MODALITIES OF RENAL REPLACEMENT

THERAPY (RRT) IN CRITICALLY ILL;

CONVECTION VERSUS DIFFUSION

Yohanes George
 ACUTE RENAL FAILURE IN CRITICAL ILL
PATIENTS

A)  Mortality rate of acute renal failure

A)  Mortality rate over 80% before intermittent
hemodialysis (HD)
B)  Drop of mortality to 50% after HD
C)  Mortality rate over 70% since 1980
B)  Reasons for high mortality rate of ARF
A)  Progressive in intensive care: antibiotics,
hemodynamic monitor, cardiovascular & respiratory
support
B)  Old age
C)  Multiple organ failure
MODALITIES OF RENAL REPLACEMENT THERAPY FOR
ACUTE RENAL FAILURE IN INTENSIVE CARE UNITS

1.  Intermittent Therapies:

Intermittent Hemodialysis (IHD), Extended Daily Dialysis (EDD), Slow
Low-efficiency Dialysis (SLED)

2.  Peritoneal Dialysis (PD)

3.  Continuous Renal Replacement Therapy (CRRT):
SCUF, CAVH, CAVHD, CAVHDF, CVVH, CVVHD, CVVHDF
 HAEMODIALYSIS

´ Fast efficient ideal for maintenance therapy in

established CRF
´ Prone to cause Haemodynamic Instability
´ May cause Cerebral Oedema due to Fluid Shifts
(DDS = Dialysis Disequilibrium Syndrome)
´ Need for Anticoagulation
HAEMODIALYSIS •  The movement of solutes from a
compartment in which they are in
high concentration to one in which
they are in lower concentration –
along an electrochemical gradient.
•  An electrolyte solution runs
countercurrent to blood flowing on
the other side of a semipermeable
(small pore) filter.
•  Small molecules such as urea move
along the concentration gradient
into the dialysate fluid.
•  Larger molecules are poorly
removed by this process
•  Solute removal is directly
proportional to the dialysate flow
rate
 HAEMODIALYSIS

Counter-current

´ The process is more

efficient than filtration if
Urea and Creatinine levels
are high
PERITONEAL DIALYSIS

´ Has the advantage of being simple and cost effective.

´ No Extracorporeal circuit is needed which avoids the
need for anticoagulation.
´ The major disadvantages of PD are :
´ poor solute clearance,
´ poor uraemic control,
´ risk of peritoneal infection and mechanical obstruction of
pulmonary and cardiovascular performance.
´ It is also unsuitable for patients who have undergone
abdominal surgery
HAEMOFILTRATION
´ Solute is carried (in solution) a fluid
across a semipermeable membrane
in response to a transmembrane
pressure gradient
´ The rate of ultrafiltration depends
upon the porosity of the membrane
and the hydrostatic pressure of the
blood, which depends upon blood
flow.
´ This is very effective in removal of
fluid and middle-sized molecules,
which are thought to cause uremia.
Moreover, most of the cytokines
involved in sepsis are “middle
molecules”.
 CRRT: AV v.s VV
´ In the past ARTERIO-VENOUS HAEMOFILTRATION was
used where the patients own heart pumped blood through the
filter from an arterial cannula and returned to the patient via a
venous canulae.
´ The system worked but could be unreliable, blood pressure
dependent
´ Recently machines which used 2 venous (or a single double
lumen ) canulae and a mechanical pump have replaced this
and Veno-venous haemofiltration now the treatment of
choice in Intensive care units.
´ Modern machines are largely and can
and administration of
replacement fluid and heparin
CRRT: AV v.s VV
* Arteriovenous therapies (AV)
- Technique simplicity
- Required large-bore arterial catheter
- Blood flow dependent on MAP
* Venovenous therapies (VV)
- No arterial line
- Pump-assisted
- Blood flow independent of blood pressure
CONTINUOUS VENO-VENOUS
HAEMOFILTRATION (CVVH)
´ Blood  is  pumped  through  a  semi-­‐
permiable  membrane  in  the  filter  
under  pressure.    
´ Small  and  mid  sized  molecules  
such  as  water  and  urea  are  
squeezed  out  and  form  the  
effluent.    
´ The  haematocrit  of  fluid  coming  
out  of  the  filter  is  higher  due  to  
fluid  loss.    
´ Replacement  fluid  is  then  added  
and  the  blood  is  returned  to  the  
pa@ent.    
 HEMODIALYSIS
Diffusion

HEMOFILTRATION :
Convection
 CONTINUOUS VENO-VENOUS
HAEMODIAFILTRATION (CVVHDF)

´ A mixture of filtration

and dialysis
DEFINITIONS OF CRRT

Any extracorporeal blood purification therapy intended to substitute for

impaired renal function over the extended period of time and
applied for, or aimed at being applied for 24 hours/day *

* Bellomo R., Ronco C., Mehta R, Nomenclature for Continuous Renal Replacement Therapies, AJKD,
Vol 28, No. 5, Suppl 3, November 1996
MODES OF CONTINUOUS RENAL
REPLACEMENT THERAPY (CRRT)

CAVH : Continuous arteriovenous hemofiltration

CAVHD : Continuous arteriovenous hemodialysis

CAVHDF: Continuous arteriovenous hemodiafiltration

CVVH : Continuous venovenous hemofiltration

CVVHD : Continuous venovenous hemodialysis

CVVHDF: Continuous venovenous hemodiafiltration

SCUF : Slow continuous ultralfiltration

DEFINITIONS (1)
ULTRAFILTRATION:
In the field of renal replacement therapy, this is a term describing the process
by which plasma water and ultrafiltrate solutes are separated from whole
blood, across a semipermeable membrane in response to transmembrane
pressue.
ULTRAFILTRATE:
The plasma water and ultrafiltered solutes produced during ultrafiltration or
hemofiltration of blood.
DIALYSATE:
The synthetic, uremic solute-free solution administered into the ultrafiltrate-
dialysate compartment of the hemofilter or hemodialyzer in order to achieve
diffusive solute clearance.
DEFINITIONS (2)
ARTERIO-VENOUS (A-V) CIRCUIT :
A term describing the arterial and venous vascular access cannulae or
shunt and the associated tubing necessary to carry blood into and out of
the hemofilter, and back into the circulation.
VENO-VENOUS (V-V) CIRCUIT:
A term describing the venous vascular access and associated tubing
carrying blood into and out of the hemofilter, and back into the
circulation.
PRE-DILUTION:
The administration of replacement fluid into the patient’s blood prior to its
entry into the hemofilter (pre-filter delivery).
DEFINITIONS (3)

POST-DILUTION:
The administration of replacement fluid into the patient’s blood after its
exit from the hemofilter (post-filter delivery).
SUCTION:
A technique whereby ultrafiltrate production is augmented by applying
negative pressure to the ultrafiltrate port of the hemofilter.
ULTRAFILTRATION CONTROL SYSTEM:
A technique whereby ultrafiltrate production is controlled by a volumetric
pumps applied to the ultrafiltrate outflow tubing.
 ADVANTAGES OF CRRT COMPARED
WITH IHD
1. CRRT maintains consistent homeostasis through slow, gradual shifts in
volume status and serum osmolality
2. CRRT avoids hypotensive or dysequilibrium episode
3. CRRT permits continuous control of fluid balance and reduces the need to
restrict fluid administration
4. CRRT requires a lower volume of blood to be circulating outside the body
5. CRRT has less effect on complement or leukocytes
6. CRRT does not require expensive equipment or extensive training of
personnel
7. CRRT has greater clearance of mid-molecular weight solute
CRRT VERSUS IHD/SLED
“THE EVIDENCE”
 Azotemia Control Profiles

With daily IHD,

BUN remains
essentially high at
90mg/dL. SLED &
CRRT provide
much better in
small solute
control

Liao et al, Artif Organs 2003

 β2M Concentration Profiles

CVVH is the
only one of the
3 therapies able
to achieve a
reduction in
B2M
concentration
(continuous and
convection)

Liao et al, Artif Organs 2003

RENAL RECOVERY/
KIDNEY SURVIVAL
 EFFECT OF DIALYSIS MODALITY ON
RECOVERY OF RENAL FUNCTION IN ARF
 RECOVERY FROM DIALYSIS
DEPENDENCE: BEST KIDNEY DATA

Recovery from dialysis dependence

1
CRRT
.8

.6
IRRT

.4

.2

0
0 20 40 60 80 100
days
 RECOVERY FROM DIALYSIS
DEPENDENCE: BEST KIDNEY

Clark et al, Blood Purif 2006

 EFFECT OF MODALITY ON RECOVERY
OF RENAL FUNCTION 2/2

Jacka et al, Can J Anesth 2005

Timing RRT (RIFLE)
 PROPOSED CRITERIA FOR THE INITIATION OF RENAL
REPLACEMENT THERAPY IN ADULT CRITICALLY ILL
PATIENTS
 
1.  Oliguria (urine output<200 ml/12 hr)
2.  Anuria/extreme oliguria (urine output<50 ml/12 hr)
3.  Hyperkalemia ([K+]>6.5 mmol/liter)
4.  Severe academia (pH<7.1)
5.  Azotemia ([urea]>30 mmol/liter)
6.  Clinically significant organ (especially lung) edema
7.  Uremic encephalopathy
8.  Uremic pericarditis
9.  Uremic neuropathy/myopathy
10.  Severe dysnatremia ([Na]>160 or<115 mmol/liter)
11.  Hyperthermia
12.  Drug overdose with dialyzable toxin
( KI 1998, R. Bellomo and C. Ronco)
 RIFLE CRITERIA FOR ACUTE RENAL
DYSFUNCTION
´ In 2002, ADQI proposed RIFLE classification system
´ Categorizes and stratifies a population of patients based on
their renal function
´ Three severity categories:
´ Risk, Injury, Failure
´ Two outcome categories:
´ Loss and End-stage disease
 RIFLE CRITERIA FOR ACUTE RENAL
DYSFUNCTION
GFR criteria UO criteria
Risk Increased creatinine x1.5 or UO <0.5 ml/kg/h x 6 h
GFR decrease >25%
Injury Increased creatinine x2 or GFR UO <0.5 ml/kg/h x 12 h
decrease >50%
Failure Increased creatinine x3 or GFR UO <0.3 ml/kg/h x 24 h or
decrease >75% or Screat  4 anuria x 12 h
mg/dl
Loss Persistent ARF = complete loss of renal function >4 weeks
ESRD End-stage renal disease (>3 months)
 ´ Data has emerged recently that suggests
smaller increases in sCr than those
considered in RIFLE criteria may be
associated with adverse outcomes

´ AKIN proposed a new classification/staging

system
CLASSIFICATION/STAGING SYSTEM FOR ACUTE
KIDNEY INJURY
Stage Serum creatinine criteria Urine output
criteria

AKIN 1 Increase in sCr of ≥ 0.3 mg/dl (≥26.4 Less than 0.5 ml/kg per
µmol/l) or to ≥ 150% to 200% (1.5 to 2 hr fro more than 6 hrs
fold) from baseline

AKIN 2 Increase in sCr to more than 200% to Less than 0.5 ml/kg per
300% (> 2-3 fold) from baseline hr for more than 12 hrs

AKIN 3 Increase in sCr to more than 300% Less than 0.3ml.kg per
(>3fold) from baseline (or sCr ≥ hr or anuria for 12 hrs
4.0mg/dl [≥354µmol/l] with an acute
increase of at least 0.5 mg/dl [44µ/l]
 PENINGKATAN KADAR SERUM KREATININ ( MG/DL)
DISESUAIKAN DENGAN KRITERIA RIFLE 11

Kadar Awal 0.5 1.0 1.5 2.0 2.5 3.0

Risk 0.75 1.5 2.25 3.0 3.75 -
Injury 1.0 2.0 3.0 - - -
Failure 1.5 3.0 4.0 4.0 4.0 4.0

Kriteria RIFLE berdasarkan urin output (UO) dan berat badan penderita

Berat badan pasien (kg)

Kriteria 40 50 60 70
RIFLE
RIFLE - R UO= <120 cc UO= <150 cc UO= <180 cc UO= <210 cc
(dalam 6 jam) (dalam 6 jam) (dalam 6 jam) (dalam 6 jam)
RIFLE - I UO = <240 cc UO = <300 cc UO = <360 cc UO = <420 cc
(dalam 12 jam) (dalam 12 jam) (dalam 12 jam) (dalam 12 jam)
RIFLE - F UO = < 288 cc UO = < 360 cc UO = < 432 cc UO = < 504 cc
(dalam 24 jam) (dalam 24 jam) (dalam 24 jam) (dalam 24 jam)
ANURI ANURI ANURI ANURI
(dalam 12 jam) (dalam 12 jam) (dalam 12 jam) (dalam 12 jam)
Rully Rusli, 2010
 APPLICATIONS FOR CRRT
RENAL APPLICATION VS NON-RENAL
APPLICATION

Renal Application ( Renal replacement and Renal support)

* Acute renal failure ( specifically complicated ARF with multiple organ failure
and cardiovascular failure)
* Oligouric ARF needs large amount of fluid or nutrition
* Acute renal failure with cerebral edema
* Acute renal failure with hypercatabolism
* An alternative to HD in the mass casualty situation
* Electrolytes and acid base disturbance
 APPLICATIONS FOR CRRT
RENAL APPLICATION VS NON-RENAL APPLICATION

Non-renal Application
* Hepatic failure complicated with hepatic coma
* Congestive heart failure refractory to diuretics
* Overhydration during & after cardiac surgery ( CPB )
* Sepsis
* Life-threatening hyperthermia
* Lactic acidosis
* Cytokine removal: Acute respiratory distress syndrome
* Tumor lysis syndrome
* Crush injury
* Inborn errors of metabolism: maple syrup disease, urea cycle disorder
SCHEME FOR SELECTION OF A RENAL REPLACEMENT
THERAPY IN INTENSIVE CARE UNITS

Renal Failure requiring renal replacement therapy

Uni-Organ failure Multi-Organ failure

Hemodynamically Hemodynamically
Intermittent hemodialysis
stable unstable

Main problems: Main problems: CRRT

biochemical/uremia fluid overload or cytokines

Intermittent Hemodialysis CRRT

Untolerant
 Conclusions
* CRRT provide good supportive treatment in the management of
patients with multiple organ failure and acute renal failure
* Maintenance of water, and electrolyte balance
* Removal of metabolic waste products
* Removal of inflammatory mediators of MOSF
* Facilitate full nutrition support
* Mortality of CRRT is non-significant difference as compared with IHD,
but severity of illness is more in CRRT