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Extracorporeal blood purification
Introduction
Extracorporeal = Outside the body
Abel et al., 1913
Father of hemodialysis – Willem J.
Kolff (1943)
Different Techniques
Renal replacement therapy (RRT)
• Intermittent (Hemodialysis)
• Continuos renal replacement therapy (CRRT)
Hemoperfusion
Plasmapheresis or Plasma Exchange
Extracorporeal Membrane Oxygenation (ECMO)
Types of RRT
Intermittent Hemodialysis (IHD)
• SCUF
• CVVHD
• CVVHF
• CVVHDF
Continuous
Dialysis (CRRT)
Principle of CRRT
Intermittent Hemodialysis (IHD)
Diffusion of Low
molecular wt. solutes
Dialysate solution
consisting of ions of
varying concentrations
Solutes < 5,000 Daltons
like urea, sodium,
potassium
Dialyzers
Key component of RRT
Increase the surface area of contact between dialysate
and blood
Components
• Semipermeable dialysis membrane
• Blood compartments
• Dialysate comparments
• Membrane supporting structure
Dialyzers
Dialyzers
Types of Dialyzer Membrane
Low-flux
(Ultrafiltration rate
<15 mL/mmHg/h and
a β2MG clearance rate
<15 mL/min)
High-flux
(Ultrafiltration rate ≥
15 mL/mmHg/h and a
β2MG clearance rate ≥
15 mL/min)
Protein-leaking
(β2MG clearance rate 50–
70mL/min and above)
Designs of Dialyzer
Parallel plate dialyzer
Coiled dialyzer
Hollow fibre dialyzer
Hemofiltration
Primarily focuses on removing
excess fluids and waste
products
Can remove solutes from 5,000
– 50,000 Daltons sizes
(Salicylates, β2-microglobulin
and inflammatory mediator)
Absence of dialysate
Ultrafiltrate remove,
Replacement fluid is added
back
Solute removal is dependent
on fluid removal
Hemofiltration
Hemofiltration
Replacement fluid
Used to achieve fluid balance in hemofiltration
a. Pre-dilution
b. Post dilution – More efficient in solute removal (Lebedo et al., 2010)
Continuous arterio-venous hemofiltration
(CAVH)
Slow continuous ultrafiltration(SCUF)
Convective modality
Gradual removal of excess fluid
Minimizing the risk of adverse effect like
hypotension
Indications :
• Fluid overload in acute kidney injury
• CHF
SCUF
Continuous Veno-venous hemofilteration
(CVVH)
Continuous Veno-venous
hemodiafilteration CVVHDF
Hemoperfusion/Hemadsorption
Passage of blood
through a column
containing
adsorbent particles
Relatively quick and
effective method
for removing toxins
contd….
Adsorbent particles –
• Typically activated charcoal or resin,inorganic aluminosilicates
(zeolites)
• Synthetic porous polymers (styrene or acrylic acid based
Adsorbent material depends specific to type of toxins
Very large surface area
Signifcant capacity to bind specifc solutes
(Venkataraman et al., 2003)
contd….
Indications –
• Acute poisoning
• Drug overdose,
• Ingestion of toxic chemicals.
Very large surface area
Signifcant capacity to bind specifc solutes
CytoSorb™
(Kellum et al., 2002)
Indication of RRT
• Systemic inflammatory response syndrome and sepsis
• Acute respiratory syndrome
• Congestive heart failure
• Cardiopulmonary bypass
• Crush injury
• Inborn errors of metabolism
• Tumour lysis syndromes
• Lactic acidosis
Non-Renal
Plasmapheresis
Two-step process
• Separation of blood
into cells and plasma
• Separated plasma is
allowed to selective
removal of
components, reinfused
back to the patient.
No (or minimal)
replacement fluids
required.
(Berlot et al., 2000)
Plasmapheresis
(Berlot et al., 2000)
Plasma Exchange
Single-step process
Blood separated into
plasma and cells
Replaced with either
donor plasma or albumin
(Berlot et al., 2000)
Plasma Exchange
Single-step process
Blood separated into
plasma and cells
Replaced with either
donor plasma or albumin
(Berlot et al., 2000)
Extracorporeal Membrane
Oxygenation (ECMO)
Sophisticated cardiopulmonary life
support system
• Severe respiratory syndrome
• Respiratory obstruction
• Cardiac failure
• Low cardiac output
• Severe hypotension
Indications
(Makdisi and Wang, 2015)
Extracorporeal Membrane
Oxygenation (ECMO)
Extracorporeal Membrane
Oxygenation (ECMO)
Sophisticated
cardiopulmonary
life support
system
Indications
• Severe respiratory
syndrome
• Pulmonary
embolism
• Cardiac failure
• Low cardiac output
• Severe hypotension
(Makdisi and Wang, 2015)
Conclusion
Extracorporeal blood purification techniques(ECBP) has revolutionized the treatment landscape
with severe medical conditions
Hemodialysis, hemoperfusion, and plasmapheresis, proven to be effective in severe renal
dysfunction, intoxications, and immune-mediated disorders in canine
It has significantly improved prognosis and played a crucial role in veterinary nephrology
and critical care
However, it's successful application requires specialized training, equipment, and team of
veterinary professionals. Additionally, cost considerations may pose a challenge.
Ongoing research and technological developments in this field hold promise of further refining
these techniques and expanding their applications extracorporeal blood purification
32
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Extracorporeal blood purification in dogs