CRRT Continuous Renal Replacement Therapies

continuous ambulatory peritoneal dialysis CAPD continuous cyclical peritoneal dialysis CCPD slow continuous ultrafiltration SCUFcontinuous arterio-venous hemofiltration CAVH continuous a

C R R T

Technical and Practical Aspects

continuous ambulatory peritoneal dialysis (CAPD) continuous cyclical peritoneal dialysis (CCPD) slow continuous ultrafiltration (SCUF)

continuous arterio-venous hemofiltration (CAVH) continuous arterio-venous hemodialysis (CAVHD) continuous arterio-venous hemodiafiltration (CAVHDF) continuous veno-venous hemofiltration (CVVH)

continuous veno-venous hemodialysis (CVVHD) continuous veno-venous high-flux dialysis (CVVHFD) continuous veno-venous hemodiafiltration (CVVHDF)

intermittent peritoneal dialysis (IPD)

Blood Purification Procedures in ICU

• diuretic-resistant fluid overload

• parenteral nutrition in cases of oligoanuria

• Hyperpotassiemia

• hypernatriaemia

• elimination of toxins and mediators (endotoxin, prostaglandin,

1977 Kramer et al Report for the first time on

continuous arterio-venous hemofiltration ( CAVH )

procedure as continuous veno-venous hemofiltration ( CVVH )

Historical Overview

• filtration dependes on blood flow (low efficiency)

• arterial access (bleeding, clot formation)

Advantage

• technically not complicated

• filtration dependes on blood flow (low efficiency)

• arterial access (bleeding, clot formation)

Disadvantages

• filtration dependes on blood flow (low efficiency)

• backfiltration

• bad elimination of large molecules

• complex machinery

• fluid balance complicated

• arterial access (bleeding, clot formation)

• backfiltration

• complex machinery

• fluid balance complicated

• arterial access (bleeding, clot formation)

• blood flow sufficient

• good elimination of large molecules

• good filtration

UF

BLD SAD

• blood flow sufficient

• good elimination of small molecules

• good filtration

D UF

• blood flow sufficient

• good elimination of small and large molecules

• exact filtration

BLD SAD

• blood flow sufficient

• good elimination of small and large molecules

CVVHDF versus CVVHFD

CVVHFD ↔ CVVHDF

effect).

 Diffusive and convective clearance in parallel

 Adapted for elimilation low and middle molecular substances.

 CVVHFD is easier from techincal side, no 4th pump necessary.

disposables and less solution.

Filter Substitution Sub./Dia Flow Blood Flow

CVVH High-Flux Lac./Bic Sub 500-2000 ml/h 100-150 ml/min

CVVHD Low-Flux Lac./Bic as Dialysate Dia 500-2000 ml/h 100-150 ml/min

CVVHDF High-Flux Lac./Bic Both 500-2000 ml/h 100-150 ml/min

HF High-Flux Lac./Bic Sub < 5000 ml/h 200-300 ml/min

HD Low-Flux Lac./Bic as Dialysate Dia 200-300 ml/min 200-300 ml/min

HDF High-Flux Lac./Bic Sub < 5000 ml/h 200-300 ml/min

PEX Plasma Filter Albumin Sol., FFP,

Plasma Expander 30% of BF 60-150 ml/min

Filter? Substitution?

Beginning Access Buffer

Membrane

Dose

Hemodynamic Mediator

50-70%

Patient spectrum has been changed:

•less uncomplicated or radiopaque material induced AKF

•more post-operative or post-traumatic AKF with sepsis and

MOF

Loss of Energy

Mortality

low heparinisation

easy patient mobilisation

high clearance of small molecules

Continuous Intermittent

Dialysis Treatment

Creatinin Clearance (ml/min)

Urin Volume (ml/min)

FeNa (%)

MAP (mmHg)

Effect of Dialysis on Renal Function in AKF Patients (Manns, 1995)

Does dialysis mode effect the residual renal function?

In CVVH similar observations! (Davenport, Bellomo)

Renal function significantly drops down during and after HD

paradoxe vasoconstriction blood circulation ↓

Kidney demage

Kidney recovement delayed

Post-ischemic kidney is more sensitive for

Conclusion

Continuous treatment protects the kidney due to better hemodinamic stability

Hypotension

• Gillum (1986): no influence of mortality after intensive (interval urea 60 mg/dl creatinine 5 mg/dl) or non-intensive HD (interval urea 100 mg/dl and creatinine 9 mg/dl)

• Tapolyai (1994): better mortality with Kt/V 1.09 and URR 58% than with Kt/V 0.89 and URR 46%

Does HD dose influence the prognosis in AKF?

HD

CVVHD

• Clark (1994), Bellomo & Ronco (1996): With same daily Kt/V of 0.59 urea plasma concentrations in intermittent treatment are significatly higher than in continuous therapy (101±12 mg/dl vs 79±17 mg/dl)

• to reach same urea concentration in intermittent treatment a daily Kt/V of 0.92 is necessary!

• Frankenfield (1993): to reach same urea elimination of 196 g/W in continuous

controversal discussion

HD

Kleinknecht (1972):

early begin of HD 29%, late begin of HD 42%

Bellomo & Ronco (1996):

early correction of electrolytes, acidosis and acotemia as criterium for the prognosis

Begin of HD

Glucose g/l

Osmol mmol/l

Osmol mmol/l

140 0-4 1.5 0.5 109-113 35 1.0 290-300

Replacement Solution

Na+-Bicarbonate

Bicarbonate Solution

Bleeding Risk Initial

IU/kg

Continuous IU/kg/h

PTT sec.

ACT sec.

Heparinisation in CRRT

Anticoagulation in CRRT

mmHg B

mmHgD

IL-6 IL-8

1 Plasma Expander Dextrane, Hydroxyethylstarch (HES), Gelatine Preparation Short

Half Life Time

Human Albumine Electrolyte

HF-Solution (ml) 850 825 800 775 750 725 700Human Albumine 20% (ml) 150 175 200 225 250 275 300

HF Solution

i.g 2 Liters 4%-Solution = 400 ml Albumine 20% + 1600 ml HF Solution

Albumine Solution

Antikoagulation in PEX

35 patients with „Immuno-paralysis“ (control-group 41 patients)

Deactivated monocytes (HLA-DR-Antigen-Expression ↓ )

No of PEX 3 on 3 following days

Treated Plasmavolume 3 litres

Substitution FFP

an important condition of good prognosis in

PEX in Sepsis Patients

Twice a Day

E’lytes (Na + , K + , Cl - ,

Ca 2+ ) Glucose Coagulation (PTT, PT, AT III, Fibrinogen) Blood Count (Hb, Hc, Thrombocytes, Leucocytes)

Once a Day

Creatinin Urea Liver Enzymes

Twice a Week

Trace Elements (Fe 2+ ,

PO 4 , Cu 2+ , Mg 2+ ) Cholesterol Triglycerides

Regularly

Drug Monitoring

Microbiology

Monitoring

Loss of Warmth up to 750 kcal/d depending on kind of

extracorporal procedure, blood and fluid flows and filtrate

volume

Hypothermia

Loss of Glucose up to 40-80 g/d → in sub Solution 100-180 mg/dl

Loss of Amino Acids in CVVH = filtrate vol x 0.25 g

Amino Acids (MW 145 D, SC 1.0) are removed by diffusive

and convective clearance Loss of 6-15 g/d

Loss of Energy

Indication SCUF Fluid Overload

CVVH Cardio-ciculatory Instability, Elimination of Middle Molecules, Sepsis (?)

CVVHD Cardio-ciculatory Instability, Elimination of Small Molcules (Hyperkaliemia)

CVVHDF Cardio-ciculatory Instability, Elimination of Middle Small /Middle Molecules, Sepsis (?)

HF Rapid Elimination of Middle Molecules, Severe Hypertonia, Sepsis (?), High Bleeding Risk

HD Rapid Elimination of Small Molcules, High Bleeding Risk

HDF Rapid Elimination of Small /Middle Molecules, Severe Hypertonia Sepsis (?),High Bleeding Risk

HP Drug Intoxication, Poisoning

PEX Liver Failure, Sepsis, Autoimmuno Dissease a.o

PAP Liver Failure, Sepsis, Autoimmuno Dissease a.o

Differential Indication

Diapact CRRT

HIGH RESOLUTION

SCREEN

HEATER PUMP PANEL FILTER

HOLDER

WEIGHING

SYSTEM

IV POLE

Diapact CRRT

1 2 3

AP-Arterial pump UF- Ultrafiltration

CVVH/HF AP UFP IP HF bic./lac buffer

CVVHD/HD AP UFP DP LF bic./lac buffer

CVVHFD/HFD AP UFP DP HF bic./lac buffer

Diapact CRRT - a versatile system

No other equipment currently on the market offers the same range of therapy modes as the Diapact CRRT:

Plasma therapies: PEX, PAP

Intermittent therapies: HF, HD, HFD

Continuous therapies: SCUF, CVVH, CVVHD,