PRISMAFLEX

Continuous Renal Replacement Therapy

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Basic Theory of the Kidney

Functions of the Kidney

SECRETORY EXCRETORY

• Renin : regulate blood • Remove excess fluid

pressure
• Remove waste products
• EPO : regulate red blood
cell production • Regulate acid/base balance

• Vitamin D : regulate calcium • Regulate electrolyte levels

uptake

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AKI Definition

The Acute Kidney Injury Network (AKIN) defined AKI as :

A sudden (within 48 h) reduction in kidney function when there

is an absolute increase in serum creatinine or a reduction in
urine output.

Facts on AKI:

•AKI is a common complication of critical illness and

is associated with a high mortality rate

•Many patients with AKI will require Renal

Replacement Therapy.

Ricci & Ronco. Kidney Diseases beyond Nephrology: intensive Care. Nephrol Dial Transplant (2008) 23: 820–826

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 Criteria for CRRT Initiation

RENAL Trial

* Bellomo R et al. Intensity of Continuous Renal-Replacement Therapy in Critically Ill Patients. N Engl J Me 2009;361:1627-38.

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Classification on RRT

Renal
Replacement
Therapy

Intermittent Continuous

Slow Low Continuous Renal

Intermittent Peritoneal
Efficiency Replacement
hemodialysis Dialysis
Dialysis Therapy

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Continuous Renal Replacement Therapy

“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.”

R. Bellomo, C Ronco and R. Mehta, Nomenclature for Continuous Renal Replacement Therapies, AJKD, Vol 28, November 1996

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Role of CRRT

Fluid
Balance Waste
Acid Base Removal
Balance

What are we
trying to achieve?

Removal of
Electrolyte
Septic
Balance
Mediators

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Indications for CRRT

KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney International Supplements
C.Ronco. Slide presentation on “Renal replacement therapy in AKI: When and how much?”.

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Why CRRT For Critically Ill Patients?

CRRT closely mimics native kidney

• Slow and gentle nature prevent further damage to kidney

• Tolerated well by hemodynamically unstable patient.

• Remove large amounts of fluid & waste products over time allowing other
supportive measure

• Regulates fluid, electrolyte, acid base balance more consistently

Bellomo, Ronco. Continous hemofiltration in the intensive care unit. Crit Care, 2000; 4(6)

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Transport Mechanism

BODY HEMOFILTER/ DIALYZER

• Diffusion • Diffusion

• Ultra filtration •Ultra filtration

• Convection • Convection

• Osmosis • Adsorption

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Transport Mechanism

Ultrafiltration

• Movement of fluid through a semi-permeable membrane driven by a pressure

gradient.

Positive Negative
Pressure Pressure

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Transport Mechanism

Diffusion
• Solutes move from an area of higher concentration to lower
concentration.

• Small molecules will diffuse across the semi permeable membrane to

the fluid side of the filter (lower concentration area).

• Dialysate is used to create a lower concentration gradient across a semi

permeable membrane.

• Diffusion will continue happen until both side of concentration gradient reach
equilibrium

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Transport Mechanism

Convection

• Movement of the solute across a membrane caused by a passage

of fluid or solvent known as “ solvent drag”
• Removal of solutes, especially middle and large molecules, by
convection or relatively large volumes of fluid and simultaneously

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Transport Mechanism

Adsorption

• Molecular adhere to the surface of the semi permeable membrane.

• AN 69 filters used in CRRT have strong adsorptive properties.

• This mechanism is available in:

SCUF

CVVH

CVVHD

CVVHDF

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 Molecular Weight

“Large”

Convection
Septic Mediators “Middle”
Interleukins
TNF

Diffusion
“Small”

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Therapies in CRRT

CRRT Modalities
• SCUF - Ultrafiltration

• CVVH - Ultrafiltration + Convection

• CVVHD - Ultrafiltration + Diffusion

• CVVHDF - Ultrafiltration + Diffusion + Convection

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CRRT Modalities

SCUF – Slow Continuous Ultrafiltration

• Require the use of blood and effluent pump.

• NO dialysate or replacement solution needed.

• Fluid removal up to 2L/hr can be achieved.

• Safe management of fluid removal

GOAL • Fluid removal by ultrafiltration

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Prismaflex Flowpath -SCUF

prismafleX SCUF

Return pressure Air detector

Syringe pump Blood pump Return Clamp

Patient
Hemofilter

Filter pressure Access pressure

BLD

Effluent Anticoagulant

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CRRT Modalities

CVVH – Continuous Veno Venous Hemofiltration

• Require the use of blood, effluent and replacement pump.

• Require a Replacement solution

Plasma and solutes are removed by

GOAL convection and ultra filtration

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Prismaflex Flowpath - CVVH

prismafleX CVVH

Return pressure Air detector

Syringe pump Blood pump Return Clamp

Patient
Hemofilter

Filter pressure Access pressure

Post Post or Pre

BLD

Replacement Effluent Replacement Infusion or Anticoagulant

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CRRT Modalities

CVVHD– Continuous Veno Venous Hemodialysis

• Require the use of blood, effluent and dialysate pump.

• Require a Dialysate solution

Plasma water & solutes are removed

GOAL by diffusion and ultrafiltration

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Prismaflex Flowpath - CVVHD

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CRRT Modalities

CVVHDF– Continuous Veno Venous HemodiaFiltration

• Require the use of blood, effluent, dialysate & replacement pump.

• Both dialysate and replacement solution are used.

Plasma water and solutes are remove by

GOAL diffusion, convection and ultrafiltration.

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Prismaflex Flowpath - CVVHDF

prismafleX CVVHDF

Return pressure Air detector

Syringe pump Blood pump Return Clamp

Patient
Hemofilter

Access pressure
Filter pressure

Dialysate Post or Pre

BLD

Dialysate Effluent Replacement Infusion or Anticoagulant

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CRRT - Summary

SCUF CVVH CVVHD CVVHDF

Blood Pump yes yes yes yes

Effluent (UF) Pump yes yes yes yes

Dialysate no no yes yes

Replacement
no yes no yes
Solution

Ultrafiltration
Principal Transport Ultrafiltration Ultrafiltration
Ultrafiltration Convection
Mechanism Convection Diffusion
Diffusion

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 Components of CRRT

Vascular Access

Jugular Subclavian
• Long term access • Easy to insert
• Patient comfort • Risk of stenosis & kinking

Femoral
• Easy to insert
• Good blood flow condition
• Risk of stenosis & infectious

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Vascular Access

Catheter
Catheter Catheter
Blood Flow
Colour Pressure

- ve Blood extract out

Red Pressure from patient

+ ve Blood return to
Blue Pressure patient

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Components of CRRT

Hemofilter

• Blood filtering device used mainly to replace the excretory functions of the
kidney.
• Also known as an “artificial kidney” or dialyzer.
• Hemofilter is composed of multiple hollow fibers.
• Blood & fluid will flows in separate channel, as blood enters the hollow fiber,
fluid flows outside of the hollow fiber.
• Each fiber wall is a semi permeable membrane.
• Hemofilter are validated for 72hrs only.
• Hemofilter are sterilize by ETO.

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 Hemofilter – Structure and Membrane

Blood Out

Dialysate IN

Effluent OUT

Blood In

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Components of CRRT – M series

M100 - Prismaflex

PRISMAFLEX M100

Characteristics:
• Membrane : AN 69
• Priming volume : 152 ml
• QB Range : 50 - 400 ml/ min
• Application : ≥ 30 kg
• Validated to use for : 72 hours

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Solutions

Bicarbonate
Purpose:
• Transport mechanism for the removal of waste product from blood
• Provide buffers for on going acid production

Why is Bicarbonate solution preferred over lactate solution?

• More physiological and better tolerated
• Do not need for metabolic activity to convert into Bicarbonate

Peritoneal dialysis
Bicarbonate Base
solution – Lactate
solution

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 Electrolyte solution: 250ml
Contains/1000 ml:

Bicarbonate Solution •CaCl2, 2H2O 5,145g

• Two-compartment bag •MgCl2, 6H2O 2.033g

– Latex free •Glucose 22.00g

– Separated by a frangible pin •Lactic acid 5.400g
– Prevents carbonate formation
/ precipitation Buffer solution: 4750ml

– Promotes stability of solution • NaCl 6.45g

• KCl 0.157g
• Over-wrap
– Prevents CO2 evaporation • Sodium hydrogen
carbonate 3.090g
– Stable pH during storage

• Shelf Life Mixed solution: 5000ml

– Unopened – 18 months •Osmolarity 297 mOsm/l
– Mixed – use immediately within 24
hours •pH 7.0 – 8.5

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Components of CRRT

Anticoagulant

Purpose:
To reduce the risk of clot formation in the blood line and the hemofilter.

Types of Anticoagulation

Systemic Regional
Anticoagulation affects both
Anticoagulation affects only
extracorperal circuit and
extracorporeal circuit
patient

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Anticoagulant

LOW MOLECULE WT HEPARIN (LMW)

• Eg: enoxaparin, dalteparin
• Decreased risk of bleeding
• Prolonged half life
• Specialized monitoring

HEPARIN
• Inexpensive
• Standard technique
• Easy reversible with protamine
• Risk of thrombocytopenia

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Anticoagulant

Regional Anticoagulant

Citrate Solution
Benefit:
 Safe to use in patient with bleeding
tendency

Disadvantage:
 Contraindicated for liver failure patient
 Labour intensive

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 Summary / Discussion

• AKI definition.
• Staging of AKI.
• Definition of CRRT.
• Role of CRRT.
• Indication of CRRT.
• Transport mechanism;
− Ultrafiltration, diffusion and convection.
• CRRT modalities;
– SCUF, CVVH, CVVHD & CVVHDF
• Hemofilter;
– M100 & membrane
• Solution – Prismasol
• Anticoagulant;
– Systemic & Regional

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 Thank You

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