that reported in the Australian experience by RENAL study investigators and in UK survey. - RENAL Study Investigators. Renal replacement therapy for acute kidney injury in Australian and New Zealand intensive care units: a practice survey. Crit Care Resusc : Gatward JJ, Gibbon GJ, Wrathall G, Padkin A. Renal replacement therapy for acute renal failure: a survey of practice in adult intensive care units in the United Kingdom. Anaesthesia 2008; 63:

11 Distribution of days according to type of treatment 75 % of dialysis days (7342 days) 2009 (8338 days) Convective (HF) Mixed (HDF) Diffusive (HD) High Vol HF CPFA SCUF+Other Figure 3

12 Indication and prescription of dialysis Indication of Dialysis Dialysis Prescription Both; 9; 38% Both; 2; 8% The indication to dialysis was done by both nephrologist and intensivist Nephrologist; 15; 63% Nephrologist; 22; 92% The prescription of dialysis is almost always on the nephrologist consultant responsibility - Where CRRT is prescribed by critical care physicians alone, according to unit policy, CRRT is the only treatment available RENAL Study Investigators. Renal replacement therapy for acute kidney injury in Australian and New Zealand intensive care units: a practice survey. Crit Care Resusc : (21) Mariano f et al, J Nephrol 2011; 24:

13 Dose of dialysis - prescribed and delivered year Down-time 47.6% 5.4 ml/kg/hour n. 21 n. 14 No control 52.4% Standard dose Septic dose 0.0 In our survey referred to the year 2007, the prescribed dose was 37.7 ml/kg/hour Control of down-time was performed only in 47.6% of centres, so the real dose delivered in ICUs patients was probably lower than that prescribed by the physician. Mariano f et al, J Nephrol 2011; 24:

14 A) - prescription of both dose ml/h and dose ml/kg/h B) - no target dosage or assessment of delivered dose was evaluate. C) - only 21% of practitioners assessed delivered dialysis dose (IHD) D) - <20% of practitioners reported using weight-based dosing of CRRT E) - absence of a consistent standard for prescription and monitoring of RRT during AKI.

15 - K Estimated = Effluent volume adjusted for effective time of treatment - K delivered = FUN (mg/dl) / BUN (mg/dl)] x effluent volume rate (ml/min) where FUN = fluid urea nitrogen The randomized ATN and RENAL studies did not demonstrate any survival benefit over ml/kg/hour The DO-RE-MI Study provided no evidence for a survival benefit afforded by delivered higher dose RRT, even after adjustment for multiple variables. - VA/NIH Acute Renal Failure Trial Network, Palevsky PM, Zhang JH, O'Connor TZ, et al. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med 2008; 359: The RENAL Replacement Therapy Study Investigators. Intensity of continuous renal-replacement therapy in critically ill patients. N Engl J Med 2009;361: Vesconi S, Cruz DN, Fumagalli R, et al. DOse REsponse Multicentre International collaborative Initiative (DO-RE-MI Study Group). Delivered dose of renal replacement therapy and mortality in critically ill patients with acute kidney injury. Crit Care 2009; 13:R57

16 Prescribed dose of dialysis ml/kg/day in 2007 data from 15/24 Centres in 2009 data from 19/25 Centres Figure 4 0 Normal Septic The near future ---- > a lower target dose prescription, and delivered dose tailored according to dialysis adequacy and tolerance

17 Type of anticoagulation - year 2007 Dermatan 8.7% No anticoagulant 10.9% Citrate 2.5% LMWH 10.0% Heparin-protamine 0.3% Predilution in patients at high bleeding risk No; 8.3% Unfractionated Heparin 67.5% Heparin dose: ±245.5 U/hour No; 91.7% - In the vast majority of dialysis sessions (5,296/7,842, 67.5%) unfractionated heparin was the anticoagulant of choice. - There was, however, a marked variation in dose in the protocols adopted by the various dialysis centres included in our study. - Predilution is a common way to increase blood circuit survival Mariano f et al, J Nephrol 2011; 24:

18 Distribution of dialysis sessions according to anticoagulation type % of dialysis days (7342 days) 2009 (8358 days) Unfract heparin No anticoag LMWH Dermatan Citrate Heparin-protamin Figure 6

19 Table II: current RRT modalities in patients at high risk of bleeding. Data are referred to a total of 1075 days (2007) and 1697 (2009) of RRT (all dialysis days done in patients at high risk bleeding) Modality number of dialysis days (%) Without/low heparin + saline flushes 857 (79.2%) 1220 (71.8%) Citrate 193 (18.0%) 452 (25.1%) Heparin-protamine 25 (2.8 %) 25 (1.4%)

20 Vascular access - year 2007 Jugular dx 28.7% Subclavian sn 4.5% Subclavian dx 5.2% Tunnellized 0.7% Jugular sn 3.1% Femoral 57.7% As vascular access was usually positioned by the intensivist, these data may well reflect the personal experience of the physician. In addition, many intensivists prefer locate vascular dialytic access in femoral sites, in order to save separate sovradiaphragmatic accesses for drug infusion, parenteral nutrition and the monitoring of central venous pressure. Mariano f et al, J Nephrol 2011; 24:

21 Distribution of vascular access according to site of insertion % of central venous catheters (669 cvc) 2009 (890 cvc) Femoral Jugular dx Subclavian dx Subclavian sn Jugular sn Tunnelized in 2007 data from 21/24 Centres in 2009 data from 23/25 Centres Figure 5

22 Incidenza della RRT nelle ICUs: distribuzione per Centro Incidence of RRT in ICUs: patients on RRT/beds numbers ratio 4 Patients/beds ratio mean 1.50 % 2007 mean 1.43 % A B C D E F G H I J K L M N O P Q R S T U V X Y Z Centres of Dialysis Figure 7

23 Risorse impiegate nella RRT in Area Critica: distribuzione per Centro RRT involvement: Acute_Days / Chronic_Days* ratio 8 *Chronic_Days are calculated as product (n. uremic patients x 3 x 52) % = (Acute_Days / Chronic_Days) x 100 % days of dialysis mean 1.58 % 2007 mean 1.41 % 0 A B C D E F G H I J K L M N O P Q R S T U V X Y Centres of Dialysis Figure 8

24 Conclusioni! Nel 2009 il trend della RRT in Area Critica e' in incremento, sia come numero di pazienti che come giorni di dialisi! I trattamenti lunghi (CRRT, PIRRT) e le metodiche che sfruttano il moto diffusivo (HDF, HD), gia' percentualmente predominanti, aumentano ancora la loro quota percentuale a scapito dei tartaamenti standard e convettivi puri (HF).! In accordo con le recenti indicazioni, la dose dialitica prescritta e' in diminuzione, e sono aumentati i trattamenti anticoagulativi con citrato.! Dal 2007 al 2009 il rapporto numero di pazienti RRT/letto ICU e' in incremento ( > 1.50), cosi come la percentuale dei giorni di dialisi acuti/cronici ( > 1.58%). Tali indici concordemente indicano che nei Centri Dialisi il carico di lavoro svolto nell'area Critica e' un aumento.

25 Elenco Referenti del Gruppo di Studio Regionale TRATTAMENTO SOSTITUTIVO RENALE IN AREA CRITICA CENTRO Medico Referente Alba (G. Viglino) Andrea CAMPO 2. Alessandria (M. Manganaro) Ernesto TURELLO 3. Aosta (P.E. Nebiolo) Massimo MANES 4. Asti (E. Biamino) Dario SASSONE 5. Biella (R. Bergia) Gian Mario BOSTICARDO 6. Borgomanero (S. Cusinato) Paola CARPANI 7. Casale (M. Gonella) Giovanni CALABRESE 8. Ceva (M. Formica) Maurizio GHERZI 9. Chieri (M. Salomone) Emanuele STRAMIGNONI 11. Chivasso (S. Savoldi) Guido MARTINA 10. Cirie (S. Savoldi) Andrea SERRA 12. Cuneo (A. Pacitti) Giorgio CANEPARI 13. Ivrea (F. Giacchino) Franco BONELLO 14. Novara (M. De Leo) Paola DAVID 15. Pinerolo (U. Malcangi) Antonio MARCIELLO 16. Rivoli (M. Saltarelli) Vincenzo TODINI 17. Torino_CTO (G. Triolo) Filippo MARIANO 18. Torino_G_Bosco (F. Quarello) Marco POZZATO 19. Torino_Martini (R. Boero) Marco TIMBALDI 20. Torino_Mauriziano (M. Marangella) Corrado VITALE 21. Torino_Molinette (G. Segoloni) Cesare GUARENA 22. Torino_OIRM (R. Coppo) Alessandro AMORE 23. Torino_San_Luigi (RM Scarpa) Giorgina PICCOLI 24. Verbania (A. Baroni) Maurizio BORZUMATI 25. Vercelli (G. Guida) Oliviero FILIBERTI