Urology & Kidney Disease News Fall 2009 - Cleveland Clinic

50 Urology & Kidney Disease News
Renal Failure
ICU Nephrology: Change and Optimism
Sevag Demirjian, MD
Incidence of renal consultations in CCF ICUs
Despite ongoing discoveries, the
2003 2004 2005 2006 2007 2008
outcome for patients who develop
Consults ESRD 280 225 200 215 235 272
renal failure requiring dialysis
Consults ARF 592 691 700 803 900 820
remains at 50% Though there have
been a number of clinical trials
addressing the issue of dialysis dose and type (continuous
vs. intermittent), no individual disruptive technology
or approach has fully altered the natural course for the
patient who develops acute kidney injury (AKI) in the ICU.
Future efforts at identifying the high risk patient, creative
approaches to preventing injury and protocols aimed at
repairing the kidney following an insult are being initiated
here. Current studies are examining the use of sRNA compounds
to prevent injury, along with a series of biomarkers
for early detection of kidney injury in postoperative and ICU
settings. While showing great promise, these markers have
not been validated against hard clinical endpoints.
The large patient volume at Cleveland Clinic combined with
state-of-the art electronic data capture has enabled our researchers
to better understand risk factors, characteristics
and complications associated with AKI and its treatment.
We also are able to better phenotype our patients at high
risk for renal complications. Subsequently, we can offer
individualized care and investigational therapy opportunities
for these patients. RENAL RES-Q clinic (Renal Risk
Evaluation for Surgery at the Q building (Glickman Tower)),
capitalizes on meticulous pre-intervention evaluation of
these high-risk patients, detailed counseling and timely
fine-tuning of their modifiable risk factors. Moreover, for
those interested, serum and urine samples will be collected
to improve predictive ability via biomarkers, and opportunities
will be provided for participation in clinical trials.
Two recent large multicenter trials renal replacement
dosage in acute kidney injury showed very high mortality
rates in critically ill patients with AKI. In contrast to earlier
smaller trials, neither trial showed a clear-cut benefit from
increased dose of renal replacement therapy. This has
prompted our nephrologists to refocus our attention on
detailed technical aspects of renal replacement in the ICU.
We hypothesize that apparently insignificant details of dialysis
prescription in the ICU may influence patient survival
by mechanisms that renal replacement therapy (RRT) dose
alone may not capture. We are probing the effects of RRT
on drug dosing, middle molecule clearance, and nutritional
health of critically ill patients.
As our understanding of critical illness and acute kidney
injury evolves, we must progress from a one-size-fits-all
approach to renal replacement in the ICU, and tailor goals
and prescription to each patient. We are incorporating
various techniques to both adequately and efficiently provide
renal replacement therapy to ICU patients utilizing
multiple different dialysis machines and RRT options. Safe
and cost-effective methods for accomplishing the dialysis
procedure without systemic anticoagulation are rapidly
replacing unfractionated heparin as the standard of care in
dialysis, and we are implementing regional anticoagulation
techniques for dialysis in our ICUs.