Dr. Kumar presented on renal replacement therapy. The key points are:
1. Approximately 5% of critically ill patients with AKI will require RRT, with a mortality rate as high as 60%.
2. RRT options include intermittent HD, continuous therapies like CVVH/CVVHD/CVVHDF, and SLED.
3. The choice of RRT depends on the patient's cardiovascular status, resources available, and whether fluid removal or solute clearance is required. CRRT is preferred for hemodynamically unstable patients.
Renal replacement therapy (RRT) refers to life-supporting treatments for renal failure and includes hemodialysis, peritoneal dialysis, and continuous renal replacement therapy. The choice of RRT depends on factors like the patient's cardiovascular status, availability of resources, and clinical considerations. Common complications include those related to vascular access and electrolyte imbalances. RRT aims to correct fluid overload, metabolic abnormalities, and remove waste through diffusion or convection.
Renal replacement therapy encompasses life-supporting treatments for renal failure such as hemodialysis, peritoneal dialysis, and continuous renal replacement therapy. Hemodialysis uses diffusion and filtration across a semi-permeable membrane to remove waste and fluid. Peritoneal dialysis infuses dialysate into the peritoneal cavity. Continuous renal replacement therapy provides 24-hour treatment through diffusion, convection, or a combination. These therapies aim to replace normal kidney functions of waste removal and fluid balance.
CRRT (continuous renal replacement therapy) involves using an extracorporeal circuit connected to the patient via catheters to slowly remove fluid and toxins over 24 hours, mimicking the function of the kidneys. It was developed for critically ill patients who cannot tolerate the fluid shifts of intermittent hemodialysis. CRRT uses a semipermeable membrane to filter fluids and small molecules from the blood based on hydrostatic pressure gradients. It provides more hemodynamic stability than intermittent hemodialysis and allows for better nutrition support by preventing fluid overload. CRRT is indicated for patients who cannot tolerate intermittent dialysis due to hemodynamic instability from their critical illness.
Renal Replacement Therapy: modes and evidenceMohd Saif Khan
This document discusses various modes of renal replacement therapy (RRT) for acute kidney injury (AKI) patients, including their principles, advantages, disadvantages, and evidence regarding optimal dosing. It summarizes that while early RRT initiation and higher RRT doses were associated with better outcomes in some studies, large randomized controlled trials found no significant differences in mortality between early versus late initiation or higher versus lower RRT doses. The optimal RRT modality and timing remains unclear based on current evidence.
This document provides an overview of principles of renal replacement therapy including hemodialysis, peritoneal dialysis, and continuous renal replacement therapy. It discusses the goals, mechanisms, equipment, and classifications of each type of therapy. Key points include that hemodialysis uses diffusion and convection to remove wastes and fluid, while peritoneal dialysis relies primarily on diffusion. Continuous renal replacement therapy is preferred for hemodynamically unstable patients as it allows for slower and steadier solute and fluid removal compared to intermittent hemodialysis. The document also notes important considerations for drug dosing in patients undergoing renal replacement therapy.
Dialysis is a procedure that substitutes for kidney function by cleaning and filtering the blood. There are different types of dialysis used to treat both acute and chronic kidney failure. Hemodialysis is the most common method and involves using an artificial kidney machine to remove waste through diffusion, osmosis, and ultrafiltration across a semipermeable membrane. A vascular access such as a catheter, arteriovenous fistula, or graft is required to access the bloodstream during hemodialysis treatments. Complications can include infections, stenosis, thrombosis, and aneurysm formation if not properly cared for.
CRRT describes a group of renal replacement therapies that provide continuous renal replacement over an extended period of time, typically 24 hours per day. There are several CRRT modalities including CVVH, CVVHD, and CVVHDF that utilize different molecular transport mechanisms like diffusion, convection, and ultrafiltration. CRRT is commonly used to treat acute kidney injury as it closely mimics the native kidney and is better tolerated by hemodynamically unstable patients. Studies have shown that earlier initiation of CRRT and achieving an adequate dose of effluent flow rate or solute clearance may improve survival rates in patients with acute renal failure.
Dr. Kumar presented on renal replacement therapy. The key points are:
1. Approximately 5% of critically ill patients with AKI will require RRT, with a mortality rate as high as 60%.
2. RRT options include intermittent HD, continuous therapies like CVVH/CVVHD/CVVHDF, and SLED.
3. The choice of RRT depends on the patient's cardiovascular status, resources available, and whether fluid removal or solute clearance is required. CRRT is preferred for hemodynamically unstable patients.
Renal replacement therapy (RRT) refers to life-supporting treatments for renal failure and includes hemodialysis, peritoneal dialysis, and continuous renal replacement therapy. The choice of RRT depends on factors like the patient's cardiovascular status, availability of resources, and clinical considerations. Common complications include those related to vascular access and electrolyte imbalances. RRT aims to correct fluid overload, metabolic abnormalities, and remove waste through diffusion or convection.
Renal replacement therapy encompasses life-supporting treatments for renal failure such as hemodialysis, peritoneal dialysis, and continuous renal replacement therapy. Hemodialysis uses diffusion and filtration across a semi-permeable membrane to remove waste and fluid. Peritoneal dialysis infuses dialysate into the peritoneal cavity. Continuous renal replacement therapy provides 24-hour treatment through diffusion, convection, or a combination. These therapies aim to replace normal kidney functions of waste removal and fluid balance.
CRRT (continuous renal replacement therapy) involves using an extracorporeal circuit connected to the patient via catheters to slowly remove fluid and toxins over 24 hours, mimicking the function of the kidneys. It was developed for critically ill patients who cannot tolerate the fluid shifts of intermittent hemodialysis. CRRT uses a semipermeable membrane to filter fluids and small molecules from the blood based on hydrostatic pressure gradients. It provides more hemodynamic stability than intermittent hemodialysis and allows for better nutrition support by preventing fluid overload. CRRT is indicated for patients who cannot tolerate intermittent dialysis due to hemodynamic instability from their critical illness.
Renal Replacement Therapy: modes and evidenceMohd Saif Khan
This document discusses various modes of renal replacement therapy (RRT) for acute kidney injury (AKI) patients, including their principles, advantages, disadvantages, and evidence regarding optimal dosing. It summarizes that while early RRT initiation and higher RRT doses were associated with better outcomes in some studies, large randomized controlled trials found no significant differences in mortality between early versus late initiation or higher versus lower RRT doses. The optimal RRT modality and timing remains unclear based on current evidence.
This document provides an overview of principles of renal replacement therapy including hemodialysis, peritoneal dialysis, and continuous renal replacement therapy. It discusses the goals, mechanisms, equipment, and classifications of each type of therapy. Key points include that hemodialysis uses diffusion and convection to remove wastes and fluid, while peritoneal dialysis relies primarily on diffusion. Continuous renal replacement therapy is preferred for hemodynamically unstable patients as it allows for slower and steadier solute and fluid removal compared to intermittent hemodialysis. The document also notes important considerations for drug dosing in patients undergoing renal replacement therapy.
Dialysis is a procedure that substitutes for kidney function by cleaning and filtering the blood. There are different types of dialysis used to treat both acute and chronic kidney failure. Hemodialysis is the most common method and involves using an artificial kidney machine to remove waste through diffusion, osmosis, and ultrafiltration across a semipermeable membrane. A vascular access such as a catheter, arteriovenous fistula, or graft is required to access the bloodstream during hemodialysis treatments. Complications can include infections, stenosis, thrombosis, and aneurysm formation if not properly cared for.
CRRT describes a group of renal replacement therapies that provide continuous renal replacement over an extended period of time, typically 24 hours per day. There are several CRRT modalities including CVVH, CVVHD, and CVVHDF that utilize different molecular transport mechanisms like diffusion, convection, and ultrafiltration. CRRT is commonly used to treat acute kidney injury as it closely mimics the native kidney and is better tolerated by hemodynamically unstable patients. Studies have shown that earlier initiation of CRRT and achieving an adequate dose of effluent flow rate or solute clearance may improve survival rates in patients with acute renal failure.
Dr. Osama El-Shahat is a consultant nephrologist and head of the nephrology department at New Mansoura General Hospital. He is also an educational ambassador for the International Society of Nephrology. The document discusses the stage-based management of acute kidney injury (AKI) including monitoring for stage 1 risk, conservative therapy for stage 2 injury, and considering renal replacement therapy for stage 3 failure. It provides recommendations at each stage to monitor patients, discontinue nephrotoxic agents, and consider ICU admission or invasive diagnostic workup as needed.
CRRT is a continuous renal replacement therapy that provides a gentler form of dialysis for critically ill patients. It works through slow, continuous removal of waste and fluid over multiple days rather than the typical 4 hour sessions of hemodialysis. This puts less stress on the heart. CRRT can be delivered through various modes including continuous venovenous hemofiltration, hemodialysis, or hemodiafiltration that utilize diffusion, convection, or both to clean the blood. Anticoagulation is required to prevent clotting of the dialysis circuit and can include regional citrate or low-dose heparin.
1) Hemodialysis and CRRT are renal replacement therapies used to treat acute kidney injury by removing waste and fluid from the blood. CRRT provides more gradual and continuous treatment compared to intermittent hemodialysis.
2) Indications for RRT include fluid overload, hyperkalemia, acidosis, rising urea/creatinine, uraemia symptoms, and sepsis. The choice of RRT depends on what needs to be removed, the patient's stability, resources, and clinical factors.
3) CRRT modalities include CVVH, CVVHD, and CVVHDF. Anticoagulation is usually needed but can be avoided if the patient is already coagulo
This document discusses various modalities of renal replacement therapy in children including peritoneal dialysis, hemodialysis, and continuous renal replacement therapy. It provides details on the principles, procedures, indications, and complications of each modality. The key points are:
- Renal replacement therapy helps clear accumulated solutes, water, or toxins from the blood via diffusion or convection across a semipermeable membrane.
- Peritoneal dialysis can be performed manually or with a machine and involves exchanging dialysate fluid into the peritoneal cavity. Hemodialysis uses an artificial kidney to filter blood outside the body. Continuous renal replacement therapy provides prolonged dialysis without interruption that is better tolerated in critically ill
This document provides information about continuous renal replacement therapies (CRRT). It begins by explaining that CRRT is a type of hemodialysis used for critically ill patients with acute or chronic kidney failure. CRRT circulates blood through a filter and slowly removes waste and excess fluid over an extended period, preventing rapid fluid shifts. The document then discusses the different modes of CRRT, including continuous venovenous hemofiltration, hemodialysis, and hemodiafiltration. It covers the principles, processes, equipment, and nursing management of CRRT.
This document discusses the role of the laboratory in renal replacement therapy. It begins by outlining the normal functions of the kidneys and describing acute kidney injury (AKI), chronic kidney disease (CKD), and the various forms of renal replacement therapy including dialysis and transplantation. It then discusses guidelines for assessing and treating AKI and CKD patients undergoing renal replacement therapy. The document also covers the laboratory's role in monitoring transplant patients and various immunosuppressive drugs. It concludes by discussing new markers being used to monitor renal replacement therapy and important considerations for long-term therapy.
Stage-based management of acute kidney injury (AKI) involves monitoring for progression from risk to injury to failure. For stage 1 (risk), monitoring to prevent progression is recommended. For stage 2 (injury), conservative therapy is recommended due to high risk of mortality/morbidity. For stage 3 (failure), renal replacement therapy (RRT) should be considered due to highest risk of death. Continuous renal replacement therapy (CRRT) is preferred for hemodynamically unstable patients and allows for slow correction while maintaining hemodynamic stability. Higher CRRT doses of 35 ml/kg/hr may improve survival compared to lower doses, though optimal dosing remains controversial.
This document summarizes a seminar on dialysis presented by Mr. Amresh Kushwaha. It defines dialysis as an artificial process used to remove water and waste from the blood when the kidneys fail. It discusses the types of dialysis including hemodialysis and peritoneal dialysis. It covers the procedures, equipment, complications and nursing management for both types of dialysis.
This document provides information on continuous renal replacement therapy (CRRT) modalities and dosing. It discusses CRRT principles, indications, modes of therapy including CVVH, CVVHD and CVVHDF. Details are given on vascular access, replacement fluids, anticoagulation options, and monitoring patients on CRRT. Examples show calculations for setting flow rates based on patient weight and condition. Complications of CRRT are outlined. Guidelines recommend CRRT for hemodynamically unstable acute kidney injury patients.
This document provides information on continuous renal replacement therapy (CRRT) modalities and dosing. It discusses CRRT principles, indications, modes of therapy including CVVH, CVVHD and CVVHDF. Details are given on vascular access, replacement fluids, anticoagulation options, and monitoring patients on CRRT. Examples show calculations for setting flow rates based on patient weight and condition. Guidelines are provided for initiating and managing heparin anticoagulation during CRRT.
1) Chronic kidney disease is defined as either kidney damage or decreased glomerular filtration rate (GFR) below 60 mL/min/1.73m2 for at least three months.
2) Fluid therapy for patients with chronic kidney disease undergoing surgery aims to prevent hypo- and hypervolemia as well as electrolyte abnormalities while avoiding exacerbating kidney injury or progression to end-stage renal disease.
3) Goal-directed fluid therapy utilizing dynamic parameters like stroke volume variation is recommended over liberal or restrictive regimens, with choice of isotonic crystalloid like Plasmalyte over normal saline given risks of hyperchloremia with the latter.
This seminar presentation provides an overview of continuous renal replacement therapy (CRRT). CRRT is a slow, continuous blood purification therapy that mimics kidney function for patients with kidney failure who are hemodynamically unstable. The presentation defines CRRT and discusses its principles, indications, features, types including CVVH, CVVHD and CVVHDF, vascular access requirements, dialysate fluids, the CRRT process, nursing management, complications and conclusions. A research study is also summarized that found comparable survival outcomes between acute peritoneal dialysis and CRRT for hemodynamically unstable patients requiring renal replacement therapy.
Dialysis without anticoagulation (Heparin Free Dialysis)Mahmoud Eid
This document discusses techniques for performing dialysis without anticoagulation. It describes indications for heparin-free dialysis such as recent surgery or bleeding risks. Techniques mentioned include regional citrate anticoagulation, saline flushes, heparin-coated membranes, and citrasate dialysate. Signs of clotting and scoring systems are provided. Tips for priming, high blood flows, and alternatives to heparin locking are also outlined. The key recommendations are to prime properly, have no rushing, follow a written protocol, and focus on patient safety above all else.
A very simple yet comprehensive presentation to understand the concept of CRRT and its implementation in Intensive Care Unit. Intended for the very beginners in ICU. After going through the presentation you will be able to say "Now I know it!"
Rrt in icu dr said khamis zagazig april 2018 latestFarragBahbah
The document provides an overview of renal replacement therapy (RRT) modalities for critically ill patients with acute kidney injury (AKI). It discusses the history and evolution of RRT, including intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT). The pros and cons of IHD and CRRT are presented. Key considerations for RRT include which modality to use, anticoagulation options, dialysate buffers, and membranes. Guidelines for determining therapy dose and duration and criteria for discontinuing RRT are summarized. Outcomes with IHD versus CRRT remain unclear due to limitations of existing studies. Overall, the document reviews best practices for delivering RRT to critically ill AK
Dialysis dose prescription (the basics) dr ujjawalUjjawal Roy
The document discusses key aspects of dialysis dose prescription, including:
1) Components of the dialysis prescription include dialyzer choice, time, blood and dialysate flow rates, ultrafiltration rate, dialysate composition, temperature, and anticoagulation.
2) Prescription goals are to restore the body's fluid and electrolyte balance and remove waste and excess water from patients with end-stage renal disease.
3) Important considerations for dialysis prescription include a patient's dry weight and risk of intradialytic hypotension.
At Malayali Kerala Spa Ajman, Full Service includes individualized care for every client. We specifically design each massage session for the individual needs of the client. Our therapists are always willing to adjust the treatments based on the client's instruction and feedback. This guarantees that every client receives the treatment they expect.
By offering a variety of massage services, our Ajman Spa Massage Center can tackle physical, mental, and emotional illnesses. In addition, efficient identification of specific health conditions and designing treatment plans accordingly can significantly enhance the quality of massaging.
At Malayali Kerala Spa Ajman, we firmly believe that everyone should have the option to experience top-quality massage services regularly. To achieve that goal we offer cheap massage services in Ajman.
If you are interested in experiencing transformative massage treatment at Malayali Kerala Spa Ajman, you can use our Ajman Massage Center WhatsApp Number to schedule your next massage session.
Contact @ +971 529818279
Visit @ https://malayalikeralaspaajman.com/
As Mumbai's premier kidney transplant and donation center, L H Hiranandani Hospital Powai is not just a medical facility; it's a beacon of hope where cutting-edge science meets compassionate care, transforming lives and redefining the standards of kidney health in India.
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Dr. Osama El-Shahat is a consultant nephrologist and head of the nephrology department at New Mansoura General Hospital. He is also an educational ambassador for the International Society of Nephrology. The document discusses the stage-based management of acute kidney injury (AKI) including monitoring for stage 1 risk, conservative therapy for stage 2 injury, and considering renal replacement therapy for stage 3 failure. It provides recommendations at each stage to monitor patients, discontinue nephrotoxic agents, and consider ICU admission or invasive diagnostic workup as needed.
CRRT is a continuous renal replacement therapy that provides a gentler form of dialysis for critically ill patients. It works through slow, continuous removal of waste and fluid over multiple days rather than the typical 4 hour sessions of hemodialysis. This puts less stress on the heart. CRRT can be delivered through various modes including continuous venovenous hemofiltration, hemodialysis, or hemodiafiltration that utilize diffusion, convection, or both to clean the blood. Anticoagulation is required to prevent clotting of the dialysis circuit and can include regional citrate or low-dose heparin.
1) Hemodialysis and CRRT are renal replacement therapies used to treat acute kidney injury by removing waste and fluid from the blood. CRRT provides more gradual and continuous treatment compared to intermittent hemodialysis.
2) Indications for RRT include fluid overload, hyperkalemia, acidosis, rising urea/creatinine, uraemia symptoms, and sepsis. The choice of RRT depends on what needs to be removed, the patient's stability, resources, and clinical factors.
3) CRRT modalities include CVVH, CVVHD, and CVVHDF. Anticoagulation is usually needed but can be avoided if the patient is already coagulo
This document discusses various modalities of renal replacement therapy in children including peritoneal dialysis, hemodialysis, and continuous renal replacement therapy. It provides details on the principles, procedures, indications, and complications of each modality. The key points are:
- Renal replacement therapy helps clear accumulated solutes, water, or toxins from the blood via diffusion or convection across a semipermeable membrane.
- Peritoneal dialysis can be performed manually or with a machine and involves exchanging dialysate fluid into the peritoneal cavity. Hemodialysis uses an artificial kidney to filter blood outside the body. Continuous renal replacement therapy provides prolonged dialysis without interruption that is better tolerated in critically ill
This document provides information about continuous renal replacement therapies (CRRT). It begins by explaining that CRRT is a type of hemodialysis used for critically ill patients with acute or chronic kidney failure. CRRT circulates blood through a filter and slowly removes waste and excess fluid over an extended period, preventing rapid fluid shifts. The document then discusses the different modes of CRRT, including continuous venovenous hemofiltration, hemodialysis, and hemodiafiltration. It covers the principles, processes, equipment, and nursing management of CRRT.
This document discusses the role of the laboratory in renal replacement therapy. It begins by outlining the normal functions of the kidneys and describing acute kidney injury (AKI), chronic kidney disease (CKD), and the various forms of renal replacement therapy including dialysis and transplantation. It then discusses guidelines for assessing and treating AKI and CKD patients undergoing renal replacement therapy. The document also covers the laboratory's role in monitoring transplant patients and various immunosuppressive drugs. It concludes by discussing new markers being used to monitor renal replacement therapy and important considerations for long-term therapy.
Stage-based management of acute kidney injury (AKI) involves monitoring for progression from risk to injury to failure. For stage 1 (risk), monitoring to prevent progression is recommended. For stage 2 (injury), conservative therapy is recommended due to high risk of mortality/morbidity. For stage 3 (failure), renal replacement therapy (RRT) should be considered due to highest risk of death. Continuous renal replacement therapy (CRRT) is preferred for hemodynamically unstable patients and allows for slow correction while maintaining hemodynamic stability. Higher CRRT doses of 35 ml/kg/hr may improve survival compared to lower doses, though optimal dosing remains controversial.
This document summarizes a seminar on dialysis presented by Mr. Amresh Kushwaha. It defines dialysis as an artificial process used to remove water and waste from the blood when the kidneys fail. It discusses the types of dialysis including hemodialysis and peritoneal dialysis. It covers the procedures, equipment, complications and nursing management for both types of dialysis.
This document provides information on continuous renal replacement therapy (CRRT) modalities and dosing. It discusses CRRT principles, indications, modes of therapy including CVVH, CVVHD and CVVHDF. Details are given on vascular access, replacement fluids, anticoagulation options, and monitoring patients on CRRT. Examples show calculations for setting flow rates based on patient weight and condition. Complications of CRRT are outlined. Guidelines recommend CRRT for hemodynamically unstable acute kidney injury patients.
This document provides information on continuous renal replacement therapy (CRRT) modalities and dosing. It discusses CRRT principles, indications, modes of therapy including CVVH, CVVHD and CVVHDF. Details are given on vascular access, replacement fluids, anticoagulation options, and monitoring patients on CRRT. Examples show calculations for setting flow rates based on patient weight and condition. Guidelines are provided for initiating and managing heparin anticoagulation during CRRT.
1) Chronic kidney disease is defined as either kidney damage or decreased glomerular filtration rate (GFR) below 60 mL/min/1.73m2 for at least three months.
2) Fluid therapy for patients with chronic kidney disease undergoing surgery aims to prevent hypo- and hypervolemia as well as electrolyte abnormalities while avoiding exacerbating kidney injury or progression to end-stage renal disease.
3) Goal-directed fluid therapy utilizing dynamic parameters like stroke volume variation is recommended over liberal or restrictive regimens, with choice of isotonic crystalloid like Plasmalyte over normal saline given risks of hyperchloremia with the latter.
This seminar presentation provides an overview of continuous renal replacement therapy (CRRT). CRRT is a slow, continuous blood purification therapy that mimics kidney function for patients with kidney failure who are hemodynamically unstable. The presentation defines CRRT and discusses its principles, indications, features, types including CVVH, CVVHD and CVVHDF, vascular access requirements, dialysate fluids, the CRRT process, nursing management, complications and conclusions. A research study is also summarized that found comparable survival outcomes between acute peritoneal dialysis and CRRT for hemodynamically unstable patients requiring renal replacement therapy.
Dialysis without anticoagulation (Heparin Free Dialysis)Mahmoud Eid
This document discusses techniques for performing dialysis without anticoagulation. It describes indications for heparin-free dialysis such as recent surgery or bleeding risks. Techniques mentioned include regional citrate anticoagulation, saline flushes, heparin-coated membranes, and citrasate dialysate. Signs of clotting and scoring systems are provided. Tips for priming, high blood flows, and alternatives to heparin locking are also outlined. The key recommendations are to prime properly, have no rushing, follow a written protocol, and focus on patient safety above all else.
A very simple yet comprehensive presentation to understand the concept of CRRT and its implementation in Intensive Care Unit. Intended for the very beginners in ICU. After going through the presentation you will be able to say "Now I know it!"
Rrt in icu dr said khamis zagazig april 2018 latestFarragBahbah
The document provides an overview of renal replacement therapy (RRT) modalities for critically ill patients with acute kidney injury (AKI). It discusses the history and evolution of RRT, including intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT). The pros and cons of IHD and CRRT are presented. Key considerations for RRT include which modality to use, anticoagulation options, dialysate buffers, and membranes. Guidelines for determining therapy dose and duration and criteria for discontinuing RRT are summarized. Outcomes with IHD versus CRRT remain unclear due to limitations of existing studies. Overall, the document reviews best practices for delivering RRT to critically ill AK
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1) Components of the dialysis prescription include dialyzer choice, time, blood and dialysate flow rates, ultrafiltration rate, dialysate composition, temperature, and anticoagulation.
2) Prescription goals are to restore the body's fluid and electrolyte balance and remove waste and excess water from patients with end-stage renal disease.
3) Important considerations for dialysis prescription include a patient's dry weight and risk of intradialytic hypotension.
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At Malayali Kerala Spa Ajman, Full Service includes individualized care for every client. We specifically design each massage session for the individual needs of the client. Our therapists are always willing to adjust the treatments based on the client's instruction and feedback. This guarantees that every client receives the treatment they expect.
By offering a variety of massage services, our Ajman Spa Massage Center can tackle physical, mental, and emotional illnesses. In addition, efficient identification of specific health conditions and designing treatment plans accordingly can significantly enhance the quality of massaging.
At Malayali Kerala Spa Ajman, we firmly believe that everyone should have the option to experience top-quality massage services regularly. To achieve that goal we offer cheap massage services in Ajman.
If you are interested in experiencing transformative massage treatment at Malayali Kerala Spa Ajman, you can use our Ajman Massage Center WhatsApp Number to schedule your next massage session.
Contact @ +971 529818279
Visit @ https://malayalikeralaspaajman.com/
As Mumbai's premier kidney transplant and donation center, L H Hiranandani Hospital Powai is not just a medical facility; it's a beacon of hope where cutting-edge science meets compassionate care, transforming lives and redefining the standards of kidney health in India.
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Renal Replacement Therapy - ICU Guidlines
1. RENAL REPLACEMENT
THERAPY
BY : Dr Nalluru Likhitha (MD Anaesthesia)
Moderator : Dr Guru Charan , MD Anaesthesia
NRIIMS
Sanghivalasa
2. Introduction
• It is estimated that a third of patients in the critical care setting have an AKI and approximately 5% will
require renal replacement therapy .
• The hospital mortality in patients with an AKI requiring RRT is as high as 60%.
• No specific treatments have been shown to reverse the course of AKI, so RRT forms the basis of further
management
20XX Presentation title 2
3. Definition
• Acute kidney injury (AKI), is defined as an abrupt (within 48 hours) reduction in kidney function.
The AKI network defines the reduction in kidney function as the presence of any one of the following:
• 1. An absolute increase in serum creatinine of ≥ 0.3 mg.dl -1(≥ 26.4 mcmol.l-1)
• 2. A percentage increase in serum creatinine of ≥ 50% (1.5-fold from baseline)
• 3. A reduction in urine output (< 0.5 ml.kg -1 per hour for more than six hours)
20XX Presentation title 3
4. Classification of AKI
R- RISK Increase in serum creatn>1.5times
baseline
Urine output < 0.5ml/kg/hr for 6hrs
I – INJURY Increase in sereum creat >2 times
baseline
Decrease in GFR > 50%
Urine output <0.5ml/kg/hr for >12hrs
F-Failure Increase in serum creat >3 times
baseline
Decrease in GFR<75%
Urine output <0.3ml/kg/hr for >24hrs
Or anuria for >12hrs
L-loss of function Persistent loss of kidney function for
>4weeks
ESRD Persistent loss of kidney function for >3
months
20XX Presentation title 4
6. Indications of RRT
➢ drugs are cleared by RRT if they are water-soluble and not highly protein-bound.
20XX Presentation title 6
Removed by RRT Not removed by RRT
Lithium
Methanol
Ethylene glycol
Salicylates
Barbiturates
Metformin
Aminoglycosides ,metronidazole,
carbapenems.cephalosporins and most
pencillins.
Digoxin
Tricyclics
Phenytoins
Beta blockers
Benzodiazepines
Macrolide and quinolone antibiotiocs
Warfarin
7. Dialyser unit
The basic components of the dialyzer unit:
• Dialyzer – cellulose, substituted cellulose, synthetic non cellulose membranes.
• Dialysis solution – dialysate : water must remain free of Al, Cu, chloramines, bacteria and endotoxin.
• Tubing for transport of blood and dialysis solution.
20XX Presentation title 7
10. Mechanism of Solute Removal
ULTRAFILTERATION :
• Movement of fluid through a semipermeable membrane.
• Along a pressure gradient.
• Net removal of fluid from patient.
20XX Presentation title 10
11. Mechanism of Solute Removal
CONVECTION:
• Convection is one way movement of solute through a semipermeable membrane with a water flow.
• Efficient for both larger and smaller molecules.
• It requires pressure gradient.
• It can be provided by adding extra fluid to create pressure difference an drag the solutes to other side.
• The extra fluid been given is called replacement fluid.
20XX Presentation title 11
12. Mechanism of Solute Removal
DIFFUSION
• Movement of solutes from area of higher concentration to lower concentration.
• This works by a difference in concentration gradient.
• We need to have a solution that is of lower concentration than blood called as DIALYSATE .
• Efficient in clearing smaller molecules.
20XX Presentation title 12
13. • Concentration difference can be created by two means : cocurrent flow and countercurrent flow.
20XX Presentation title 13
15. Modes of renal replacement techniques
20XX Presentation title 15
Peritoneal dialysis
16. Peritoneal Dialysis
• Procedure using peritoneum as a membrane for fluid exchange therapy in azotemic patients.
• It is performed using peritoneum as a semipermeable membrane.
• This allows water and solute transport from vascular system to peritoneal cavity.
• The peritoneal cavity holds upto 3litres of fluid.
• Uses diffusion and ultrafiltration as principles.
20XX Presentation title 16
17. Peritoneal Dialysis
Indications : Contraindications:
Renal : CKD/AKI with Absolute : severe IBD ,ischemic bowel disease ,
Vascular access failure acute active diverticulosis
Intolerance to hemodialysis peritoneal fibrosis and adhesions
Children 0-5years. abdominal abscess
Chronic infections
Non renal indications : Relative :severe malnutrition
Refractory congestive cardiac failure obesity
Hepatic failure hernias
Pancreatitis colostomy
20XX Presentation title 17
20. Complications :
Due to catheter placement :
• Bowel perforation
• Bleeding
• Wound infection
• Peritonitis
• Hernias
Due to procedure :
• Protein loss
• Hyperglycemia
• Hypertriglyceredimia
• Weight gain
• Shoulder pain
• Raised ICP
20XX Presentation title 20
21. Intermittent hemodialysis
• Intermittent haemodialysis involves dialysing with higher flow rates than CRRT for defined periods of time.
• A typical regime is 3-5 hours of dialysis 3 times a week.
• The high flow rates and rapid fall in plasma osmolality mean that it is only suitable for patients who are
cardiovascularly stable.
• It forms the basis of long term RRT for chronic renal failure but is not often used in the critical care setting.
20XX Presentation title 21
22. Intermittent therapies
Relatively inexpensive
Flexible timing allows for mobility and transport
Rapid correction of fluid overload
Rapid removal of dialysable drugs
Rapid correction of acidosis and electrolyte abnormality
Minimises anticoagulant exposure
20XX Presentation title 22
23. Complications of IHD
• Systemic hypotension
• Arrhythmia
• Hypoxaemia
• Haemorrhage
• Infection
• Line-related complications(e.g. pneumothorax)
• Seizure or dialysis disequilibrium
• Pyrogen reaction or haemolysis
• Delay in recovery of renal function
20XX Presentation title 23
24. Continuos Renal Replacement
Therapy
• It 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 24hours a day.
• The concept behind continuos renal replacement techniques is to dialyse patients in a more physiologic way
slowly over 24 hours just like kidney.
20XX Presentation title 24
25. Continuos renal replacement therapy
Hemodynamic stability
Stable and predictive volume control
Stable intracranial pressure
Disease modification by cytokine removal as in sepsis
20XX Presentation title 25
26. IHD VERSUS CRRT
IHD CRRT
Mainly diffusive
High flow (50-0-800l/min)
On line dialysis production
Usually 4hr per dialysis session.
Technically demanding .
Usually used in patients who are hemodynamically stable
Mainly convenctive (CVVH),diffusive (CVVHD) or
both(CVVHDF)
Low flow(1-2L/hr) or no dialysate flow in CVVH
Use commercial fluid
continuos
Technically less demanding
Usually used in patients with hemodynamic instability or
increased ICP
20XX Presentation title 26
27. SCUF
• High flux membranes
• Up to 24 hrs per day
• Objective VOLUME control
• Not suitable for solute clearance
• Blood flow 50-200 ml/min
• UF rate 2-8 ml/min
20XX Presentation title 27
28. CVVH
• Extended duration up to weeks
• High flux membranes
• Mainly convective clearance
• UF > volume control amount
• Excess UF replaced
• Replacement pre- or post-filter
• Blood flow 50-200 ml/min
• UF rate 20-25ml/hr
• Use convection principle .
20XX Presentation title 28
29. CVVHD
• Mid/high flux membranes
• Extended period up to weeks
• Diffusive solute clearance
• Countercurrent dialysate
• UF for volume control
• Blood flow 50-200 ml/min
• UF rate 1-8 ml/min
• Dialysate flow 15-60 ml/min
• By Diffusion principle.
20XX Presentation title 29
30. CVVHDF
20XX Presentation title 30
• Use diffusive and convective principles.
• Require dialysate as well as
replacement fluid.
• Rate of filtration 8-12ml/min
31. SUSTAINED LOW EFFICIENCY DIALYSIS
• Aims to combine the logistic and cost advantages of IHD with the relative cardiovascular stability of CRRT.
• Treatments are intermittent but usually daily and with longer session durations than conventional IHD.
• Solute and fluid removal are slower than IHD, but faster than CRRT
20XX Presentation title 31
33. WHICH FORM OF RRT TO BE USED?
20XX Presentation title 33
34. WHICH FORM OF RRT TO BE USED?
20XX Presentation title 34
2. The patient`s cardiovascular status
• CRRT causes less rapid fluid shifts and is the preferred option if there is any degree of cardiovascular
instability.
3. The availability of resources
• CRRT is more labour intensive and more expensive than IHD
• Availability of equipment may dictate the form of RRT.
4. The clinician`s experience
• It is wise to use a form of RRT that is familiar to all the staff involved.
5. Other specific clinical considerations
• Convective modes of RRT may be beneficial if the patient has septic shock
• CRRT can aid feeding regimes by improving fluid management
• CRRT may be associated with better cerebral perfusion in patients with an acute brain injury or fulminant
hepatic failure
35. NEED FOR RRT
IHD/SLED
20XX Presentation title 35
AKI/ESRD
ON PRESSORS??
NO YES
BP
STABLE
??
NO
CRRT
YES
Severe
hyperkalemia
Severe fluid overload Acidosis with untreated cause
Yes
IHD/
CRRT
NO
SLED
YES
CRRT
NO
SLED
YES
CRRT
NO
SLED
36. Vascular access :
• Venovenous RRT requires a double lumen vascular catheter placed in central vein.
• The tip should be sited in IVC for femoral lines or SVC for internal jugular and subclavian veins.
• The catheters are usually made of polyurethrane or silicone and need to be stiff enough to prevent kinking.
20XX Presentation title 36
38. DIALYSATE FLUID
• Bicarbonate buffer solutions is used in IHD to replenish serum bicarbonate levels and neutralise metabolic
acids that are usually present in patients with renal failure.
• Acetate buffer solutions present the body with a large acetate load to be metabolised by the skeletal muscle.
• In critically ill patients the acetate levels rise due to decreased skeletal muscle metabolism.
• Increased acetate levels have been associated with hypotension and hypoxia due to its negative inotrope
effect and vasodilatation
• Lactate buffer solutions
20XX Presentation title 38
39. DIALYSATE FLUID
• Electrolyte concentration of a commonly available dialysate solution
20XX Presentation title 39
Electrolyte Concentration
Sodium
Potassium
Lactate
Chloride
Calcium
Magnesium
Glucose
Osmolality
140mmol/L
1mmol/L
45.5mmol/l
102mmol/l
1.6mmol/l
0.82mmol/l
10.9mmol/l
285mmol/l
40. Parameters
Dose :
• Defined by effluent rate .( recommended I 25ml/kg/hr)
• Higher rates used for metabolic acidosis ( 40-70ml/kg/hr ) until corrected..
Filtration fraction :
• Defined as proportion of plasma water entering the dialyser which is filtered.
• Usually maintained below 20%
• FF=ultrafiltration flow rate / plasma water flow rate .
Blood flow rate :
• For patients on anticoagulation : 200ml/min
• No anticoagulation : 300l/min
• Lower flow rates cause blood stasis and clotting.
20XX Presentation title 40
41. Anticoagulation
• extracorporeal circuit will activate coagulation pathways and the premature clotting of a filter is a common
problem.
• Even a small amount of clot formation will reduce filter performance.
NON-PHARMACOLOGICAL MEASURES
1. adequate central venous pressure,
2. optimising vascular access
3. adding a proportion of the replacement fluid to the patients blood before it passes through the haemofilter
(this is predilution)
20XX Presentation title 41
42. Guidelines for “ no AnticoAGulAtion”
• There is a already a degree of coagulopathy
• INR > 2-2.5
• APTT > 60 seconds
• platelet count < 60 x 10³.mm3
• There is a high risk of bleeding
• The patient is receiving activated protein C
• Anticoagulants should be considered in all other situations and aim is to anticoagulated the filter and not the
patient.
20XX Presentation title 42
43. Anticoagulation
The forms of anticoagulation available are :
• Unfractionated heparin (UFH) [5-30kDa] is the most commonly used anticoagulant in the UK and atypical
regime involves a 40-70 IU.kg-1 bolus followed by a pre-filter infusion at 5-10 IU.kg.-1hr-1.
• It is the most cost effective anticoagulant and is fully reversible with protamine.
• The APTT should be monitored to avoid excessive anti-coagulation but there is no evidence that elevating
the APTT prolongs filter life.
20XX Presentation title 43
44. Anticoagulation
• Low molecular weight heparins (LMWH) [4.5-6kDa] are only used for RRT in 4% of intensive care
units in the UK.
• They are dependant on renal elimination so in this setting their dosing needs to be guided by anti-factor Xa
levels (aiming for 0.25-0.35 IU.ml-1).
• The half life of LMWHs is longer than for UFH (2-6 hrs versus 1.5-3hrs) and their effect can only be partially
reversed with protamine.
• There is not a huge amount of data on the use of LMWH in CRRT and there is no evidence to suggest that
they are superior to UFH.
20XX Presentation title 44
45. Anticoagulation
Prostaglandins :
• Prostaglandins (prostacyclin or prostaglandin E2) inhibit platelet function and can either be used on their own
or in combination with heparin whereby they have a synergistic effect.
• Prostaglandins have a short half life (several minutes) so are administered as an infusion (2.5 – 10
ng.kg1.min-1).
• Theanticoagulant effect stops within 2 hours of discontinuing the infusion making them a useful alternativeto
heparin in patients at high risk of bleeding.
• The main side effect is vasodilation which may include a reduction in hypoxic pulmonary vasoconstriction
leading to hypoxemia.
• The other downside is that they are expensive and so are only used as second line therapy
20XX Presentation title 45
46. Anticoagulation
Regional citrate anticoagulation :
• Regional citrate anticoagulation is an effective therapy especially when there is an increased risk of
bleeding.
• Sodium citrate is infused into the circuit pre-filter which chelates calcium and inhibits clot formation.
• The calcium citrate complex is freely filtered so a calcium infusion is required post-filter.
• This form ofanticoagulation is limited by the metabolic derangements that it can cause: Hypocalcaemia,
hypomagnesaemia (Mg2+ is also chelated), hypernatraemia (sodium load in sodium citrate), metabolic
alkalosis (citrate is metabolised to bicarbonate), metabolic acidosis (caused by the citrate especially if
the body`s citrate handling is impaired e.g. liver failure).
20XX Presentation title 46
47. Filters
The properties of a filter that have an impact on its function are:
Biocompatibility
• The degree to which the membrane will activate the patient`s inflammatory and coagulation pathways. The greater the
biocompatibility of a membrane less activation it will cause.
Flux
• The permeability of the filter. High flux membranes are hydrophobic and may have more or larger pores allowing more
water and solute to move across the membrane.
Adsorption
• The ability of larger solutes to adhere to the surface of the membrane. A highly adsorptive membrane offers the potential
benefit of adsorbing mid sized molecules including inflammatory mediators but only until it is saturated with them (usually
after the first few hours).
Thickness
• Thinner membranes allow greater movement of solute by diffusion and also favour convective movement
Surface area
• The surface area of the membrane determines the available area for diffusion and ultrafiltration
20XX Presentation title 47
48. Replacement fluids
Replacement fluids vary slightly in their composition but are all are balanced salt solutions with either a lactate
or bicarbonate buffer.
• Lactate-based solutions are stable and hence the cheaper and more practical option, however, their buffering
capacity depends on the conversion of lactate into bicarbonate.
• Under normal physiological conditions the body converts lactate into bicarbonate on an equimolar basis.
• This is not always the case in critically ill patients, particularly if they have impaired liver function or already
have a lactic acidosis.
• In these situations, RRT using a lactate-based replacement fluid can worsen the patient’s acidosis so a
bicarbonate-based replacement solution should be used.
• If, however, this is not possible and serum lactate levels are not excessive then an alternative option is to
continue with the lactate based replacement solution and commence an intravenous infusion of bicarbonate
20XX Presentation title 48
49. Replacement fluids
• Bicarbonate-based replacement solutions have a more reliable buffering capacity but need to be prepared
just prior to use.
• At present, there is no evidence to suggest that the choice of replacement fluid has an impact on survival or
renal recovery.
• Replacement fluid can be added pre- or post-filter in varying ratios.
• The benefit of adding some of the replacement fluid pre-filter is that it lowers the haematocrit of the blood
which reduces the likelihood of the filter clotting.
20XX Presentation title 49
50. Complications common to
IHD,CRRT,Hybrid therapies
• Complications related to the cath (including line-related sepsis)
• Haemodynamic instability
• Air emboli
• Platelet consumption
• Blood loss
• Electrolyte imbalances
• Hypothermia
• Effects of anticoagulation (bleeding or specific side-effects of the anticoagulant used e.g. heparin induced
thrombocytopenia).
20XX Presentation title 50
51. Summary
• AKI is common and 5% of the critical care population receive RRT.
• There are various forms of RRT but they all remove unwanted solutes using the processes of diffusion
(dialysis) and/or convection (filtration).
• RRT can be administered continuously or intermittently.
• No single form of RRT has been shown to offer a survival benefit over the others but there are often other
reasons why a particular technique may be preferable in a given situation.
• There is some evidence that high volume haemofiltration may improve survival in patients with septic shock
but there have been no large randomised controlled trials in this area.
• Lifespan of the circuit is dependant on good quality vascular access and appropriate anticoagulation.
• 60% of people receiving RRT for AKI will die during that admission but 80% of the survivors will be free from
RRT one year later.
20XX Presentation title 51
52. References
1. Morgan and Mickhail’s clinical anesthesiology 5 edition
2. Stoelting’s physiopharmacology
3. Millers Anaesthesia 8 edition
4. Renal replacemenent therapy in crtitical care by Dr Andrew Baker , et all.
5. Uchino S, Kellum JA, Bellomo R, et al. Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA 2005; 294: 813
6. Liu, KD, Himmelfarb, J, Paganini, E, et al. Timing of initiation of dialysis in critically ill patients with acute kidney injury. Clin J Am Soc Nephrol
2006; 1: 915-9
20XX Presentation title 52