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Continuous Renal Replacement Therapy Jai Radhakrishnan, MD, MS

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Page 1: Columbia Nephrology

Continuous Renal Replacement Therapy

Jai Radhakrishnan, MD, MS

Page 2: Columbia Nephrology

History of the CRRT program

1988Open heart programActive transplant programDeep dissatisfaction with peritoneal dialysis in hemodynamicallyunstable patients

Page 3: Columbia Nephrology
Page 4: Columbia Nephrology
Page 5: Columbia Nephrology
Page 6: Columbia Nephrology

Objectives

Physiologic principlesPatient Selection for CRRTModality SelectionPrescription VariablesFluid CompositionManagement of Fluid and Electrolyte problemsControversies

Page 7: Columbia Nephrology

Basic Concepts

Pressure

Convection(Plasma water moves along pressure gradients)

Page 8: Columbia Nephrology
Page 9: Columbia Nephrology

•SCUF

•CVVH

•CVVHD

•CVVHDF

Continuous Renal Replacement Therapy

Page 10: Columbia Nephrology

SCUF:Slow Continuous Ultra Filtration

Maximum Patient Fluid RemovalRate = 2000 ml/hr

Therapy Options

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Page 11: Columbia Nephrology

CVVHContinuous Veno-Venous HemoFiltration

Maximum Patient Fluid Removal Rate = 1000 ml/hr

Therapy Options

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PPRRIISSMMAA

Page 12: Columbia Nephrology

CVVHDContinuous Veno-Venous HemoDialysis

Maximum Patient Fluid Removal Rate = 1000 ml/hr

Therapy Options

Access

Return

Effluent

PRISMA

Dialysate

Page 13: Columbia Nephrology

CVVHDFContinuous Veno-Venous HemoDiafiltration

Maximum Pt. fluidremoval rate = 1000 ml/hr

Therapy Options

Access

Return

Effluent

Replacement

PRISMA

Dialysate

Page 14: Columbia Nephrology

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)

Page 15: Columbia Nephrology

Indications for Renal Replacement

Standard indications Volume overloadHyperkalemiaMetabolic AcidosisUremic Platelet DysfunctionUremic Encephalopathy

Page 16: Columbia Nephrology

Modality Selection

SCUF

CVVHCVVHD

CVVHDF

CVVHDF

Volume only

Solutes +/- Volume

Hypercatabolic+/- Volume

Page 17: Columbia Nephrology

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

Page 18: Columbia Nephrology

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

Page 19: Columbia Nephrology

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

Page 20: Columbia Nephrology

Solutes: Azotemia

AzotemiaIncrease replacement fluid and/or dialysateflow rate

Page 21: Columbia Nephrology

Solutes: Sodium

HyponatremiaAdd 3% NaCl to dialysate @70 cc/5L bag

HypernatremiaIncrease peripheral IV D5W (1L) or 1/2 NS

Page 22: Columbia Nephrology

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

Page 23: Columbia Nephrology

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

Page 24: Columbia Nephrology

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

Page 25: Columbia Nephrology

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

Page 26: Columbia Nephrology

Anticoagulation

Heparin250 - 500 U/hr

HIT: Argatroban0.5 - 1 mg/hr

Bleeding risk:CitrateNo anticoagulation

Page 27: Columbia Nephrology

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

Page 28: Columbia Nephrology

Citrate Regional Anticoagulation

Cointault O.. Nephrol Dial Transplant. 2004 Jan;19(1):171-8.

Page 29: Columbia Nephrology

CRRT in LVAD circuit

LVAD

CRRT

Page 30: Columbia Nephrology

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

Page 31: Columbia Nephrology

Lactate vs HCO3 Replacement

N=117Open-label trial randomized to Replacement Fluid:

HCO3

Lactate

Kidney International 58 (4), 1751-1757

Page 32: Columbia Nephrology

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

Page 33: Columbia Nephrology

Intensity of Renal Support in Critically Ill Patients with Acute Kidney Injury

N Engl J Med. 2008 Jul 3;359(1):7-20

Page 34: Columbia Nephrology

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

Page 35: Columbia Nephrology

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

Page 36: Columbia Nephrology
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Impact of dialytic modality on mortality (HD vs CRRT)

Am J Kidney Dis. 2002 Nov;40(5):875-85

Page 38: Columbia Nephrology

Impact of dialytic modality on renal recovery.

Page 39: Columbia Nephrology

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

Page 40: Columbia Nephrology

Clearances

Page 41: Columbia Nephrology

Hemodynamic Parameters

MAP HR

CO SVR

Page 42: Columbia Nephrology

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.

Page 43: Columbia Nephrology

Outcome: Renal Function

Page 44: Columbia Nephrology

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%

Page 45: Columbia Nephrology

Complications