Samsung Medical Center (SMC) held a workshop last month for 13 Thai nephrologists and critical care physicians who visited to learn about the latest Continuous Renal Replacement Therapy (CRRT).

CRRT is gaining recognition for its hemodynamic stability, allowing continuous treatment of patients experiencing hypotension during dialysis.

It can also provide a stable fluid and nutrition supply, including sufficient water removal and electrolyte and acid-base balance maintenance. In particular, CRRT has been increasingly used as a renal replacement therapy for acute kidney injury patients in intensive care units with multiple growth failure syndrome or unstable hemodynamic status.

On Nov. 22, the Thai medical professionals attended an educational workshop with their counterparts at SMC, which operates a dedicated CRRT team and has accumulated research and treatment experience, to share key considerations and cases in CRRT treatment.

Thirteen Thai medical professionals participated in the workshop, including Professor Phitphiboon Deawtrakulchai of Srinagarind Hospital. From SMC, Professors Jang Hye-ryoun, Jeon Jun-seok, and Lee Kyung-ho of the Department of Nephrology and CRRT-specialized nursing team attended it.

The workshop began with introducing the CRRT team and specialized nursing group at SMC. It proceeded to the Principles and prescription of CRRT, management of electrolyte imbalance and acidemia in CRRT, optimal CRRT operation method and hemoperfusion therapy, linkage of ECMO and CRRT, and problematic situations that may occur in practical application and how to respond to them.

Thailand's National Health Security Office (NHSO) recently revised the insurance system to include CRRT, unreimbursed treatment, in the list of insurance coverage. Despite the coverage, the adoption rate of CRRT in Thailand still stands at 27 percent. One of the main reasons for the low uptake of CRRT treatment is the lack of experience with CRRT among Thai medical workers.

Against this backdrop, 13 Thai healthcare providers participated in the workshop to benchmark SMC’s CRRT team and protocols, introduce them to Thai hospitals, and provide optimal CRRT treatment to more patients with acute kidney injury.

Hospital-specific protocol is essential to meet growing demand for CRRT

SMC has abundant experience in CRRT, with more than 600 patients receiving CRRT annually and an average of more than 5,000 treatment days per year. SMC provides specialized and systematic CRRT treatment through a dedicated team of nephrology professors, full-time doctors, and nursing specialists. Within the CRRT team are three nephrologists and specialized nurses exclusively responsible for CRRT and ICU.

SMC’s CRRT team has developed and applied standardized CRRT protocols and published numerous papers on CRRT-related national projects and studies.

The jobs of the CRRT team include determining and maintaining CRRT treatment strategies, CRRT education, CRRT steering meetings, multidisciplinary team operations and meetings, training, research, education, and consultation, including protocol formulation and improvement.

The critical care advanced practice nurses in the team handle the technical aspects of CRRT operations other than indications and prescriptions, such as rounding on CRRT patients, taking initial steps to apply CRRT and exchanging CRRT sets, as well as solving CRRT-related problems and responding to treatment-related inquiries. Deploying separate specialized staff for CRRT nursing has been recognized as significantly reducing the workload on intensive care unit (ICU) nursing staff.

"In Korea, the demand for CRRT treatment is increasing along with the increasing severity of ICU patients," Professor Jeon said. "It is important that nephrologists and critical care physicians collaborate with other specialties to determine the appropriate start and end of CRRT through a systematic approach. This can help to avoid delayed initiation of CRRT, improve discontinuation success rates, and reduce the frequency of unnecessary prolongation of CRRT, thereby contributing to improved outcomes for critically ill patients."

Establishing a CRRT protocol ensures a minimum quality of care in applying CRRT and reduces the likelihood that CRRT prescriptions will vary by prescriber. It also has the added benefit of reducing CRRT prescribing errors. Jeon explained that it can also improve the safety of CRRT treatment and the competence of nursing staff, so it is appropriate for medical institutions that provide CRRT treatment to have such a protocol in place.

SMC has established its protocols for CRRT prescription, CRRT solution management, electrolyte imbalance management, and CRRT dosing under the leadership of the CRRT team. Research is being done to establish a CRRT discontinuation protocol to determine when CRRT treatment should be discontinued to achieve optimal treatment outcomes.

"It is important to remember that CRRT protocols need to be constantly reviewed and revised even after they are developed and that protocols may vary from institution to institution depending on medical resources and equipment available," Professor Lee said. "Even with protocols in place, there are limitations to applying them consistently in all situations. The experience and judgment of a trained healthcare professional is still critical in off-protocol situations."

Thai visitors said they were impressed by SMC’s CRRT team.

"We also have a CRRT protocol at (Srinagarine Hospital), but I think Samsung Medical Center's protocol is more detailed, especially in terms of electrolyte imbalance, and I was impressed by the fact that it's very detailed and based on the patient's situation," Professor Phitphiboon said. “In Thailand, we used to use only one electrolyte solution and thought it would be good to add various solutions. I was also impressed that the lecture mentioned the importance of communication (in CRRT treatment) and that they have regular meetings between ICU and nephrology."

"CRRT is expected to play an increasingly important role. However, in Thailand, there is a lack of specialized training in the therapy and no systematic protocols, making it difficult to prescribe and treat in practice," said a professor at Konlawij Trongtrakul, Maharaj Nakorn Chiang Mai Hospital. "This workshop was a great opportunity to discuss various treatment cases and the latest advances in CRRT, from principles to application, with CRRT experts in one place. We hope this will lead to a more advanced CRRT treatment environment in Thailand."