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Prolonged Intermittent Kidney Replacement Therapy


Changing the face of dialysis in the ICU.

PIKRT may help you improve resource utilization, patient care, and early patient mobilization programs.

Prolonged Intermittent Kidney Replacement Therapy ("PIKRT") is a gentle 6- to 12-hour hybrid kidney replacement therapy that may be used as an alternative to kidney replacement therapies in the ICU.

Resource Utilization

PIKRT can free dialysis nurses from managing KRT in the ICU, allowing them to manage other patients and/or tasks, which may decrease overtime costs.1 The ICU nurses are empowered to manage their patient’s therapy and schedule without a significant increase in workload when dialysis staff is involved in system set-up and take-down.

Using PIKRT in the ICU helps to increase staff competencies with more frequent use of the same system in the ICU.1 Additionally, PIKRT can be used during times of high census or during a disaster/emergency, allowing for more than one patient to be treated per system within 24-48 hour period with existing equipment.

 

References

  1. Concepcion LA, et al. ARF requiring dialysis: use of shift CVVHD vs. conventional dialysis. J Am Soc Nephrol. 2009; Suppl, F-P01557 (Abstract).

Patient Care

PIKRT may help you achieve your patient care goals, whether it be fewer hypotensive episodes, reduction in anticoagulation use, or early patient mobilization.

When used in place of IHD, PIKRT provides a gentle, effective therapy for patients who cannot tolerate the intensity of a 3–4 hour IHD treatment.1 Utilizing PIKRT has been shown to reduce hypotensive episodes while removing as much or more fluid due to the longer therapy duration.1

PIKRT may also be used in place of CKRT, providing adequate volume and solute control with shorter treatments and higher flow rates.2 Shorter treatments allow for flexibility in scheduling diagnostic and therapeutic procedures,2 and providing time for physical and occupational therapies.3 The shortened treatment time and increased blood flow rates may result in a reduction of the frequency of filter clotting4,5 and the use of anticoagulation (if typically prescribed), which can decrease the bleeding risk.

 

References

  1. Concepcion LA, et al. ARF requiring dialysis: use of shift CVVHD vs. conventional dialysis. J Am Soc Nephrol. 2009; Suppl, F-P01557 (Abstract).
  2. Gashti CN, Salcedo S, Robinson V, Rodby RA. Accelerated venovenous hemofiltration: early technical and clinical experience. Am J Kidney Dis. 2008;51(5):804-810.
  3. Edrees F, Li T, Vijayan A. Prolonged Intermittent Renal Replacement Therapy. Adv in Chronic Kidney Disease. 2016:23:No 3:195-202.
  4. Kox WJ, et al. Practical aspects of renal replacement therapy. The International Journal of Artificial Organs, Vol. 19, No 2, 100-105, 1996.
  5. Davies H., et al. Maintaining the CRRT Circuit; non-anticoagulant alternatives. Australian Critical Care; Vol. 19, No. 4, November 2006

Early Patient Mobilization

Early patient mobilization in the ICU has been associated with improved outcomes, including reduction in ICU and hospital length of stay, more ventilator-free days, and better functional status. PIKRT can provide patients with time off therapy, allowing them to receive physical and occupational therapy. When patients no longer need 24-hour CKRT, PIKRT can help you achieve early patient mobilization goals.1
 

Early Patient Mobilization with Prolonged Intermittent Kidney Replacement Therapy

References

  1. Edrees F, Li T, Vijayan A. Prolonged Intermittent Renal Replacement Therapy. Adv in Chronic Kidney Disease. 2016:23:No 3:195-202.

A Simple and Practical KRT Option

PIKRT provides a gentle therapy with similar hemodynamic, clearance, and survival outcomes to Continuous Kidney Replacement Therapy ("CKRT")1 and Intermittent Hemodialysis Therapy ("IHD"),2 if deemed appropriate by the physician. As patients become more hemodynamically stable, CKRT patients can be transitioned using PIKRT. Additionally, PIKRT can be used in place of conventional IHD or Sustained Low-Efficiency Daily Dialysis ("SLEDD") for patients who cannot tolerate the intensity of a 3-4 hour treatment.

PIKRT vs. CKRT

PIKRT is a practical alternative to CKRT. By increasing the blood flow rate to run over a 6- to 12-hour period, higher hourly hemofiltration rates are feasible. This allows for an accelerated treatment period, yet provides a gentle therapy.1

Typical Dosing
Using approximate flow rates of 300 mL/min blood flow and a 5 L/hr prescription fluid rate, the use of PIKRT has been demonstrated to be an effective and efficient therapy.2

Potential Benefits of PIKRT vs Conventional CKRT with NxStage System One

Risks and Responsibilities

Renal replacement therapy, as with any medical therapy is not without risks. The decision of which therapy and medical device to use should be made by the physician, based on previous experience and on the individual facts and circumstances of the patient.

There is no literature demonstrating that one therapy is clinically better than the other.6

The use of anticoagulation is at the discretion of the prescribing physician.


References

  1. Gashti CN, Salcedo S, Robinson V, Rodby RA. Accelerated venovenous hemofiltration: early technical and clinical experience. Am J Kidney Dis. 2008;51(5):804-810.
  2. Concepcion LA, et al. ARF requiring dialysis: use of shift CVVHD vs. conventional dialysis. J Am Soc Nephrol. 2009; Suppl, F-P01557 (Abstract).
  3. Kox WJ, et al. Practical aspects of renal replacement therapy. The International Journal of Artificial Organs, Vol. 19, No 2, 100-105, 1996.
  4. Davies H., et al. Maintaining the CRRT Circuit; non-anticoagulant alternatives. Australian Critical Care; Vol. 19, No. 4, November 2006
  5. Edrees F, Li T, Vijayan A. Prolonged Intermittent Renal Replacement Therapy. Adv in Chronic Kidney Disease. 2016:23:No 3:195-202.
  6. Kraus MA. Selection of Dialysate and replacement fluids and management of electrolyte and acid-base disturbances. Semin Dial 2009;22(2):137-140.

PIKRT vs. IHD

In a retrospective analysis of 280 patients with acute renal failure in the ICU, an 8-hour PIKRT* was demonstrated to be an effective and efficient therapy compared to conventional IHD.

Typical Dosing
Using approximate flow rates of 300 mL/min blood flow and a 5 L/hr prescription fluid rate, the use of PIKRT has been demonstrated to be an effective and efficient therapy.1

Potential Benefits of PIKRT vs Conventional IHD with NxStage® System One™

The compact design of the NxStage System One, with no special electrical or plumbing needs, frees up valuable space when compared to equipment required for conventional IHD (including HD system, supply cart and portable RO).

*PIKRT is also known as SHIFT Therapy

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Risks and Responsibilities

Renal replacement therapy, as with any medical therapy is not without risks. The decision of which therapy and medical device to use should be made by the physician, based on previous experience and on the individual facts and circumstances of the patient.

There is no literature demonstrating that one therapy is clinically better than the other.2

The use of anticoagulation is at the discretion of the prescribing physician.


References

  1. Concepcion LA, et al. ARF requiring dialysis: use of shift CVVHD vs. conventional dialysis. J Am Soc Nephrol. 2009;Suppl, F-P01557 (Abstract).
  2. Kraus MA. Selection of Dialysate and replacement fluids and management of electrolyte and acid-base disturbances. Semin Dial 2009;22(2):137-140.

PIKRT vs. SLEDD

PIKRT is a practical alternative to SLEDD, allowing you to use one simple system to treat patients requiring renal replacement therapy in the ICU.

Typical Dosing
Using approximate flow rates of 300 mL/min blood flow and a 5 L/hr prescription fluid rate, the use of PIKRT has been demonstrated to be an effective and efficient therapy.1

Potential benefits of PIKRT vs SLEDD with NxStage® System One™

The compact design of the NxStage System One, with no special electrical or plumbing needs, frees up valuable space when compared to equipment required for conventional IHD (including HD system, supply cart, and portable RO).

Risks and Responsibilities

Renal replacement therapy, as with any medical therapy is not without risks. The decision of which therapy and medical device to use should be made by the physician, based on previous experience and on the individual facts and circumstances of the patient.

There is no literature demonstrating that one therapy is clinically better than the other.2

The use of anticoagulation is at the discretion of the prescribing physician.


References

  1. Concepcion LA, et al. ARF requiring dialysis: use of shift CVVHD vs. conventional dialysis. J Am Soc Nephrol. 2009;Suppl, F-P01557 (Abstract).
  2. Kraus MA. Selection of Dialysate and replacement fluids and management of electrolyte and acid-base disturbances. Semin Dial 2009;22(2):137-140.

Dosing Guidelines for PIKRT

Leading experts have established PIKRT dosing and antibiotic guidelines.

Dosing Guidelines

According to RENAL and ATN trials, contemporary dosing guidelines suggest 20-25 ml/kg/hr1,2

References

  1. Palevsky, PM, et al (The VA/NIH Acute Renal Failure Trial Network); Intensity of Renal Support in Critical Ill Patients with Acute Kidney Injury, N Engl J Med; Vol. 359, No. 1, 2008.
  2. Bellomo R., et al. Intensity of Continuous Renal-Replacement Therapy in Critically Ill Patients (RENAL). NEJM 2009; 361:1627-38.
  3. Adapted from Diaz-Buxo, et al. Standard Kt/V: Comparison of Calculation Methods. Artificial Organs, 30(3): 178-185, 2006.
  4. Reported data based on the experience of one institution.

Antibiotic Dosing Recommendations

Antibiotic dosing for Kidney Replacement Therapy (KRT) can be a challenge.
Recommendations based on the literature have been established specifically for Prolonged Intermittent Kidney Replacement Therapy (PIKRT) in 11 of the most common antibiotics used in the ICU.

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References

  1. Jang, JM, Mueller BA, et al; A Monte Carlo Simulation Approach for Beta-Lactam Dosing in Critically Ill Patients Receiving Prolonged Intermittent Renal Replacement Therapy. The Journal of Clinical Pharmacology. 2018 Oct; 58(10):1254-1265.
  2. Lewis, SJ Mueller, BA, et al. In silico trials using Monte Carlo simulation to evaluate ciprofloxacin and levofloxacin dosing in critically ill patients receiving prolonged intermittent renal replacement therapy. Renal Replacement Therapy. (2016) 2:45.
  3. Lewis, SJ, Mueller, BA, et al; Use of Monte Carlo Simulations to Determine Optimal Carbapenem Dosing in Critically Ill Patients Receiving Prolonged Intermittent Renal Replacement Therapy. The Journal of Clinical Pharmacology. 2016 Oct;56(10):1277-87.
  4. Gharibian, KN, Mueller BA. Fluconazole dosing predictions in critically-ill patients receiving prolonged intermittent renal replacement therapy: a Monte Carlo simulation approach. 2016 Jul;86(7):43-50.
  5. Lewis, SJ, Mueller, BA. Development of a vancomycin dosing approach for critically ill patients receiving hybrid hemodialysis using Monte Carlo simulation. SAGE Open Medicine. 2018; 6, 1-10.

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Risks and Responsibilities

Kidney replacement therapy, as with any medical therapy is not without risks. The decision of which therapy and medical device to use should be made by the physician, based on previous experience and on the individual facts and circumstances of the patient.

There is no literature demonstrating that one therapy is clinically better than the other.3

The use of anticoagulation is at the discretion of the prescribing physician.

References

  1. Gashti CN, Salcedo S, Robinson V, Rodby RA. Accelerated venovenous hemofiltration: early technical and clinical experience. Am J Kidney Dis. 2008;51(5):804-810.
  2. Concepcion LA, et al. ARF requiring dialysis: use of shift CVVHD vs. conventional dialysis. J Am Soc Nephrol. 2009;Suppl, F-P01557 (Abstract).
  3. Kraus MA. Selection of Dialysate and replacement fluids and management of electrolyte and acid-base disturbances. Semin Dial 2009;22(2):137-140.

 

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