Next is Dr Busi Mrara, who unfortunately couldn't make it, but managed to record the talk and sent it to us. She will be talking about 'Augmented Renal Clearance'
#CCSSA2022 #FOAMcc #critcare
#CCSSA2022 #FOAMcc #critcare
ARC in sepsis was first described as early as 2008, and is defined as CrCl >130ml/min/1.73m2 based on a timed urine creatinine clearance.
It was compared to early kidney disease in diabetics. It was also described
doi.org/10.1177/031005…
It was compared to early kidney disease in diabetics. It was also described
doi.org/10.1177/031005…
Another proposed definition is 10% above upper limit of normal (GFR>160ml/min/1.73m2 in men and >150ml/kg/1.73m2 in women) by the australian group headed by Bara alumnus Prof Jeff Lipman. #CCSSA2022
What is the pathophysiology - its still unclear...
Underlying is probably the loss of renal blood flow autoregulation, the involvement of ANP, the use of vasopressors and hypertonic solutions. Also the concept of renal functional reserve may play a role. #CCSSA2022
Underlying is probably the loss of renal blood flow autoregulation, the involvement of ANP, the use of vasopressors and hypertonic solutions. Also the concept of renal functional reserve may play a role. #CCSSA2022
How to detect it?
Estimation of GFR equations (e.g. CKD-EPI) are limited in this population. To properly diagnose ARC, you should use a timed renal creatinine clearance? Collection time doesn't have to be 24h, can be brought down to 6h. BSA is important for accuracy.
#CCSSA2022
Estimation of GFR equations (e.g. CKD-EPI) are limited in this population. To properly diagnose ARC, you should use a timed renal creatinine clearance? Collection time doesn't have to be 24h, can be brought down to 6h. BSA is important for accuracy.
#CCSSA2022
Because creatinine clearance is not practical in all patients, prediction scores have been proposed. One studied scoring system in trauma patients includes the ARCTIC score.
doi.org/10.3390/pharma…
doi.org/10.3390/pharma…
But why is this even important, surely high renal clearance is better than normal? The implications relate to drug pharmacokinetics - particularly antibiotics, anticoagulants and antiepileptics.
For example - doi.org/10.1016/j.egja…
#CCSSA2022
For example - doi.org/10.1016/j.egja…
#CCSSA2022
This is best described in antibiotic prescription, where ARC may drop serum levels to below effective levels. For example a 25ml/min/1.73m2 increase in CrCl results in a 60% reduction in the probability of achieving a trough concentration of 4MIC in betalactams.
#CCSSA2022
#CCSSA2022
Antibiotics that may be affected - beta-lactams linezolid, colisitin, aminoglycosides and fluoroquinolones.
#CCSSA2022
#CCSSA2022
The BLING-2 study showed that giving more drugs according to CrCl may not be an appropriate compensation strategy, unfortunately - at least not with beta-lactams. Much uncertainty still exists.
doi.org/10.1016/j.ijan…
#CCSSA2022
doi.org/10.1016/j.ijan…
#CCSSA2022
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