continuous renal replacement therapy

1. Continuous
Renal
Replacement
Therapy
© Copyright L.Burchell, Gambro 2003 1

2. CRRT = CONTINUOUS RENAL REPLACEMENT THERAPY
Defined as
– “Any 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 24 hours /day.” *
* Bellomo R., Ronco C., Mehta R, Nomenclature for Continuous Renal
Replacement Therapies, AJKD, Vol 28, No. 5, Suppl 3, November 1996
© Copyright L.Burchell, Gambro 2003 2

3. © Copyright L.Burchell, Gambro 2003 3
Evolution of
CRRT
CAVHD
BSM - VPM
PRISMA
2nd Generation
extracorporeal
blood purification
system

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History of CRRT
1950’s - CRRT concept originated
1960’s - Scribner proposed CAVHD in context of ARF
1977 - Kramer introduces CAVH
1980 - Paganini introduces SCUF
1984 - Geronemus and Schneider propose CAVHD

5. History of CRRT, cont’d.
© Copyright L.Burchell, Gambro 2003 5
1987 - Uldall introduces CVVHD
1990’s - Transition to VV therapies from AV
therapies
1996 - R. Mehta, UCSD, hosts the first
international conference on CRRT in San Diego

6. REVIEW OF BASICS…
© Copyright L.Burchell, Gambro 2003 6

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11. “large”
© Copyright L.Burchell, Gambro 2003 11
Molecular Weights
• Albumin (55,000 - 60,000)
• Beta 2 Microglobulin (11,800)
• Inulin (5,200)
• Vitamin B12 (1,355)
• Aluminum/Desferoxamine Complex (700)
• Glucose (180)
• Uric Acid (168)
• Creatinine (113)
• Phosphate (80)
• Urea (60)
• Potassium (35)
• Phosphorus (31)
• Sodium (23)
100,000
50,000
10,000
5,000
1,000
500
100
50
10
5
0
molecular weight,
daltons
}
}
}
“small”
“middle”

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RIFLE Criteria

13. INDICATIONS FOR
CHOOSING
Continuous Renal
Replacement Therapy
© Copyright L.Burchell, Gambro 2003 13

14. Clinical Indications for CRRT
© Copyright L.Burchell, Gambro 2003 14
Renal Indications
• Azotemia
• Fluid Overload
• Tumor lysis Syndrome
• Sepsis
• Cerebral edema
Non-renal Indications
• Metabolic Disorders
• Fluid Overload
• CPB, IABP, ECMO
• Sepsis
• ARDS
• Crush injuries
• CHF

15. INDICATIONS FOR CHOOSING
Continuous Renal Replacement Therapy
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Cardiovascular instability
Ongoing acidosis
Large obligatory fluid intake
Increased catabolism
Increased intracranial pressure
Sepsis ?

16. Introduction to CRRT
• Continuous therapies closely mimic the
native kidney in treating ARF and fluid
overload
• Slow, gentle and well tolerated by
hypotensive patients
• Remove large amounts of fluid and
waste products over time
• Tolerated well by the hemodynamically
unstable patient.
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Why
continuous
therapies?

17. What are we trying to achieve?
© Copyright L.Burchell, Gambro 2003 17
Waste removal
Electrolyte balance
Fluid balance
Acid-Base balance
Removal of septic mediators

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Advantages
Hemodynamic stability
Management of fluid overload
Control of Urea and creatinine
Nutritional support
Membrane absorption and removal of humoral mediators
of sepsis

19. Principles of CRRT clearance
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.
© Copyright L.Burchell, Gambro 2003 19

20. Replacement Fluids
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 what you replace
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21. Continuous Renal Replacement Therapy
SCUF Slow Continuous Ultra-Filtration
CVVH Continuous Veno-Venous Hemofiltration
CVVHD Continuous Veno-Venous Hemodialysis
CVVHDF Continuous Veno-Venous Hemodiafiltration
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Renal Recovery?
CRRT does affect
resumption of
function.

23. By avoiding hypotensive
episodes, the risk of further
kidney damage is reduced
and the chance for renal
recovery is enhanced
© Copyright L.Burchell, Gambro 2003 23

24. Recovery from Dialysis Dependence: BEST Kidney Data
CRRT
IRRT
© Copyright L.Burchell, Gambro 2003 24
1
.8
.6
.4
.2
0
30610
0 20 40 60 80 100
days
Recovery from dialysis dependence
Manuscript under review
Leading the way…

25. CRRT vs. IHD in Renal Recovery
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
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Access Location
Internal Jugular Vein
• Primary site of choice due to lower associated risk of
complication and simplicity of catheter insertion.
Femoral Vein
• Patient immobilized, the femoral vein is optimal and
constitutes the easiest site for insertion.
Subclavin Vein
• The least preferred site given its higher risk of
pneumo/hemothorax and its association with central
venous stenosis

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Advanced therapy
• Therrapeutic
plasma
exchang
TPE HP • Hemoperfusion

28. THANK YOU
© Copyright L.Burchell, Gambro 2003 28