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Choosing a Kidney Replacement Therapy in the COVID-19 Era
In the early stages of the COVID-19 pandemic, one of the life-threatening complications that became evident was acute kidney injury (AKI). The virus can attack patients’ bodies in such a way that they go from somewhat mild symptoms to presenting with organ failure, sometimes within a matter of hours.
“The patients become acutely ill very fast,” says Dr. Casey Gashti*, a board-certified nephrologist at Rush University Medical Center (RUMC) in Chicago. “They can be on the general medical floors and all of a sudden they get transferred to the intensive care unit (ICU) because of acute decompensation.”
Dr. Gashti said once in the ICU, severe COVID-19 patients are often intubated and placed on oxygen, respiratory therapies, and low blood pressure treatments. Many also experience AKI. It can all happen very quickly, he explained.1
"COVID-19 severity impacts the numbers of patients that require kidney replacement therapy (KRT) and ICUs can be overwhelmed. They needed to find solutions that could address resource shortcomings.2
As Dr. Gashti discusses in his presentation, PIRRT in the Era of COVID-19, hybrid therapies such as prolonged intermittent kidney replacement therapy (PIKRT, also called prolonged intermittent renal replacement therapy, PIRRT, accelerated venovenous hemofiltration, AVVH, or sustained low-efficiency dialysis, SLED) have proven successful in treating AKI3 and—due to their versatility—potentially helping hospitals address situations such as nursing shortages and dwindling of resources, which can occur in the wake of natural disasters or widespread illness.
Preparing for Surges and Providing Solutions
Aside from its associated health problems, a major effect of COVID-19 pandemic is the burden on the healthcare community. Long hours, equipment deficits, and nursing shortages—especially in the field of nephrology—have been felt nationwide, and an influx of cases and hospitalizations made matters more critical. Hospitals have been forced to make the most of the staff and equipment they have on hand.2
“One of the ways we can help fix both staffing and equipment issues and improve management of our current resources is to consider prolonged intermittent kidney replacement therapy,” explains Dr. Gashti. “This is essentially a hybrid therapy, a shorter treatment compared to a 24-hour continuous therapy so that we can use our machines and our staff in more places, but longer and gentler than intermittent HD, which may not be well tolerated by very sick patients.”
The problem isn’t just the number of patients arriving at hospitals, explains Dr. Gashti, it is also the severity of their condition and their length of stay.
“One of the things really binding up hospital beds and nursing is, unlike some of the other patient populations that get better and then they leave, [COVID-19 patients] stay for 10, 14, 21 days,” Dr. Gashti points out. “So that's another area where this is a little different than just your regular pneumonia or septic shock.”1
Dr. Gashti referred to a scenario where a unit normally running three to five KRT treatments simultaneously could suddenly be inundated with 10 to 20 acutely ill COVID-19 patients in need of therapy.
“Resource utilization becomes a very significant issue,” he cautions. In these situations, PIKRT can help.
While continuous kidney replacement therapy (CKRT) runs 24 hours a day and requires heavy ICU nursing support, PIKRT is typically administered five to six days a week for periods of 6 to 12 hours each.
“So, if you run your PIKRT treatment over 10 hours, you could use the same machine to dialyze two patients instead of one patient [in one 24-hour period],” Dr. Gashti clarifies. “That would address some of the surge in patients. You still need nursing coverage and you've got your fluids and tubing and cartridges—those will remain the same. But at least you could optimize and be more efficient with what you have.”1
Not only does PIKRT allow for flexibility, but when compared to another common KRT treatment—intermittent hemodialysis (IHD)—it is gentler4 on patients and takes some of the burden off dialysis nurses. IHD is only administered for three to five hours per session, but it requires a dialysis nurse to be present throughout the entire treatment. It can be harsh on a patient’s organs, as it quickly draws off large amounts of fluid, which may be dangerous if a patient is prone to hemodynamic unstablity.5
“If you look at hybrid therapies, we essentially take advantage of what CKRT provides (gentler, prolonged therapy) as well as what IHD provides,” says Dr. Gashti. “So, you can really take the best of both and combine that into PIKRT.”
Kidney Replacement Therapy Considerations in Challenging Times
CKRT is the therapy of choice for patients with hemodynamic instability while IHD is the likely option for more stable patients.
“Continuous therapies tend to achieve better fluid balance because you can space out your volume removal over a longer period of time and you have better hemodynamics to do so,” says Dr. Gashti.
IHD’s advantages, he explains, include rapid removal of poisons or toxins, limited utility anticoagulation, and a lower requirement for ICU nursing support due to its shorter treatment span (usually three to five hours).5 However, in situations presented by the pandemic, a hybrid therapy might be a better option, because it combines some of the benefits of both IHD and CKRT.6
According to Dr. Gashti, beyond caring for patients, the focus on PIKRT in the era of COVID-19 is to optimize machine use.1 In this area, his team has the additional advantage of administering therapies with the NxStage System One, which is capable of CKRT, PIKRT, and IHD treatments. This extra versatility allows for the same machine to be used for different therapies and for more than one patient on the same day, while achieving similar clearances.
Making a Difference with Kidney Replacement Therapy
Critical care comes with unique challenges, regardless of the circumstances. With the COVID-19 pandemic, however, the ICU environment became a veritable testing ground for the care of AKI patients. With beds, supplies, and staff in short supply, choosing the appropriate KRT treatment is one way clinicians can manage resources and provide the therapy AKI patients desperately need.
Whether a pandemic, a natural disaster, or another emergency situation for which dialysis resources become a focal point, KRT versatility can help provide for the needs of both staff and patients.
*Paid speaker for NxStage Medical
INDICATIONS FOR USE:
The NxStage System One is indicated for the treatment of acute and chronic renal failure, or fluid overload using hemofiltration, hemodialysis, and/or ultrafiltration, in an acute or chronic care facility. The NxStage System One is also indicated for Therapeutic Plasma Exchange in a clinical environment. All treatments must be administered under a physician’s prescription, and must be observed by a trained and qualified person, considered to be competent in the use of this device by the prescribing physician. NxView is a computer-based touch screen user interface that provides online instructions for use, summarized system information, and remote access.
NxView is contraindicated as the sole method of monitoring a patient during treatment.7
Kidney replacement therapy, as with any medical therapy, is not without risks. The decision of which therapy 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 one therapy is clinically better than another.8
- Physician experience.
- Anger MS, Mullon C, Ficociello LH, et al. Meeting the Demand for Renal Replacement Therapy during the COVID-19 Pandemic: A Manufacturer’s Perspective. Kidney360 2021;2(2):350-4.
- Schwenger V, Weigand MA, Hoffmann O, et al. Sustained low efficiency dialysis using a single-pass batch system in acute kidney injury - a randomized interventional trial: the REnal Replacement Therapy Study in Intensive Care Unit PatiEnts. Crit Care 2012;16(4):R140.
- Gashti CN, Salcedo S, Robinson V, Rodby RA. Accelerated venovenous hemofiltration: early technical and clinical experience. Am J Kidney Dis 2008;51(5):804-10.
- Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2012;2(1):1-138.
- Abdeen O, Mehta RL. Dialysis modalities in the intensive care unit. Crit Care Clin 2002;18(2):223-47.
- NxStage System One User Guide, NC4921 Rev. K 2021-10.
- Nash DM, Przech S, Wald R, O'Reilly D. Systematic review and meta-analysis of renal replacement therapy modalities for acute kidney injury in the intensive care unit. J Crit Care. 2017 Oct;41:138-144.
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CAUTION: Federal law restricts this device to sale by or on the order of a physician.
P/N 105028-01 Rev A 02/2022 / APM4442 REV A