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 P
R
I
S

Continuous M
A

Ultra Filtration

Maximum Patient Fluid Removal Effluent

Rate = 2000 ml/hr
Therapy Options

Access

Return

CVVH
Continuous P
R

Veno-Venous I
S
M
A
Replacement

HemoFiltration

Effluent
Maximum Patient Fluid Removal
Rate = 1000 ml/hr
Therapy Options

Access

Dialysate
Return

CVVHD
P

Continuous R
I
S
M

Veno-Venous A

HemoDialysis

Maximum Patient Fluid Removal

Effluent
Rate = 1000 ml/hr
Therapy Options
Access
Dialysate
Return

CVVHDF P
R

Continuous I
S
M Replacement
A

Veno-Venous
HemoDiafiltration

Maximum Pt. fluid Effluent

removal rate = 1000 ml/hr
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

CVVH
Solutes +/- Volume CVVHD
CVVHDF

Hypercatabolic
CVVHDF
+/- Volume
Prescription Variables
Dialysate

Access
„ Blood Flow
„ Up to 180 ml/min Return

„ Replacement
„ Up to 4500 ml/hr
P
R
„ Dialysate I
S
„ up to 2500 ml/hr M
A
Replacement

„ Patient Fluid Removal

„ Up to 2000 ml/hr

Effluent
Fluid Composition: Dialysate

Prismasate® 5000mL Premixed Dialysate®

„ Na+ = 140 mEq/L 5000mL
„ K+ = 0 mEq/L ƒ Na+ = 140 mEq/L
„ K = 2.0 mEq/L
„ Cl- = 109.5 mEq/L +

„ Cl = 117 mEq/L
„ Ca2+ = 3.5 mEq/L -

„ Ca
„ Mg2+ = 1 mEq/L 2+ = 3.5 mEq/L

„ Mg
„ Lactate = 3 mEq/L 2+ = 1.5 mEq/L

„ HCO3 = 32 mEq/L „ Lactate = 30 mEq/L

„ Glucose = 0 mg/dL „ 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 > 4.5 – 5.5 mEq /

Liter
Add 4 mEq / Liter 10 mL 50 mL < 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

160
Diffusive transport
Clearance (ml/min)

120 Convective transport

80

40

0 Urea, 60 D
10 102 103 104 105 106
Creatinine, 113 D
Molecular Weight 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 HR

CO 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 50% 5%

Serum Creatinine

Renal replacement: (Oliganuria 25% 3%

for >48 h despite 1 g IV furosemide)

Mortality
In hospital 14% 2%
One-year 30% 10%
Complications