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Continuous Renal Replacement Therapy
Jai Radhakrishnan, MD, MS
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History of the CRRT program
1988Open heart programActive transplant programDeep dissatisfaction with peritoneal dialysis in hemodynamicallyunstable patients
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Objectives
Physiologic principlesPatient Selection for CRRTModality SelectionPrescription VariablesFluid CompositionManagement of Fluid and Electrolyte problemsControversies
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Basic Concepts
Pressure
Convection(Plasma water moves along pressure gradients)
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•SCUF
•CVVH
•CVVHD
•CVVHDF
Continuous Renal Replacement Therapy
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SCUF:Slow Continuous Ultra Filtration
Maximum Patient Fluid RemovalRate = 2000 ml/hr
Therapy Options
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RReettuurrnn
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PPRRIISSMMAA
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CVVHContinuous Veno-Venous HemoFiltration
Maximum Patient Fluid Removal Rate = 1000 ml/hr
Therapy Options
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RReeppllaacceemmeenntt
PPRRIISSMMAA
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CVVHDContinuous Veno-Venous HemoDialysis
Maximum Patient Fluid Removal Rate = 1000 ml/hr
Therapy Options
Access
Return
Effluent
PRISMA
Dialysate
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CVVHDFContinuous Veno-Venous HemoDiafiltration
Maximum Pt. fluidremoval rate = 1000 ml/hr
Therapy Options
Access
Return
Effluent
Replacement
PRISMA
Dialysate
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A Case
35 year old female is s/p OHT, POD#1.Remains intubated, MAP 65 on Levo 20, Pit 3, Milrinone 0.25Urine output 10 ml.hour (Intake 150ml/h)PAD 20FiO2 0.60- ABG 7.45/35/102BMP 132/4.6/103/18/25/1.3 (Baseline 1.0)
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Indications for Renal Replacement
Standard indications Volume overloadHyperkalemiaMetabolic AcidosisUremic Platelet DysfunctionUremic Encephalopathy
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Modality Selection
SCUF
CVVHCVVHD
CVVHDF
CVVHDF
Volume only
Solutes +/- Volume
Hypercatabolic+/- Volume
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Prescription Variables
Blood FlowUp to 180 ml/min
ReplacementUp to 4500 ml/hr
Dialysateup to 2500 ml/hr
Patient Fluid RemovalUp to 2000 ml/hr
Access
Return
Effluent
Replacement
PRISMA
Dialysate
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Fluid Composition: Dialysate
Prismasate® 5000mLNa+ = 140 mEq/LK+ = 0 mEq/LCl- = 109.5 mEq/LCa2+ = 3.5 mEq/LMg2+ = 1 mEq/LLactate = 3 mEq/LHCO3 = 32 mEq/LGlucose = 0 mg/dL
Premixed Dialysate®
5000mL Na+ = 140 mEq/LK+ = 2.0 mEq/LCl- = 117 mEq/LCa2+ = 3.5 mEq/L Mg2+ = 1.5 mEq/LLactate = 30 mEq/LGlucose = 100 mg/dL
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Peripheral Electrolyte Replacement
In the event of high volume Bicarbonate solutions, if Ca free:Peripheral CaCl2/MgSO4
In the event of high clearance:prn Na phosphate
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Solutes: Azotemia
AzotemiaIncrease replacement fluid and/or dialysateflow rate
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Solutes: Sodium
HyponatremiaAdd 3% NaCl to dialysate @70 cc/5L bag
HypernatremiaIncrease peripheral IV D5W (1L) or 1/2 NS
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Solutes: K
HyperkalemiaZero K+, increase replacement and/or dialysate flow rate
1 L bag 5 L bag Serum Potassium
Add 0 mEq / Liter None None > 5.5 mEq / Liter
Add 3 mEq / Liter 7.5 mL 37.5 mL > 4.5 – 5.5 mEq / Liter
Add 4 mEq / Liter 10 mL 50 mL < 4.5 mEq / Liter
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Solutes: pH
Metabolic AcidosisNaHCO3 (50%) 100 cc over 1 hour IVSS, prnChange replacement to D5W (1L) + 3 amps NaHCO3
Metabolic AlkalosisChange replacement solution to NS + sliding scale KCl
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Solutes: Calcium
HypercalcemiaChange to HCO3 dialysate (Ca2+ free) Increase HCO3 dialysate or replacement flow rate
HypocalcemiaCaCl2 (10%) 10 cc/100 cc NS or D5W over one hour, prnPremixed calcium drip
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Solute: Mg and Phospate
HypomagnesemiaMgSO4 (50%) 2 ml in 100 cc NS or D5W over one hour, prnPremixed magnesium drip
HypermagnesemiaSame as Rx for hypercalcemia
HypophosphatemiaNa Phosphate (3 mmol/ml) 5cc in 100cc NS IVSS over 2 hours, prn (repeat x 1 if PO4 <1.0 mg/dl)
HyperphosphatemiaSame as Rx for hypercalcemia
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Anticoagulation
Heparin250 - 500 U/hr
HIT: Argatroban0.5 - 1 mg/hr
Bleeding risk:CitrateNo anticoagulation
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Argatroban CRRT Anticoagulation Protocol
1. Call Hematology for approval.2. In a 20 cc syringe (1000 mcg/mL): 30 microgram/kg/hr (0.5 microgram/kg/min)
Rate: _____ microgram/hr = ____ mL / hr (Range 0.5 – 5 mL/hr)Use lower dose with liver failure. (15 mcg/kg/hr)
Disconnect: Flush lumen with _____ mL of 1000 microgram/mL argatroban in each port (use internal volume as stated on catheter).
Reconnection: Aspirate 5 mL from each port before re-connecting.3. Write argatroban order separately.4. Check PTT q 12 hours
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Citrate Regional Anticoagulation
Cointault O.. Nephrol Dial Transplant. 2004 Jan;19(1):171-8.
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CRRT in LVAD circuit
LVAD
CRRT
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CRRT- Controversial Issues
HCO3- vs lactate solutions
High vs standard delivered doseConvection vs diffusionCost of CRRT vs HD.Does CRRT improve outcome (vs HD)?CRRT to prevent contrast nephropathy
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Lactate vs HCO3 Replacement
N=117Open-label trial randomized to Replacement Fluid:
HCO3
Lactate
Kidney International 58 (4), 1751-1757
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Effects of different doses of CVVH on outcomes of ARF
425 patients with ARF.Patients were randomly assigned ultrafiltration at
• 20 mL/kg/h (Gr 1, n=146)• 35 mL/kg/h (Gr 2, n=139)
• 45 mL/kg/h (Gr 3, n=140).
Primary endpoint: survival at 15 days after stopping haemofiltration.
Lancet. 2000 Jul 1;356(9223):26-30
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Intensity of Renal Support in Critically Ill Patients with Acute Kidney Injury
N Engl J Med. 2008 Jul 3;359(1):7-20
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Diffusion vs. Convection
100
40
80
120
160
Molecular Weight
Cle
aran
ce (m
l/min
)
102 103 104 105 106 Urea, 60 DCreatinine, 113 DVit. B12, 1355 DInulin, 5200 DAlbumin, 55-60 kD
Diffusive transportConvective transport
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Cost of acute renal failure requiring dialysis in the intensive care unit: clinical and resource implications of renal recovery.
DesignRetrospective cohort study Patients with ARF needing dialysis April 1, 1996, - March 31, 1999.
Setting: Two tertiary care intensive care units in Calgary, Canada.Patients: 261 critically ill patients.Outcomes:
in-hospital and subsequent survival and renal recoveryThe immediate and potential long-term costs
Manns: Crit Care Med, 31(2). 2003.449-455
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Impact of dialytic modality on mortality (HD vs CRRT)
Am J Kidney Dis. 2002 Nov;40(5):875-85
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Impact of dialytic modality on renal recovery.
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Efficacy and cardiovascular tolerability of extended dialysis incritically ill patients: A randomized controlled study
Kielstein JT..Am J Kidney Dis. 2004 Feb;43(2):342-9.
Genius single-pass dialysis machine
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Clearances
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Hemodynamic Parameters
MAP HR
CO SVR
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The Prevention of Radiocontrast-Agent–Induced Nephropathy by Hemofiltration
N Engl J Med 2003; 349:1333-1340,
•CVVH 1000 ml/h,
•4-8 hours pre and 18-24 hours after angiogram.
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Outcome: Renal Function
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Outcomes
OUTCOME CONTROLS CVVH
25% increase in Serum Creatinine
50% 5%
Renal replacement: (Oliganuriafor >48 h despite 1 g IV furosemide)
25% 3%
MortalityIn hospital One-year
14%30%
2%10%
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Complications