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Kidney Week

Abstract: PO0665

Prolonged Intermittent Renal Replacement Therapy for AKI in COVID-19 Patients with Acute Respiratory Distress Syndrome

Session Information

Category: Coronavirus (COVID-19)

  • 000 Coronavirus (COVID-19)

Authors

  • Ramirez-Sandoval, Juan Carlos, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico, Mexico, Mexico
  • Gaytan, Jorge, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico, Mexico, Mexico
  • Arvizu-Hernandez, Mauricio, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico, Mexico, Mexico
  • Mejia-Vilet, Juan M., Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico, Mexico, Mexico
  • Xolalpa Chavez, Pedro, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico, Mexico, Mexico
  • Correa-Rotter, Ricardo, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico, Mexico, Mexico
  • Vega, Olynka, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico, Mexico, Mexico
Background

Patients with COVID-19 associated acute respiratory distress syndrome (ARDS) frequently develop severe AKI. Although continuous renal replacement therapy (CRRT) is standard of care for critically ill patients, prolonged intermittent renal replacement therapy (PIRRT) is a feasible option.

Methods

Prospective analysis of 101 PIRRT treatments in a COVID-19 reference hospital in Mexico City (Mar-May 2020).

Results

Of 142 severe COVID-19 patients, 91 (64%) developed AKI, 42 (29%) Stage 3, and 14 (7%) initiated PIRRT; median age 51 y [IQR 51-59, range 40-73], male 11 [78%], diabetes 5 [36%], median BMI 31 kg/m2 [27-51], SOFA score 10 [IQR 9-11], ferritin 888 [510-1374 ng/mL], and D-dimer 3076 [1929-5858 ng/mL]. In 81/101 (81%) PIRRT sessions, ultrafiltration (UF) goal was achieved. Duration of PIRRT was 6-8 h in 65/101 (64%) yet in 16/101, procedure was extended 2-4 additional h, to reach UF goal. In subjects with vasopressors, there was a mean norepinephrine dose increase of 0.067 mcg/kg/min (95% CI 0.047-0.101). Intradialytic hypotension (SBP decrease ≥20 mmHg) occurred in 39 (39%) of PIRRT procedures, and 13/101 (13%) PIRRT were discontinued due to severe hypotensive episodes, with 2 patients switched to CRRT. System clotting was a frequent event during the first weeks of March (7 events in the first 30 PIRRT procedures) until concomitant enoxaparin (0.5 mg/kg/day) and regional anticoagulation (unfractionated heparin 500 U/h) were employed. During follow-up, 5 patients (36%) recovered from AKI and respiratory failure, 3 (21%) died, and 6 (43%) are still hospitalized at the time of this report. In those who recovered renal function (9/14), the median number of PIRRT sessions was 6 [IQR 5-8]. Table shows changes in our PIRRT protocol during the COVID-19 outbreak.

Conclusion

PIRRT therapy was feasible and appropriate in most patients who exhibited an exuberant inflammatory response, severe hemodynamic instability, and hypercoagulability.

Recommendation 
“Early” placement of vascular accessPlace CVC before adopting prone position in high risk patients for RRT
Timing for initiation of PIRRTDo not reduce net positive fluid balance until complete fluid resuscitation is confirmed (consider high insensible losses due fever)
Limit COVID-19 exposureLimit HD staff exposure (place patients close in the ICU to simultaneously deliver PIRRT and limit time of nursing staff to max 4-6 h per person)
Prothrombotic complicationsUse of systemic and regional anticoagulation
Severe mixed acidemiaIncreased dialysate base yet avoid sudden pH normalization