Welcome to que digo conversations in Nephrology.
This episode is titled deciding when and who should start a
cute. Dialysis from evidence to
bedside practice. Here's your host.
Dr. Ravi Mehta. There are important decisions to
be made regarding when and who should start a kid.
Dialysis, how the conditions take this from evidence to
bedside practice. Hello and welcome to Katie, go
conversation Nephrology. I'm dr.
Avi. Metha professor of medicine at
the University of California in San Diego and joining me to
discuss the ins and out of starting a coup Dallas's is dr.
Marley's, Osterman. Dr. Osterman is a consultant in
critical care and a prodigy at guy's and St.
Thomas Foundation. Trust of London and her clinical
research, interests include acute, kidney injury.
In the critically ill, including biomarkers, and long-term
complications, and all aspects, related to acute.
Kidney replacement therapy. Dr. Osterman.
Welcome to the program. Thank you.
Professor media for this kind introduction.
It's a great honor to participate in today's
discussion about timing of acute.
Dialysis such an important topic in routine clinical practice.
So let's get started. There's been considerable
interest in defining the optimal timing for starting, dialysis
and critically ill patients. Why is This an area of
controversy. That's a very good question.
I'm afraid. Acute.
Kidney injury is very common in critically ill patients in the
Intensive Care Unit and patients, who develop acute
kidney injury often spend longer in hospital and have a much
higher risk of complications. It's a particularly high risk of
dying in those who need a cute dialysis.
So, on the one hand acute paralysis can be life-saving,
but I'm afraid it also has adverse effects and can cause
harm and we as clinicians we want to avoid harm if possible.
So with regards to acute, dialysis, we grapple with the
decision when to start. If we start too early, we may
prevent the complications of acute kidney injury, but we
will. Give a treatment to patients who
don't actually need it. And if we wait too long, the
treatment May no longer be beneficial.
So this harm versus benefit question is a real challenge in
clinical practice when caring for an individual patient?
Fortunately, in the last few years, a lot of Trials have been
published and a lot of Publications have given us more
insight and important results and findings.
So what have these recent trials on timing analysis.
Shown us that can help us guide clinical application.
We've had a lot of Publications including five Landmark trials,
and I'll just mention them briefly.
We had the Elaine trial, a Kiki, wanted a key to Ideal ICU and
start Aki. These are Landmark tried in the
field of critic, an apology. They all explored timing of
acute paralysis, but they addressed, this question from
different perspectives. So, for instance, the Elaine
trial was a The center study with the aim to find out whether
starting acute Dallas's in patients with moderate acute.
Kidney injury could reduce mortality.
And indeed the trial showed a significantly lower 90-day
mortality in patients, who receive dialysis treatment
earlier, in contrast, the a Kiki and ideal ICU tries for
multicenter studies, which explored the question is it safe
to wait? They enrolled patients with more
severe. Acute kidney injury.
And showed that 60 or 90 day mortality, was no different in
patients who had received a cute analysis.
Later compared to those who had received the cute dialysis, much
earlier importantly. They also found that acute
paralysis could be avoided in a large number of patients who had
been randomized to the delayed arm.
However, should be mentioned, that mortality was higher.
If patients in the delayed arm actually needed a cute dog.
Treatment. And then we have these start Aki
trial which is today the largest study with more than 3,000
patients from 168, different icus from 15 countries.
And this study focused on patients where clinicians had
equipoise and had no objections to either accelerated or delayed
initiation. We study showed no difference in
90-day. Mortality between the
Accelerated versus standard initiation group, like the
previous two studies. It also showed that acute
paralysis could be avoided in almost 40 percent of patients
and importantly, they highlighted some harm from
starting dialysis early. There was a higher risk of
dialysis dependence at 90 days and there were more Adverse
Events in the accelerated group. And overall.
There was no obvious benefit from starting a cute doll.
This earlier. So this then brings us to the
next question. How long can you wait?
And this was a question explored in the icky to trial?
Patients with severe, acute kidney injury and oliguria or
uremia were randomized to delayed or very delayed
initiation of dialysis. The trial showed that again,
Dallas is could be avoided if you waited for longer, but
60-day mortality was higher. So together.
These trials have given us important information and
explored the question from different angles, but they have
still not giving us enough information to manage an
individual patient at the bedside because we still do not
know which patient actually needs acute paralysis and who
can be managed conservatively in all studies be criteria for
either early or late initiation was based on serum creatinine or
severity of acute, kidney injury, but in real life at the
bedside, there are many other Area in fact, acute paralysis is
a form of organ support, which we use to prevent fluid overload
or normalized metabolic derangements or correct fluid
overload. And so we clearly need more
information at the bedside to guide us.
Dr. Osterman. You're in a very experienced
clinician and these trials, as you've pointed out, have not
been fully comprehensive and telling us what we need.
So what are the most relevant parameters that influence your
In on who you offer dialysis to when you start and when you
stopped, my main aim is to give treatments to patients who will
benefit from them and to avoid treatments that may either cause
more harm than benefits and Q. Dallas is no exception.
So I view acute paralysis as a form of kidney support and I
want to start it and offer it to patients who are in whom King.
Any function is not sufficient to cope with the complications
including metabolic derangements or fluid overload and I want to
start it before the kidneys actually fail completely and
therefore my Approach consists of repeated assessments and
evaluation of the trajectories and an assessment of the future,
including the next 12-24 hours per day.
None of what may happen and looking at these Trends and
predicting whether patients will come to harm from the metabolic
derangement or the accumulation of fluid guides me.
So if patients are getting worse and fluid is building up and
metabolic derangements are contributing to their condition
and acute paralysis is in line with the patient's wishes and
their overall treatment goal. Then I start from Gardeners of
the level of creatinine. I hope this demonstrates that
there are many more factors than just creating it alone or stage
of acute kidney injury, which guide and determine our
management at the bedside. And it became very clear during
the recent pandemic, but we may need to modify our general
approach. When dealing with sick patients
with acute, kidney injury for those just tuning in.
You're listening to Katy. Your conversation in a prodigy.
Our topic today is deciding when and who should start a cute
dialysis from evidence to bedside practice.
I'm dr. Avi Mehta and I'm speaking with
dr. Molly saw Steven.
Dr. Osterman has your experience with managing patients change
during the covid-19 pandemic. And if so in what way, I'm
afraid during the pandemic, we had to change our approach to
acute Paralysis on many fronts. We like many colleagues facing
Unexpected challenges, including reduced, dialysis capacity,
unexpected Supply problems and a major shortage of nursing staff.
And the first thing we learned was that there are at least two
key processes that influence timing of acute Paralysis on the
one hand. There is a decision process
which focuses on the medical decision, but a patient needs
dialysis. And then there are the logistics
and they certainly influence and impact timing.
And these challenges forced us to adapt our practice.
We obviously recruited one nurses.
We expanded the dialysis modalities and use different
types of dialysis. We even produce dialysis fluid
and house to overcome some of the challenges.
We also changed our approach to timing and we carefully assessed
and reassessed which patient needed dialysis urgently.
We always ask the question. Question, whether it was safe to
wait, without causing harm, whether there are any potential
Alternatives. And then, lastly, whether we
actually had the necessary kid and the nurses available to
deliver Reno, replace dialysis treatment.
Overall. The aim was to deliver the
greatest good for the greatest number of patients.
I'm very pleased. But we've recovered from this
period. And now, we are back to business
as usual, which means a more personalized approach to timing
of Dallas has so, what additional information is needed
currently to help us improve care of patients.
In the setting, what should conditions due to currently
manage their patients? And are there.
Any final messages you'd like to leave with our listeners?
My key messages to emphasize that acute, dialysis is a form
of support therapy, which should be considered before kidney
function, actually fails completely, and the optimal time
varies from Patient to Patient. And to deliver this form of
personalized medicine, taking into account, all the various
aspects from metabolic derangement and fluid
accumulation to potential. Trajectories means that we need
more diagnostic tools and techniques to come to the right
decision. And as I already mentioned, it's
clearly important that we all work together.
And communicate, well with all the relevant people caring for
patients including staff and the team delivering acute paralysis
in order to devoid delays. After decision, in favor of the
queue Dallas has been made. I also want to highlight again
that acute paralysis is delivered and monitored very
differently across the world. I mean, speaking to colleagues,
it's clear that we all use different quality metrics and I
think It would be nice for us to agree, some quality indicators
so that we can at least have similar standards and put
Improvement projects in place. And then lastly, I would plead
have an update of the existing Official Guidelines because none
of them have included the data of the recent studies and
randomized, controlled trials. With that in mind.
I was very pleased to hear that KD go is making preparation for
a State of the que digo guideline.
That's a great way to round out our discussion today.
I would like to thank my guests. Dr. Molly's Osterman for joining
me. Dr. Osterman.
It was great. Having you on the program.
It's been a great honor to participate.
And I hope today's discussion has highlighted some of the
ongoing challenges but also the enormous advances and progress
made in the last 10 years since the release of the que digo.
Valid in 2012. I'm dr.
Avi Mehta. To access this and other
episodes in the series visit que digo dot org slash podcast.
Thanks for listening. This episode of que digo
conversations in Nephrology was provided by KD go and supported
by Baxter Healthcare.