Continuous Renal Replacement Therapy

(CRRT)
Muhammad Asim Rana
MBBS, MRCP, SF-CCM, EDIC, FCCP
Critical Care Medicine
King Saud Medical City
Riyadh, Saudi Arabia
 Dedication
Todays presentation is dedicated to
Dr Mohammed Odat
Dr Waleed Tharwat Hasim
Being the PIONEERS in KSMC ICU to start
lectures on CRRT
 Case 1
35 yrs male pt, involved in RTA
Massive crush injury to legs
Severe Rhabdomyolysis, AKI Creat 250
Trauma to liver and spleen post laparotomy
Received 15 Blood transfusions in OR
Severe DIC, metabolic acidemia pH 7.0
TRALIARDS FiO2 100%, Sat O2 80%
Shocked on 2 inotropes moderate doses
Seen by ICU consultant decided.. CRRT
 Case 2
75 yrs female pt, DM, IHD, mild renal
impairment
Admitted with SOB with high BP
CXR showed B/L infiltration BAT Wing
ECHO EF 45%
Diagnosed as acute pulmonary edema
Lasix trial failed, pt intubated for worsening
dyspnea and hypoxia
 Case 3
45 yrs male pt, known drug addict
Admitted with decreased LOC
ABGs showed severe metabolic acidemia
Creatinin 180, BUN 10
Urine positive for oxalate
Papilloedema
Rx ..CRRT
 Case 4
56 yrs male pt, no past medical hx
Admitted with bilateral pneumonia
Ventilted developed MOF, Septic Shock
ABGs showed severe metabolic acidemia
Creatinin 300, BUN 29
Urine out put 10 ml/hr
Fluid Balance +13L
Rx ..CRRT
 Objectives
To understand the theory of CRRT
To appreciate the difference b/w IHD & CRRT
Understanding the modes of CRRT
To learn the indications and timing of CRRT
Dosage writing
 Introduction

Main functions of the kidney:

maintenance of fluid balance
maintenance of acid base balance
elimination of waste products
20 30 % of ICU patients develop AKI
Many ICU are already on IHD
 Options for Renal Replacement Therapy

Intermittent Hemo-Dialysis
Peritoneal Dialysis
Continuous Renal Replacement Therapy
 Intermittent Hemodialysis

The gold standard

Usually 2 3 times a week for 3 4 hours
Involves a vascular access
Pump, filter, dialysate & anticoagulation
 Advantages/Disadvantages

Very efficient
Hemodynamic instability in 30 % of patients
Causes rapid shifts in osmolarity
(Disequilibrium syndrome)
It is Intermittent
 Peritoneal Dialysis

Simple and cheap, but .

Poor solute clearance
Poor uremic control
Risk of peritoneal infection
Mechanical impedance
Pulmonary and cardiovascular function
 Continuous Renal Replacement Therapy

Concept- dialyze patients more physiologically

Avoids the accumulation of waste products

Avoids the rapid shifts in volume & osmolarity

Avoids disadvantages of Peritoneal Dialysis

 Advantages

Precise volume control

Very effective control of uremia and K
Rapid control of metabolic acidosis
Suitable for hemodynamically unstable pts
Improved nutritional support
(no need for volume restriction)
 Advantages

Needs minimal training

Safer for patients with TBI & CVS disorders
May have an effect in sepsis
Probable advantage in terms of renal recovery
 Disadvantages

Expensive
Anticoagulation
Hypothermia
Severe depletion of electrolytes K+ and PO4
Complications of line insertion and sepsis
Risk of line disconnection
 Principal

2 processes in waste product removal in RRT

1. DiffusionDialysis

2. Convection.Hemofiltration
Diffusion/Dialysis
Semipermiable Membrane
Semipermiable Membrane
(Dalton) Molecular Weights
100000 Albumin (55000 60000)
50000

Beta 2 Microglobulin (11800)

10000
5000
Inulin (5200)

1000 Vit B12 (1355)

500
Aluminium/Desforoxamine complex (700)
Glucose (180)
100 Uric Acid (168)
Creatinine (113)
50 Phosphate (80)

Urea (60)
Potassium (35)
Phosphorus (31)
Sodium (23)
Diffusion
 Ultrafiltration

The passage of water through a membrane

under a pressure gradient.
Driving pressure can be
+ve (push fluid through the filter)
ve (pull fluid to other side of filter)
Pressure gradient is created by effluent pump
Ultrafiltration
 Convection
Movement of solutes through a membrane by
the force of water.
solvent drag
The water pulls the molecules along with it as
it flows through the membrane.
Can remove middle and large molecules, as
well as large fluid volumes.
Maximized by using replacement fluids.
Convection
Convection
Convection
 Adsorption
Adsorption is the removal of solutes from the
blood because they cling to the membrane.
Think of an air filter. As the air passes through it,
impurities cling to the filter itself.
Eventually the impurities will clog the filter and it
will need to be changed.
The same is true in blood purification. High
levels of adsorption can cause filters to clog
and become ineffective
Adsorption
 Dialysate

Dialysate is any fluid used on the opposite side of the filter from
the blood during blood purification.
 Replacement Fluids
Used to increase the amount of convective
solute removal in CRRT.
Replacement fluids do not replace anything.
Fluid removal rates are calculated
independently of replacement fluid rates.
The common replacement fluid is 0.9% saline
Can be pre or post filter.
Replacement Fluids
 Comparison Pre & Post Dilution
PRE-FILTER POST-FILTER
No solute dilution,
Increases filter life improved diffusion and
Increases convective solute clearance
transport
Reduced solute clearance
Increased
Some of delivered hemoconcentration
replacement fluid lost by Higher delivered dose
hemofiltration of hemofiltration
Lower anticoagulation
requirements
Higher UF required given
loss of replacement fluid
through filter
 Indications
Acidemia (pH <7.1)
Electrolytes
Hyperkalemia (K > 6.5 mEq/L)
Severe dysnatremia (Na <115 or >160 mEq/L)
Ingestions (Toxins, Drugs)
Overload/ Oliguria (urine output <200 mL/12 h)
Uremia (urea >30 mg/dL)
Uremic encephalopathy
Uremic pericarditis
Uremic neuro-myopathy
AEIOU
 Dialysable or Not
Dialysable Non-Dialysable
Barbiturates Digoxin
Tricyclic
Lithium
Antidepressents
Alcohols, Amglcoside Phenytoin
Salicylates Benzodiazepines
Theophyllin B-blockers
Penicillins, (atenolol is removed)
Carbapenems, Cephalo Metformin

PC-B L A S T
 Timing
Inadequate data available to answer this Q

Observational data suggests better outcomes

are associated with early RRT initiation

Getting et al 19992. Urea 15.2 vs 33.7 conferred survival benefit.

Ronco et al 20003 and Saudan et al 20064 both dose/outcome studies suggested an early start.

Liu et al 20065 observational PICARD study (Urea 27) suggested an early start
RENAL study, NEJM 2009, 1508 pts.
Demirkilic 2004, Elahi 2004, Piccini 2006
Early Initiation means
 CRRT Modalities

CRRT includes several treatment modalities

that use a veno-venous access.
The choice will depend on the needs of the
patient and on the preference of the
physician.
Slow Continuous Ultrafiltration (SCUF)
Removal of ultrafiltrate at low rates
without administration of a substitution solution.

The purpose is to prevent or treat volume overload

when waste product removal or pH correction isnt
necessary.
Primary indication for SCUF - fluid overload
Mechanism of water transport is Ultrafiltration.
No dialysate or replacement fluid is used.
 Other solutes are removed but are negligible
The amount of fluid in the effluent bag is the
same as the amount removed from the pt.
Removal rates are closer to 100 ml/hour.
Understanding Flow
 Lets Revise
Primary therapeutic goal:
Safe management of fluid

Primary indications:
Fluid overload without metabolic imbalance

Principle used:
Ultrafiltration
Therapy characteristics:
No dialysate or substitution solutions
Fluid removal only
 SCUF Dosage Writing

Blood flow:
80 200 ml/min
Duration:
(as advised by the physician)
Ultrafiltration:
20-100 ml/hr (or total volume)
Anticoagulation. Acc to physician
Dialysate .. NO
Replacement fluid.. NO
 Effects of different doses in CVVH on outcome of ARF
Ronco & Bellomo study. Lancet . july 00

Prospective study on 425 patients - 3 groups:

Study:
survival after 15 days of HF stop
recovery of renal function
Effects of different doses in CVVH on outcome of ARF - Ronco
& Bellomo study. Lancet . july 00

100
p < 0.001
90

80

70 p < 0.001 p n..s.

Survival (%)

60

50

40

30

20 41 % 57 % 58 %
10

Group 1(n=146) Group 2 (n=139) Group 3 (n=140)

(Uf = 20 ml/h/Kg) (Uf = 35 ml/h/Kg) (Uf = 45 ml/h/Kg)

306100135
 Continuous Veno-venous Hemofiltration
(CVVH)

An extremely effective method of solute removal and

is indicated for uremia or severe pH or electrolyte
imbalance with or without fluid overload.
Particularly good at removal of large molecules,
because CVVH removes solutes via convection.
Convective removal of waste products (small and
large molecules) utilizing a substitution solution.
pH is affected with the buffer contained in the
substitution solution.
 Solutes can be removed in large quantities
while easily maintaining a net zero or even a
positive fluid balance in the patient.

The amount of fluid in the effluent bag is

equal to the amount of fluid removed from
the patient plus the volume of replacement
fluids administered.

No dialysate is used.
Understanding Flow
 Lets Revise
Primary therapeutic goal:
Solute removal and safe fluid management
Primary indications:
Uremia, severe acid/base or electrolyte imbalance
Removal of larger mol wt substances
Principle used:
convection
Therapy characteristics:
Substitution solution to drive
No dialysate solution

Effective at removing small and large molecules

 CVVH Dosage
Blood flow:
80 200 ml/min
Dosage:
Duration: 30ml/kg/hr
As advised by physician 70x30=2100ml
Replacement fluid
Ultrafiltration:
So
20-100 ml/hr (or total volume) This Replacement can be
Replacement Fluid: divided into pre & post filter
Depending upon physician
1000 2000 ml/hr,pre or post filter Ex, 500 pre and 1500ml post
Anticoagulation (All can be pre or post)
Dialysate. NO
 Continuous Veno-venous Hemodialysis (CVVHD)

Effective for removal of small to medium sized molecules.

Solute removal occurs primarily due to diffusion.
No replacement fluid is used.
Dialysate is run on the opposite side of the filter.
Fluid in the effluent bag is equal to the amount of fluid
removed from the patient plus the dialysate.
Continuous diffusive removal of waste products (small
molecules) utilizing a dialysis solution.
pH is also affected with the buffer contained in the
dialysate.
Understanding flow
 CVVHD Dosage
Blood flow:
80 200 ml/min
Duration:
Dosage:
As advised by physician 45ml/kg/hr
Ultrafiltration: 70x45=3150ml
Dialysatefluid
20 -100 ml/hr (or total volume) So
Anticoagulation: Dialysate can be 3 liters /hr
Dialysate:
600 1800 ml/hr (up to 3 lit/hr).
Replacement fluid.NO
 Lets Revise
Primary therapeutic goal:
Solute removal and safe management of fluid volume
Primary indications:
Uremia, severe acid/base or electrolyte imbalance
Principle used:
Diffusion
Therapy characteristics:
Requires dialysate solution to drive diffusion
No substitution solution
Effective at removing small to medium molecules
Continuous Veno-venous Hemodiafiltration
(CVVHDF)

The most flexible of all the therapies, and

combines the benefits of diffusion and
convection for solute removal.
The use of replacement fluid allows adequate
solute removal even with zero or positive net
fluid balance for the patient.
 Amount of fluid in the effluent bag equals the fluid
removed from the patient plus the dialysate and the
replacement fluid.

Dialysate on the opposite side of the filter and

replacement fluid either before or after the filter.
Continuous diffusive and convective removal of
waste products (small and large molecules)
Utilizing both dialysate and substitution solution.
pH is also affected with the buffer contained in the
dialysate and substitution solution.
Understanding Flow
 Lets Revise
Primary therapeutic goal:
Solute removal and safe management of fluid volume
Primary indications:
Uremia, severe acid/base or electrolyte imbalance
Removal of large molecular weight substances is required
Unstable haemodunamics
Principle used:
diffusion and convection
Therapy characteristics:
Requires dialysate fluid and substitution solution to drive
diffusion and convection
Effective at removing small, medium and large
molecules
 CVVHDF Dosage
Blood flow:
80 200 ml/min Dosage:
45ml/kg/hr
Duration: 70x45=3150ml
As advised by the physician as Dialysate& as
Replacement fluid
Ultrafiltration:
So
20-100 ml/hr (or total volume) 1500ml as Dialysate
Anticoagulation: 1500ml as Replacement can
be divided into pre & post
Dialysate: filter
600 1800 ml/hr (up to 3 lit/hr) Depending upon physician
Ex, 500 pre and 1000ml post
Replacement fluid:
1000-2000 ml/hr, pre or post filter (up to 3 lit/hr)
 Thank you
I think thats enough