3. • CRRT (Continuous renal replacement therapy)
– Who ?
• Hemodynamic instability
• Intermittent hemodialysis could not control volume or
metabolic derangements
– Slower solute clearance and removal of fluid
→ better hemodynamic tolerance
– Venovenous circuit
4. 1. Intractable hyperthermia
2. Overdose of dialysable
drugs or toxin (heparin,
myoglobin, vancomycin)
3. Radiocontrast nephropathy
5. Optimal timing for initiation of RRT in AKI
• The optimal indication and timing of initiation of RRT in critically ill
patients with AKI in not known
• Absence of robust predictive biomarkers
• Traditional indications (based on fluid, electrolytes, and metabolic status)
are late complication of AKI
• RRT is usually started preemptively before the development of overt
complications of AKI. According to clinical state of the patient includings
age, the severity, other organ dysfunctions, and the degree of renal
dysfunctions.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27. 1. Vascular assess
• Short term uncuffed nontunneled dialysis catheter
• Use 12-15 cm (Rt JV) > 20-25 cm (femoral vein) > 15-20
cm (Lt JV) >> subclavian vein (for dominant side)
• Ultrasound guidance for catheter insertion
• CRX after placement of IJV catheter/ before first use
28. 2. BFR (blood flow rate)
• 최소한 혈류 속도를 체중 (Kg) x 2ml/min 이상 유지할 것.
– Ex> 50kg : 100 ml/min, 70kg : 140 ml/min
• 혈류 속도를 높일 수록 solute clearance 가 높아지고 filter clot 의
가능성이 낮아지므로, 환자의 상태에 따라서 증/감 시도가 가능
– 비교 > intermittent HD의 BFR > 200 – 350 ml/min
29. 3. Dose of CRRT in AKI
• No evidence for superiority of higher CRRT dose
Dose threshold below which mortality may increase
- 35 mL/kg/hr is a reasonable target for prescription
- > 25 mL/kg/hr should be effectively delivered
• KDIGO Clinical Practice Guidelines for AKI, 2012
Delivering an effluent volume of 20-25 mL/kg/h for CRRT in AKI
30.
31.
32. • Dialysate flow rate
– Small molecular toxin 또는 electrolyte 제거 효율이 증가
(diffusion 증가)
– Hypokalemia, hypophosphatemia 가 조장될 수 있음
• Replacement flow rate
– Middle molecular toxin 제거에 용이 (convection 증가)
– Predilutional replacement flow rate or pre-blood pump (PBP)
• Filter clot 의 위험성은 감소
• 그러나 대개 10-20% 정도의 clearance는 감소
– Postdilutional replacement flow rate
• Clearance는 증가
• Filter clot 위험성이 증가
33.
34. 4. Total I/O (patients removal)
• Rationale of fluid therapy
– Increasing preload and stroke volume
– Restoration right ventricular end-diastolic volume
– Restoration of cardiac output
– Restoration of systemic blood pressure
– Reversal of renal ischemia
– Dilution of nephrotoxin
35. 1B
5. Anticoagulation
(1C)
Unfractionated/ LMWH
Unfractionated/ LMWH
Regional citrate in
CRRT
Cix: Heparin in CRRT
Heparin in intermittent RRT
Potential risk vs. benefits from anticoagulation
Not increasing bleeding risk/ not systemic AC
Use AC during RRT in AKI
(NG)
(1B)
Avoid regional heparin in CRRT
(2B)
(2C)
(2C)
Heparin-induced thrombocytopenia
Argatroban (direct thrombin inhibitor)
Danaparoid/fondaparinux (fXa inhibitors) rather than no AC during RRT
(1A)
39. Stopping renal replacememt therapy
• One of the following reasons
– Improvement in renal function adequate to meet patient needs
• Minimun creatinine clearance > 15 ml/min
– RRT is no longer consistent with the goals of care
• ATN study : creatinine clearance
– < 12 mL/min : continue RRT
– > 20 mL/min : discontinue RRT
– 12-20 mL/min : decisions were left to the clinician
• Develop a strategy based on
– Hemodynamic stability, adequate fluid balance, nutritional
delivery switch to IHD
Editor's Notes
Classic indication -> little debate
Potential indication -> 많은 수의 전문가들이 이 상황에서 CRRT 적절하다고 생각
5.3.1.1: We recommend using anticoagulation during RRT in AKI
if a patient does not have an increased bleeding risk or impaired coagulation
and is not already receiving systemic anticoagulation. (1B)
5.3.2.1: For anticoagulation in intermittent RRT, we recommend using
either unfractionated or low-molecular-weight heparin, rather than other anticoagulants. (1C)
5.3.2.2: For anticoagulation in CRRT, we suggest using regional citrate anticoagulation
rather than heparin in patients who do not have contraindications for citrate. (2B)
5.3.2.3: For anticoagulation during CRRT in patients who have contraindications for citrate,
we suggest using either unfractionated or low-molecular-weight heparin, rather than other anticoagulants.(2C
5.3.3.1: We suggest using regional citrate anticoagulation, rather than no anticoagulation,
during CRRT in a patient without contraindications for citrate. (2C)
5.3.3.2: We suggest avoiding regional heparinization during CRRT in a patient with increased risk of bleeding. (2C)
