Extracorporeal Blood Purification

1. Why CEBP?

2. Who & When to start?

3. How to do it
4. The fluid to use
5. Care & Management
6. Case studies
7. Setting up the service

Ian Tan
MRCP(UK), FHKCA, HKCA(IntCare), FANZCA, FFICANZCA, FJFIntCareMed

Director of Critical Care

Mount Elizabeth Hospital, Singapore
 Who to start (indications)
Non-renal indications
ESRD
Acute kidney injury (includes acute on chronic)
When to start: non-renal indications
Removal of Toxins
– Toxicology: exogenous toxins, drugs
– Liver failure
– Systemic inflammation/MODS, sepsis, pancreatitis
– Tumour lysis syndrome
– Autoantibodies, cryoglobulins, myeloma light chains, etc
Removal of Fluid
– Heart failure, diuretic resistant
– Fluid management: massive transfusion, bypass
Removal of Heat
 When to start: ESRD
Start when
– 1. Uremia: symptoms, or urea>35 mM, or Kcr<20 ml/min/1.73m2
– 2. severe hyperkalemia, uncontrolled with medical Rx
– 3. Severe acidosis, uncontrolled with alkali
– 4. Fluid overload, refractory to diuretics
Important! Remember this number
– ‘standard adult’: Kcr 20 ml/min ~ 1200 ml/h
– it means
patients get into trouble (K, pH, fluid, urea) below Kcr 20
Dialysis dose should be more than Kcr 20
 When to start: AKI
Start when
– 1. Uremia: symptoms, or urea>35 mM, or Kcr<20 ml/min/1.73m2
– 2. severe hyperkalemia, uncontrolled with medical Rx
– 3. Severe acidosis, uncontrolled with alkali
– 4. Fluid overload, refractory to diuretics
Important! Remember this number
– ‘standard adult’: Kcr 20 ml/min ~ 1200 ml/h
– it means
patients get into trouble (K, pH, fluid, urea) below Kcr 20
Dialysis dose should be more than Kcr 20
 When to start: AKI
trial urea mM %mort comment
Parsons. Lancet 1961 71 vs 48 88 vs 25 n= 33, retro
Fischer. Surg Gyn Obs1966 71 vs 54 74 vs 57 n=235, retro
Kleinknecht. Kidney Int 1972 58 vs 33 42 vs 29 n=500, retro
Gettings. Int Care Med 1999 34 vs 15 80 vs 61 n=100, retro

Earlier groups dialysed later

Urea is a surrogate for timing
 Single centre, retrospective study
100 trauma patients: ARF treated with CRRT
Early starters: BUN < 60 mg/dl
Late starters: BUN > 60 mg/dl
100
90
80
BUN (mg/dL)

70
60
50
40 late starters
30 early starters
20
10
0
Days of CRRT
0 2 4 6 8 10 12 14 16 18 20 22 24

Gettings, et al. Outcome in post-traumatic acute renal failure when continuous

renal replacement is applied early vs. late. Intensive Care Med 1999;25:805
 All Early Start Late Start P val

Hospital LOS (days) 50.3 (43.4) 46.2 (37.0) 53.0 (47.4) 0.46
Duration of CRRT (days) 19.2 (16.5) 17.7 (15.1) 20.2 (17.5) 0.45
Number of CRRT days 18.8 (16.3) 17.6 (15.2) 19.6 (17.1) 0.55
Survival (%) 28.0 39 20.3 0.04
Recovery of renal function (%) 96.4 100 91.6 0.25

Gettings, et al. Outcome in post-traumatic acute renal failure when continuous renal
replacement is applied early vs. late. Intensive Care Med 1999;25:805
RCT n=425, AP2 23, lactate, PS, urea 18, Cox

45 ml/h/kg
35 ml/h/kg
25 ml/h/kg
 BUN at start of CVVH: hazard ratio 1.05
Survivors Non Survivors
80
p < 0.01 p < 0.01 p < 0.01
70
Blood Urea Nitrogen (mg/dl)

60
50

40
30
20
10

0
Group 1 Group 2 Group 3
Ronco C, et al. Effects of different doses in continuous veno-venous haemofiltration on
outcomes of acute renal failure: a prospective randomised trial. Lancet 2000;355:26-30
using urea as surrogate for timing

Early RRT improves survival

Can we improve survival further?
 We found
RRT d from ICU adm <2d 2-5d >5d
Patients (total 1250) 795 176 268
Traditional criteria
– pH 7.29 7.32 7.33
– K 4.8 4.6 4.6
– Urea 21 26 34
– Fluid overload % 37 39 41
Survival % 41 38 27
RRT duration 5 6 7
Hosp LOS 20 26 38
Bagshaw SM, et al. Timing of RRT and clinical outcomes in critically
ill patients with severe AKI. J Crit Care. 2009;24:129-40
Seabra VF, et al. Timing of renal replacement therapy initiation in
acute renal failure: a meta-analysis. Am J Kidney Dis. 2008;52:272-84.

“This hypothesis-generating meta-analysis suggests that early initiation of RRT in

patients with ARF might be associated with improved survival …”
Timely diagnosis of
ARF: oliguria
Presumed non-
prerenal, non-
postrenal
Oliguria refers to low
urine FLOW
– pay attention to time as
well as the volume
Does it take 12h to
resuscitate a patient?
Oliguria is NOT an indication for
diuretics

Diuretics may increase mortality

Patients given diuretics had lower BUN, Creatinine, but
higher mortality and non-recovery of renal function
statistical method odds ratio
– Confirmatory propensity adjusted mortality model 1.21
– New propensity adjusted mortality model 1.22
– Multicollinearity adjusted logistic regression analysis 1.22
Diuretic use is not associated with mortality, but
…
magnitude and direction of the odds ratio
between diuretic use and outcome was towards
worse outcome
223 patients treated with CRRT: RIFLE status significant predictor of survival

R, I

F, L, E
 Retrospective
N = 40 + 40
EIHF: 45 ml/h/kg x6h
then 20 ml/h/kg
Within 12h of ICU admission

EIHF control
MV wean 70% 37%
MV duration/d 11 20
Pressor off 75% 25%
Hosp LOS 19 34
Control: 20 ml/h/kg
renal failure criteria
 LATE EARLY
BUN>84 Urine<100ml/8h N = 64
Cr>2.8 observational
K>6

Because did not

Wait for BUN rise

Also lower:
LOS ICU & hospital
MOF incidence

Elahi MM, et al. Early hemofiltration improves survival in post-cardiotomy patients

with acute renal failure. Eur J Cardiothorac Surg. 2004 Nov;26(5):1027-31
Oliguria is not the only criteria

Your experience counts

You know they will die if you wait…
Severe sepsis, severe catabolism?
fluid overload causing hypoxia?
tumor lysis?
severe acidosis, rapid K rise?