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Care Units
* High Mortality
* Mortality relates to severity of underlying condition
* Acute renal failure occurs as part of a complex of
multiple organ failure caused by infection, sepsis,
hypotension, hypovolemia and drug therapy
* Fluid overload causes pulmonary edema
* Increase in interstitial water with "leaky capillary"
leading to impaired tissue perfusion
* Acid-base and electrolyte abnormalities
* Disseminated intravascular coagulation
* Toxic metabolites and drug accumulation
* Frequently hemodynamic unstable
* Required positive pressure ventilation
Principles of CRRT
Adsorption: affinity
gradient
Operational Characteristics of
CRRT
Continuous Hemodialysis
* Solute removal based on diffusion driven by concentration
gradient
* Large molecules more restricted and diffusive clearance
decreases with increasing molecular weight
* In CRRT blood flow rates exceed dialysate flow rates thereby
resulting in
complete equilibration between blood and
dialysate
* Capacity of solute to diffuse through membrane and saturation
dialysate is expressed as Sd.
Sd = Cd/Cp
Sd: Dialysate saturation
Cd: Drug concentration in dialysate
Cp: Solute concentration in plasma
* Diffusive clearance = Dialysate flow x Sd
ClHD = Qd X Sd
CAVH
CVVH
CAVHD
14-16
Convection
Urea
7-10
Convection
Diffusion+small
15-17
Diff.:
amount of convection
Conv: 2-5
CVVHD
14-16
Diffusion+small
Diff.:
amount of convection
Conv: 2-5
CAVHDF
Diffusion+convection
Diff.: 18-20
Substitution or Dialysate
Solution
Lactate Ringer's solution
*
* 1.5% peritoneal dialysate solution
* Bicarbonate with dextrose
* Bicarbonate without dextrose
Bag A:
Bag B:
1 liter 0.9% NaCl
1 liter 0.45% NaCl
80 ml 7% NaHCO3
10 ml 5% CaCl2
4 ml 15% KCl
Bag A : Bag B run 1 : 1
Na 142 mEq/L
K
3.8 mEq/L
Cl
117 mEq/L
Fluid balance
Medication, TPN, Colloids
Azotemia control
BUN, Scr, PCR, Phosphorus
Cytokine maniputation
Factor maniputation
Fluid
Regulation
Ultrafiltration rate
To meet anticipated needs
Greater than
(UFR)
anticipated needs
Fluid management
Adjust UFR
amount of
replacement fluid
Fluid balance
Zero or negative balance
negative,
or zero balance
Volume removed
Based on physician estimate
patient
characteristics
Application
Easy, similar to
Adjust
Positive,
Driven by
Requires
Membrane
Adsorption
TNF, IL-1
TNF, IL-1
TNF
Convection
minimal TNF
IL-1, IL-
TNF, IL-1
IL-1
TNF, IL-1,
Membrane
AN69
PA
Adsorption of
PA
PS and PAN
PAN
PAN
PS and PAN
PAN
PS
PA
PAN
PS
Convection of
TNFa, IL6, IL
factor D
TNF
TNF, IL-1
IL-1, not ILIL-6
IL-6, IL-8
TxB2
Clinical
Bleeding
Hematomas
Thrombosis
Infection and
Allergic
Hypothermia
Nutrient losses
Insufficient
No
%
Bleeding
18
8.4
Haematoma
3.7
Access Malfunction
0.4
Line disconnection
8.0
Frequent filter clotting
2.3
Treatment-induced hypotension
3.3
Cannulation site infection
0.9
Hypothermia
0.9
8
1
17
5
7
2
4
Clinical condition
Antibiotic nephrotoxicity
Cardiogenic shock
CP bypass
Complicated ARF in ICU
Uremia
IHD
Increased
intracranial pressure
Shock
Nutrition
Subarachnoid hemorrhage,
hepatorenal syndrome
Sepsis, ARDS
Burns
Preferred
IHD, PD
CRRT
CRRT,
CRRT
CRRT
CRRT
RRT:
Hyperkalemia kills
Pulmonary edema
kills
Experience before
RRT available
Visible effects of
uremia
Against
RRT
Costs money
No RCT it makes
any difference
Side effects
PD vs standard IHD
PD:
Standard
Hemodynamic
stability
Continuous therapy
IHD:
Better clearances
No glycemic swings
No abdominal leaks
No splinting of
diaphragm
Decreased risk of
infection
Biocompatible vs.
bioincompatible dialysis
Biocompatible:
Biologic rationale
Two RCTs showing
clinical advantage
Non issue if
convective CRRT
used
Bioincompatible:
Cheaper
Some negative RCTs
(power limitations)
IHD:
CRRT:
urea
(mmol/L)
50
45
40
35
30
25
20
15
10
5
0
p<0.05
CRRT
IHD
Days
van Bommel et al. Am J Nephrol 1995
Changes in [creatinine]:
CRRT vs IHD
p<0.05
800
700
600
[creat]
(mcmol/L)
500
CRRT
IHD
400
300
200
100
0
0
Days
p<0.05
15
% of patients
10
CRRT
IHD
5
0
Volume
control
Change in pH
after 24 h of treatment
0.5
0.4
p<0.05
0.3
CRRT
IHD
0.2
0.1
0
pH
p<0.001
40
35
30
25
20
15
10
Days of Treatment
HCO-13
HCO-12
HCO-11
HCO-10
HCO-9
HCO-8
HCO-7
HCO-6
HCO-5
HCO-4
HCO-3
HCO-2
HCO-1
HCO-0
[HCO3-]
mmol/L
p<0.001
7
6
5
4
Days of Treatment
K-13
K-12
K-11
K-10
K-9
K-8
K-7
K-6
K-5
K-4
K-3
K-2
K-1
K-0
[K+]
mmol/L
p<0.001
155
150
145
140
135
130
125
Days of Treatment
Na-13
Na-12
Na-11
Na-10
Na-9
Na-8
Na-7
Na-6
Na-5
Na-4
Na-3
Na-2
115
Na-1
120
Na-0
[Na+]
mmol/L
p<0.001
5
4
3
2
Days of Treatment
P13
P12
P11
P10
P9
P8
P7
P6
P5
P4
P3
P2
P1
P0
[Phos.]
mmol/L
Total %
VT/SVT/VF
CRRT
IHD
> 20% fall
in MAP
Events
10
9
8
7
6
5
4
3
2
1
0
p<0.05
100
90
80
70
60
50
40
30
20
10
0
p<
0.01
CRRT
IHD
Recovery
Late
Early
10
20
30
% survival
Gettings et al. Intensive Care Med 1999
40
50
2003-4
Issues of dose become important
High volume hemofiltration
Multicentre work more common
ADQI defines research goals
New membranes being developed
New circuit modifications for sepsis
BUN (mg/dl)
Creatinine (mcmol/L)
150
100
50
0
RCT of UF dose
80
**
70
*p<0.05
**p<0.001
60
50
APACHE II
UF (l/day)
40
30
20
10
0
Group I
Group II
Group III
Ronco C, Bellomo R et al. Lancet 2000; 355: 2630
p=0.0013
45ml/kg/hr
Survivors
Total
35ml/kg/hr
20 ml/kg/hr
0
50
100
150
Best Kidney:
Survey of ARF in
Asia,Australia,USA,Canada,Europe,South
America ( 29.269 pts)
ARF : 1758 pts.
1260 pts in 24 hours ( BUN > 80 mg/dl).
151 pts > 24 hours. 498 did not receive RRT.
Incidence of ARF : 6,3 % Asia, 6,4% Aus 5,5%
Europe, 5,4% S . America.
No diff in SAPS II score, striking difference in
timing , morbidity , mortality . LOS.