Continuous Renal Replacement Therapy

Jai Radhakrishnan, MD, MS

History of the CRRT program

1988 Open heart program Active transplant program Deep dissatisfaction with peritoneal dialysis in hemodynamically unstable patients

Objectives
Physiologic principles Patient Selection for CRRT Modality Selection Prescription Variables Fluid Composition Management of Fluid and Electrolyte problems Controversies

Basic Concepts

Pressure

Convection
(Plasma water moves along pressure gradients)

Continuous Renal Replacement Therapy

SCUF CVVH CVVHD CVVHDF

Therapy Options
Access

Return

SCUF:
Slow Continuous Ultra Filtration
P R I S M A

Maximum Patient Fluid Removal Rate = 2000 ml/hr

Effluent

Therapy Options
Access Return

CVVH
Continuous Veno-Venous HemoFiltration
P R I S M A

Replacement

Effluent

Maximum Patient Fluid Removal Rate = 1000 ml/hr

Therapy Options
Access Dialysate Return

CVVHD
Continuous Veno-Venous HemoDialysis
Maximum Patient Fluid Removal Rate = 1000 ml/hr
P R I S M A

Effluent

Therapy Options
Access Dialysate Return

CVVHDF
Continuous Veno-Venous HemoDiafiltration
Maximum Pt. fluid removal rate = 1000 ml/hr

P R I S M A

Replacement

Effluent

A Case
35 year old female is s/p OHT, POD#1. Remains intubated, MAP 65 on Levo 20, Pit 3, Milrinone 0.25 Urine output 10 ml.hour (Intake 150ml/h) PAD 20 FiO2 0.60- ABG 7.45/35/102 BMP 132/4.6/103/18/25/1.3 (Baseline 1.0)

Indications for Renal Replacement

Standard indications
Volume overload Hyperkalemia Metabolic Acidosis Uremic Platelet Dysfunction Uremic Encephalopathy

Modality Selection

Volume only

SCUF CVVH CVVHD CVVHDF CVVHDF

Solutes +/- Volume

Hypercatabolic +/- Volume

Prescription Variables
Dialysate Access

Blood Flow Up to 180 ml/min Replacement Up to 4500 ml/hr Dialysate up to 2500 ml/hr Patient Fluid Removal Up to 2000 ml/hr
P R I S M A

Return

Replacement

Effluent

Fluid Composition: Dialysate

Prismasate 5000mL Na+ = 140 mEq/L K+ = 0 mEq/L Cl- = 109.5 mEq/L Ca2+ = 3.5 mEq/L Mg2+ = 1 mEq/L Lactate = 3 mEq/L HCO3 = 32 mEq/L Glucose = 0 mg/dL

Premixed Dialysate 5000mL Na+ = 140 mEq/L K+ = 2.0 mEq/L Cl- = 117 mEq/L Ca2+ = 3.5 mEq/L Mg2+ = 1.5 mEq/L Lactate = 30 mEq/L Glucose = 100 mg/dL

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

Solutes: Azotemia
Azotemia
Increase replacement fluid and/or dialysate flow rate

Solutes: Sodium
Hyponatremia
Add 3% NaCl to dialysate @70 cc/5L bag

Hypernatremia
Increase peripheral IV D5W (1L) or 1/2 NS

Solutes: K
1 L bag Add 0 mEq / Liter Add 3 mEq / Liter Add 4 mEq / Liter None 7.5 mL 10 mL 5 L bag None 37.5 mL 50 mL Serum Potassium > 5.5 mEq / Liter > 4.5 5.5 mEq / Liter < 4.5 mEq / Liter

Hyperkalemia Zero K+, increase replacement and/or dialysate flow rate

Solutes: pH
Metabolic Acidosis
NaHCO3 (50%) 100 cc over 1 hour IVSS, prn Change replacement to D5W (1L) + 3 amps NaHCO3

Metabolic Alkalosis
Change replacement solution to NS + sliding scale KCl

Solutes: Calcium
Hypercalcemia
Change to HCO3 dialysate (Ca2+ free) Increase HCO3 dialysate or replacement flow rate

Hypocalcemia
CaCl2 (10%) 10 cc/100 cc NS or D5W over one hour, prn Premixed calcium drip

Solute: Mg and Phospate

Hypomagnesemia
MgSO4 (50%) 2 ml in 100 cc NS or D5W over one hour, prn Premixed magnesium drip

Hypermagnesemia
Same as Rx for hypercalcemia

Hypophosphatemia
Na Phosphate (3 mmol/ml) 5cc in 100cc NS IVSS over 2 hours, prn (repeat x 1 if PO4 <1.0 mg/dl)

Hyperphosphatemia
Same as Rx for hypercalcemia

Anticoagulation
Heparin
250 - 500 U/hr

HIT: Argatroban
0.5 - 1 mg/hr

Bleeding risk:
Citrate No anticoagulation

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

Citrate Regional Anticoagulation

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

CRRT in LVAD circuit

CRRT

LVAD

CRRT- Controversial Issues

HCO3- vs lactate solutions High vs standard delivered dose Convection vs diffusion Cost of CRRT vs HD. Does CRRT improve outcome (vs HD)? CRRT to prevent contrast nephropathy

Lactate vs HCO3 Replacement

N=117 Open-label trial randomized to Replacement Fluid: HCO3 Lactate

Kidney International 58 (4), 1751-1757

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

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

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

Diffusion vs. Convection

160 Clearance (ml/min) 120 80 40 0 10
Urea, 60 D Creatinine, 113 D Vit. B12, 1355 D Inulin, 5200 D Albumin, 55-60 kD

Diffusive transport Convective transport

102

103

104

105

106

Molecular Weight

Cost of acute renal failure requiring dialysis in the intensive care unit: clinical and resource implications of renal recovery. Design Retrospective 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 recovery The immediate and potential long-term costs

Manns: Crit Care Med, 31(2). 2003.449-455

Impact of dialytic modality on mortality (HD vs CRRT)

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

Impact of dialytic modality on renal recovery.

Efficacy and cardiovascular tolerability of extended dialysis in critically ill patients: A randomized controlled study

Genius single-pass dialysis machine

Kielstein JT..Am J Kidney Dis. 2004 Feb;43(2):342-9.

Clearances

Hemodynamic Parameters

MAP

HR

CO

SVR

The Prevention of Radiocontrast-AgentInduced Nephropathy by Hemofiltration

CVVH 1000 ml/h, 4-8 hours pre and 18-24 hours after angiogram.

N Engl J Med 2003; 349:1333-1340,

Outcome: Renal Function

Outcomes

OUTCOME
25% increase in Serum Creatinine Renal replacement: (Oliganuria
for >48 h despite 1 g IV furosemide)

CONTROLS
50%

CVVH
5%

25%

3%

Mortality In hospital One-year

14% 30%

2% 10%

Complications