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Dr osama elshahat crrt
- 3. ©
Is an extracorporeal blood purification therapy
intended to substitute for impaired renal function over
an extended period of time and applied for or aimed
at being applied for Extended time 24 -72 h.
Bellomo R., Ronco C., Mehta R, Nomenclature for Continuous Renal Replacement Therapies, AJKD, Vol 28, No. 5, Suppl 3, November 1996
- 4. ©
Mimic the functions and physiology of the native organ
Qualitative and quantitative blood purification
Restore and maintain of homeostasis
Avoid complications and good clinical tolerance
Provide conditions favoring recovery of renal function
- 5. ©
• CRRT clearance of solute is dependent on the following:
◦ The molecule size of the solute
◦ The pore size of the semi-permeable membrane
• The higher the ultrafiltration rate (UFR), the greater the
solute clearance.
- 6. ©
• Small molecules easily pass through a membrane driven by
diffusion and convection.
• Middle and large size molecules are cleared primarily by
convection.
• Semi-permeable membrane remove solutes with a molecular
weight of up to 50,000 Daltons.
• Plasma proteins or substances highly protein—bound will not
be cleared.
- 7. ©
• Sieving Coefficient
◦ The ability of a substance to pass through a membrane from
the blood compartment of the hemofilter to the fluid
compartment.
◦ A sieving coefficient of 1 will allow free passage of a
substance; but at a coefficient of 0, the substance is unable to
pass.
• .94 Na+
• 1.0 K+
• 1.0 Cr
• 0 albumin will not pass
- 18. ©
Survival and recovery of renal function for patients with AKI in the intensive care unit
were retrospectively examined over a 7-year period. Factors associated with mortality
and renal recovery were analyzed based on severity of illness as defined by Cleveland
Clinic Foundation (CCF) score.
RESULTS:
Of patients who underwent CRRT, 230/330 met inclusion criteria.. Patients initiated
on CRRT > 6 days after AKI diagnosis had significantly higher mortality compared
with those initiated earlier (odds ratio = 11.66, p = 0.0305).
Patients receiving CRRT >10 days had a higher mortality rate compared with those
with shorter exposure (71.3% vs. 45.5%, respectively, p = 0.012).
CONCLUSIONS:
Delay in initiation and length of CRRT exposure may have poorer prognosis.
Renal fail 2011;33(7):698-706
- 19. ©
Single-center randomized clinical trial of 231 critically ill patients with AKI (KDIGO) stage 2 (≥2 times baseline or urinary output <0.5 mL/kg/h for ≥12 hours) and
plasma neutrophil gelatinase–associated lipocalin level higher than 150 ng/mL enrolled between August 2013 and June 2015 from a university hospital in Germany.
Interventions Early (within 8 hours of diagnosis of KDIGO stage 2; n = 112) or
delayed (within 12 hours of stage 3 AKI or no initiation; n = 119) initiation of RRTThe primary end
point was mortality at 90 days after randomization.
Secondary end points included 28- and 60-day mortality, clinical evidence of organ dysfunction, recovery of renal function, requirement of RRT after day 90,
duration of renal support, and intensive care unit (ICU) and hospital length of stay.
Results Among 231 patients (mean age, 67 years; men, 146 [63.2%]), all patients in the early group (n = 112) and 108 of 119 patients (90.8%) in the delayed group
received RRT. All patients completed follow-up at 90 days. Median time (Q1, Q3) from meeting full eligibility criteria to RRT initiation was significantly shorter in
the early group (6.0 hours [Q1, Q3: 4.0, 7.0]) than in the delayed group (25.5 h [Q1, Q3: 18.8, 40.3]; difference, −21.0 [95% CI, −24.0 to −18.0]; P < .001). Early
initiation of RRT significantly reduced 90-day mortality (44 of 112 patients [39.3%]) compared with delayed initiation of RRT (65 of 119 patients [54.7%]; hazard
ratio [HR], 0.66 [95% CI, 0.45 to 0.97]; difference, −15.4% [95% CI, −28.1% to −2.6%]; P = .03). More patients in the early group recovered renal function by day
90 (60 of 112 patients [53.6%] in the early group vs 46 of 119 patients [38.7%] in the delayed group; odds ratio [OR], 0.55 [95% CI, 0.32 to 0. 93]; difference, 14.9%
[95% CI, 2.2% to 27.6%]; P = .02). Duration of RRT and length of hospital stay were significantly shorter in the early group than in the delayed group (RRT: 9 days
[Q1, Q3: 4, 44] in the early group vs 25 days [Q1, Q3: 7, >90] in the delayed group; P = .04; HR, 0.69 [95% CI, 0.48 to 1.00]; difference, −18 days [95% CI, −41 to 4];
hospital stay: 51 days [Q1, Q3: 31, 74] in the early group vs 82 days [Q1, Q3: 67, >90] in the delayed group; P < .001; HR, 0.34 [95% CI, 0.22 to 0.52]; difference, −37
days [95% CI, −∞ to −19.5]), but there was no significant effect on requirement of RRT after day 90, organ dysfunction, and length of ICU stay.
Conclusions and Relevance Among critically ill patients with AKI, early RRT compared
with delayed initiation of RRT reduced mortality over the first 90 days.
JAMA 315(20):2190-2199May 24/31, 2016
- 23. ©
1. Peritoneal dialysis (PD)
2. Intermittent Hemodialysis (IHD)
3. Slow Low-Efficiency Dialysis (SLED)
4. Continuous Renal Replacement Therapy (CRRT)
• Slow Continuous Ultrafiltration (SCUF)
• Continuous Venovenous Hemofiltration (CVVH)
• Continuous Venovenous Hemodialysis (CVVHD)
• Continuous Venovenous Diafiltration (CVVHDF)
- 24. ©
Advantages
Hemodynamic stability
Slow correction
Easy access placement
No Anticoagulation
Tolerated in children
Disadvantages
Risk of infections
Difficulty to use with abdominals
surgery
Logestics
- 25. ©
PD … the modality first used for the treatment of KI
- 29. SCUF
Syringe pump
Return Pressure Air Detector
Blood Pump
Access PressureFilter Pressure
BLD
Hemofilter
Patient
Effluent Pump
Return Clamp
Pre Blood Pump
Effluent Pressure
- 30. ©
CVVHF
Return Pressure Air Detector
Return Clamp
Patient
Access Pressure
Syringe Pump
Hemofilter
Post
Replacement Pump Pre Blood Pump
Replacement Pump
Pre
Effluent Pump
Effluent Pressure
Filter Pressure
- 31. ©
CVVHD
Return Pressure Air Detector
Return Clamp
Access Pressure
Blood PumpSyringe Pump
Filter Pressure
Hemofilter
Patient
Effluent Pump Pre Blood Pump
BLD
Effluent Pressure
Dialysate Pump
- 32. ©
CVVHDF
Return Pressure Air Detector
Return Clamp
Patient
Access Pressure
Syringe Pump
Hemofilter
Pre Blood Pump
Replacement Pump
Pre
Effluent Pump
Effluent Pressure
Filter Pressure
Dialysate Pump
- 33. ©
Ronco C et al Kidney Int 56 ( suppl 72 ) s-8-s-14 , 1999
- 34. ©
5.6.2: We suggest using CRRT, rather than standard
intermittent RRT, for hemodynamically unstable patients. (2B)
5.6.1: Use continuous and intermittent RRT as complementary
therapies in AKI patients. (Not Graded
- 37. ©
0
.2
.4
.6
.8
1
0 20 40 60 80 100
IRRT
CRRT
days
Recovery from Dialysis Dependence: BEST Kidney DataRecoveryfromdialysisdependence
Manuscript under review
Leading the way…
- 38. ©
Recent studies suggest that CRRT is superior to IHD with
respect to recovery of renal function
Implications go far beyond just “hard” endpoint of renal
recovery
Need for chronic dialysis impairs quality of life
If length of stay (LOS) in ICU can be reduced this will have a
major impact on hospital budget
Patients dependent on chronic dialysis will consume significant
health care resources and have an impact on the community health
care budget
Leading the way…
- 39. ©
Study Modality % recovering renal function
SUPPORT IHD* 67%**
Morgera et al. CRRT 90%
Ronco et al. CRRT 90%
Mehta et al.
IHD
CRRT
59%
92%
BEST Kidney†
IHD
CRRT
65%
89%
- 40. ©
The elimination of
inflamatory mediator
occurs only during the 1st
hour after application of
new filter.
Cytokines removal
capacity of curently
available membranes
hardly matches the
productin observed in
severly affected septic
patients.
De Vriese As-JAM Soc Nephrol 10-846-853 1999
- 41. ©
Typically performed over 6-12 hours
Can be performed with a conventional dialysis
machine
– A little less labor intensive
– Requires less training/startup
Fliser D and Kielstei JT Nat Clin Pract Nephrol, 2006
Slow Low-Efficiency Daily Dialysis (SLED)
- 42. ©
Major advantages: flexibility, reduced costs, low or absent
anticoagulation
Similar adequacy and hemodynamics
One small study (16 pts) showed slightly higher acidosis and lower
BP (Baldwin 2007)
VA trial (Palevsky NEJM 2008) suggests similar outcomes as
CRRT and IRRT.
Vanholder et al. Critical Care 2011, 15:204
- 43. ©
CRRT requires:
◦ A central double-lumen veno-venous hemodialysis catheter
◦ An extracorporeal circuit and a hemofilter
◦ A blood pump and a effluent pump.
◦ With specific CRRT therapies dialysate and/or replacement
pumps are required.
Solution
Anticoagulation
Dose
- 44. ©
5.4.1: We suggest initiating RRT in patients with AKI via an uncuffed
nontunneled dialysis catheter, rather than a tunneled catheter. (2D)
5.4.2: When choosing a vein for insertion of a dialysis catheter in
patients with AKI, consider these preferences (Not Graded):
First choice: right jugular vein;
Second choice: femoral vein;
Third choice: left jugular vein;
Last choice: subclavian vein with preference for the dominant side.
Vascular access
KDIGO® AKI Guideline March 2012
- 45. ©
• The length of the catheter chosen will depend upon the
site used
Size of the catheter is important in the pediatric population.
• The following are suggested guidelines for the different
sites:
RIJ= 15 cm French
LIJ= 20 cm French
Femoral= 25 cm French
Vascular access
- 46. ©
• Physician Rx and adjusted based on pt. clinical need.
• Sterile replacement solutions may be:
Bicarbonate-based or Lactate-based solutions
Electrolyte solutions
Must be sterile and labeled for IV Use
Higher rates increase convective clearances
You are aware what you replace
- 47. ©
Bicarbonate versus lactatebased fluid replacement in CVVH
Prospective, randomized study
Results
Serum lactate concentration was
significantly higher and the
bicarbonate was lower in patients
treated with lactatebased solutions
Increased incidence of CVS events in
pts ttt with lactate solution
◦ Hypotension
◦ Increased dose of inotropic support
barenborck and colleague
Barenbrock M et al; Kidney Int (2000
Replacement Fluids
- 48. ©
5.7.3: We suggest using bicarbonate, rather than lactate, as a
buffer in dialysate and replacement fluid for RRT in patients
with AKI and liver failure and/or lactic acidemia. (2B)
KDIGO® AKI Guideline March 2012
- 49. ©
5.5.1: We suggest to use dialyzers with a biocompatible membrane
for IHD and CRRT in patients with AKI. (2C)
High Flux membrane , synthetic , biocompatable ,
acting by providing both methods of detoxications:
A. Diffusion : for low molecular weight toxins.
B. Convection : for large molecules.
KDIGO® AKI Guideline March 2012
- 50. ©
• Hemofilter membrane are composed of:
High flux material
Synthetic/biocompatible material
• Structural design is characterized by:
High fluid removal
Molecular cut-off weight of 30,000-50,000 Daltons.
- 51. ©
Modality Advantages Disadvantages
Heparin Good anticoagulation Thrombocytopenia bleeding
LMWH Less thrombocytopenia bleeding
Citrate Lowest risk of bleeding
Metabolic alkalosis,
hypocalcemia special dialysate
Regional Heparin Reduced bleeding Complex management
Saline flushes No bleeding risk Poor efficacy
Prostacycline Reduced bleeding risk Hypotension poor efficacy
- 55. ©
Prospective study on 425 patients - 3 groups:
Study:
Survival after 15 days of HF stop
Recovery of renal function
- 56. ©
100
90
80
70
60
50
40
30
20
10
0
Group 1(n=146)
(Uf = 20 ml/h/Kg)
Group 2 (n=139)
(Uf = 35 ml/h/Kg)
Group 3 (n=140)
(Uf = 45 ml/h/Kg)
41 % 57 % 58 %
p < 0.001 p n..s.
p < 0.001
Survival(%)
Effects of different doses in CVVH on outcome of ARF - Ronco & Bellomo study.
Lancet . july 00
- 57. ©
An increased treatment dose from 20 ml/h/kg to 35 ml/h/kg
significantly improved survival.
A delivery of 45ml/kg/hr did not result in further benefit in
terms of survival, but in the septic patient an improvement was
observed.
Our data suggest an early initiation of treatment and a
minimum dose delivery of 35 ml/h/kg (ex. 70 kg patient =
2450 ml/h) improve patient survival rate.
Effects of different doses in CVVH on outcome of ARF - Ronco & Bellomo study. Lancet . july 00
- 58. ©
• Vascular access
Vascular spasm(initial BFR too high)
Movement of catheter against vessel wall
Improper length of hemodialysis catheter inserted
• Fluid volume deficit
Excessive fluid removal without appropriate fluid
replenishment
- 59. ©
• Hypotension
Intravascular volume depletion
Underlying cardiac dysfunction
• Electrolyte imbalances
High ultrafiltration rates (high clearance)
Inadequate replenishment of electrolytes by intravenous
infusion,
Inadequate replenishment of bicarbonate loss during
CRRT
- 60. ©
• Acid/base imbalance
Renal dysfunction
Respiratory compromise
• Blood loss
Ineffective anticoagulation therapy
Clotting of hemofilter
Inadvertent disconnection in the CRRT system
Hemorrhage due to over-anticoagulation
Blood filter leaks
- 61. ©
◦ Blood pressure
◦ Patency of circuit
◦ Hemodynamic stability
◦ Level of consciousness
◦ Acid/base balance
◦ Electrolyte balance
◦ Hematological status
◦ Infection
◦ Nutritional status
◦ Air embolus
◦ Blood flow rate
◦ Ultrafiltration flow rate
◦ Dialysate/replacement flow
rate
◦ Alarms and responses
◦ Color of ultrafiltrate/filter
blood leak
◦ Color of CRRT circuit
- 62. ©
CRRT is the modality of choice for hemodynamically unstable patients
who needs RRT .
The current trend is to provide RRT earlier
There may be a recovery advantage to using CRRT vs. HD for initial
management of AKI but no difference on mortality
CRRT has many non renal indication which must be considered
Dose: Optimal intensity of CRRT is 35 ml/h lkg
Dialytic Support by CRRT = Individualizatio
