Continuous Renal Replacement Therapy

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
Maximum Patient Fluid Removal
Rate = 2000 ml/hr
P
R
I
S
M
A
Effluent
Therapy Options
Access
Return
CVVH
Continuous
Veno-Venous
HemoFiltration
P
R
I
S
M
A
Effluent
Maximum Patient Fluid Removal
Rate = 1000 ml/hr
Replacement
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
Effluent
Replacement
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
Solutes +/- Volume
CVVH
CVVHD
CVVHDF
Hypercatabolic
+/- Volume
CVVHDF
Prescription Variables
Dialysate
Access
„ Blood Flow
„
Up to 180 ml/min
Return
„ Replacement
„
Up to 4500 ml/hr
„ Dialysate
„
up to 2500 ml/hr
P
R
I
S
M
A
„ Patient Fluid Removal
„
Up to 2000 ml/hr
Effluent
Replacement
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
ƒ Na+ = 140 mEq/L
+
„ K = 2.0 mEq/L
„ Cl = 117 mEq/L
2+ = 3.5 mEq/L
„ Ca
2+ = 1.5 mEq/L
„ Mg
„ 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
5 L bag
Serum Potassium
Add 0 mEq / Liter
None
None
> 5.5 mEq / Liter
Add 3 mEq / Liter
7.5 mL
37.5 mL
Add 4 mEq / Liter
10 mL
50 mL
> 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
z
Hypercalcemia
Change to HCO3 dialysate (Ca2+ free)
„ Increase HCO3 dialysate or replacement flow
rate
„
z
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
Clearance (ml/min)
160
Diffusive transport
Convective transport
120
80
40
0
10
102
103
104
Molecular Weight
105
106
Urea, 60 D
Creatinine, 113 D
Vit. B12, 1355 D
Inulin, 5200 D
Albumin, 55-60 kD
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
CO
HR
SVR
The Prevention of Radiocontrast-Agent–Induced 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
CONTROLS
CVVH
25% increase in
Serum Creatinine
50%
5%
Renal replacement: (Oliganuria
25%
3%
14%
30%
2%
10%
for >48 h despite 1 g IV furosemide)
Mortality
In hospital
One-year
Complications