Continuous Renal Replacement Therapy. Jai Radhakrishnan, MD, MS

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1 Continuous Renal Replacement Therapy Jai Radhakrishnan, MD, MS

2 History of the CRRT program 1988 Open heart program Active transplant program Deep dissatisfaction with peritoneal dialysis in hemodynamically unstable patients

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

7 Basic Concepts Pressure Convection (Plasma water moves along pressure gradients)

9 Continuous Renal Replacement Therapy SCUF CVVH CVVHD CVVHDF

10 Therapy Options Access Return SCUF: Slow Continuous Ultra Filtration P R I S M A Maximum Patient Fluid Removal Rate = 2000 ml/hr Effluent

11 Therapy Options Access CVVH Continuous Veno-Venous HemoFiltration P R I S M A Return Replacement Maximum Patient Fluid Removal Rate = 1000 ml/hr Effluent

12 Therapy Options Access Dialysate Return CVVHD Continuous Veno-Venous HemoDialysis P R I S M A Maximum Patient Fluid Removal Rate = 1000 ml/hr Effluent

13 Therapy Options Access Dialysate Return CVVHDF Continuous Veno-Venous HemoDiafiltration P R I S M A Replacement Maximum Pt. fluid removal rate = 1000 ml/hr Effluent

14 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 FiO ABG 7.45/35/102 BMP 132/4.6/103/18/25/1.3 (Baseline 1.0)

15 Indications for Renal Replacement Standard indications Volume overload Hyperkalemia Metabolic Acidosis Uremic Platelet Dysfunction Uremic Encephalopathy

16 Modality Selection Volume only SCUF Solutes +/- Volume CVVH CVVHD CVVHDF Hypercatabolic +/- Volume CVVHDF

17 Prescription Variables Dialysate Blood Flow Up to 180 ml/min Access Return 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 Replacement Effluent

ml/hr Dialysate up to 2500 ml/hr Patient Fluid

18 Fluid Composition: Dialysate Prismasate 5000mL Na + = 140 meq/l K + = 0 meq/l Cl - = meq/l Ca 2+ = 3.5 meq/l Mg 2+ = 1 meq/l Lactate = 3 meq/l HCO 3 = 32 meq/l Glucose = 0 mg/dl Premixed Dialysate 5000mL Na + = 140 meq/l K + = 2.0 meq/l Cl - = 117 meq/l Ca 2+ = 3.5 meq/l Mg 2+ = 1.5 meq/l Lactate = 30 meq/l Glucose = 100 mg/dl

19 Peripheral Electrolyte Replacement In the event of high volume Bicarbonate solutions, if Ca free: Peripheral CaCl 2 /MgSO 4 In the event of high clearance: prn Na phosphate

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

21 Solutes: Sodium Hyponatremia Add 3% NaCl to cc/5l bag Hypernatremia Increase peripheral IV D 5 W (1L) or 1/2 NS

22 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 > meq / Liter Add 4 meq / Liter 10 ml 50 ml < 4.5 meq / Liter Hyperkalemia Zero K +, increase replacement and/or dialysate flow rate

23 Solutes: ph Metabolic Acidosis NaHCO 3 (50%) 100 cc over 1 hour IVSS, prn Change replacement to D 5 W (1L) + 3 amps NaHCO 3 Metabolic Alkalosis Change replacement solution to NS + sliding scale KCl

24 Solutes: Calcium Hypercalcemia Change to HCO 3 dialysate (Ca 2+ free) Increase HCO 3 dialysate or replacement flow rate Hypocalcemia CaCl 2 (10%) 10 cc/100 cc NS or D 5 W over one hour, prn Premixed calcium drip

25 Solute: Mg and Phospate Hypomagnesemia MgSO 4 (50%) 2 ml in 100 cc NS or D 5 W 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 PO 4 <1.0 mg/dl) Hyperphosphatemia Same as Rx for hypercalcemia

26 Anticoagulation Heparin U/hr HIT: Argatroban mg/hr Bleeding risk: Citrate No anticoagulation

27 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 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

28 Citrate Regional Anticoagulation Cointault O.. Nephrol Dial Transplant Jan;19(1):171-8.

29 CRRT in LVAD circuit CRRT LVAD

30 CRRT- Controversial Issues HCO - 3 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

31 Lactate vs HCO 3 Replacement N=117 Open-label trial randomized to Replacement Fluid: HCO 3 Lactate Kidney International 58 (4),

32 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 Jul 1;356(9223):26-30

33 Intensity of Renal Support in Critically Ill Patients with Acute Kidney Injury N Engl J Med Jul 3;359(1):7-20

34 Diffusion vs. Convection Clearance (ml/min) Diffusive transport Convective transport Urea, 60 D Creatinine, 113 D Molecular Weight Vit. B 12, 1355 D Inulin, 5200 D Albumin, kd

35 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, 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)

37 Impact of dialytic modality on mortality (HD vs CRRT) Am J Kidney Dis Nov;40(5):875-85

38 Impact of dialytic modality on renal recovery.

39 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 Feb;43(2):342-9.

40 Clearances

41 Hemodynamic Parameters MAP HR CO SVR

42 The Prevention of Radiocontrast-Agent Induced Nephropathy by Hemofiltration CVVH 1000 ml/h, 4-8 hours pre and hours after angiogram. N Engl J Med 2003; 349: ,

43 Outcome: Renal Function

44 Outcomes OUTCOME CONTROLS CVVH 25% increase in Serum Creatinine Renal replacement: (Oliganuria for >48 h despite 1 g IV furosemide) 50% 5% 25% 3% Mortality In hospital One-year 14% 30% 2% 10%

45 Complications

Advantages and disadvantages of CRRT in ARF patients. Norbert Lameire Renal Division University Hospital Ghent, Belgium

Advantages and disadvantages of CRRT in ARF patients Norbert Lameire Renal Division University Hospital Ghent, Belgium Alexandria, 17/2/2005 Indications for RRT in critically ill ARF patients Renal Replacement