RENAL REPLACEMENT THERAPY

BY DR LEE JUNE LYNG Supervisor: DR ZIHNI

OUTLINE
INTRODUCTION INITIATION OF THERAPY PRINCIPLE OF RRT RRT TECHNIQUES AND ITS INDICATION PROS AND CONS COMPLICATIONS OCCURS IN CRRT COMPARISON BTW IHD AND CRRT

INTRODUCTION
When ARF is severe, resolution may take several days or weeks During this time, the kidneys cannot maintain homeostasis of fluid, K+ , metabolic acid and waste products in which some may respond to medical measure and some may not. Those who are not responsive to medical measure, acute renal replacement therapy (ARRT) is vital.

Too many questions?

What therapy should we use? When should we start it? What are we trying to achieve? How much therapy is enough? When do we stop/switch? Can we improve outcomes?

Initiation of Therapy

RIFLE Criteria

Level of injury

Outcome measures

 RIFLE correlated with prognosis Limitations:

Serum Cr were strong predictors of ICU mortality but not UO criteria Change in Serum Cr not directly correlate with changes in GFR Baseline CR is necessary to calculate the change

From RIFLE to AKIN

Serum Creatinine
Increase SCr 24.6mmol/L

Stage 1 Stage 2

2-3 folds

Stage 3

or urine output Patients receiving RRT are Stage 3 regardless of urine output

The Acute Kidney Injury Network Classification ( AKIN)

 Modification of the RIFLE criteria by Acute Kidney Injury Network Both diagnostic and staging system Diagnostic criteria
abrupt in onset within 48 hrs Absolute increase in serum Cr >=0.3mg/dL or 26.4 mmol/L or % increase of Cr >=50% or oliguric for >=6 hrs After volume status optimised and urinary tract obstruction excluded

Staging system
RIFLE Loss and ESRF are removed

Indication for RRT

Oliguria <200ml/12h Anuria < 50ml/12h Urea>30mmol/l K+ >6.5mmol/l or rapidly rising Pulmonary edema unresponsive to diuretics Metabolic acidosis ph<7.0 Dysnatremia <110mmol/l and >160mmol/l Temperature >40 degree Uremic complication Overdose with dialyzable toxin (eg: lithium)

Dose and intensity of RRT

The dose of dialysis which is currently defined as derivation of fractional urea clearance during a single dialysis treatment and is governed by patient size, residual kidney function, daily protein intake, degree of catabolism and anabolism, and presence of co-morbid conditions Efficiency of RRT: Kt/Vd K clearance of urea in ml/min t is time of treatment in min Vd urea distribution volume in liter

Target n RRT
Current targets include:
Reduction of urea >65-70% Kt/Vd is above 1.3 CRRT at urea clearance of 35 40l/day

PRINCIPLE OF RRT

PRINCIPLE OF RRT
DIFFUSION (HEMODIALYSIS) CONVECTION (HEMOFILTRATION) ULTRAFILTRATION(ALL THERAPIES) DIFFUSION AND CONVECTION (HEMODIAFILTRATION)

DIFFUSION
is the movement of solutes from a higher to a lower solute concentration area. Efficient in removing small molecules (<500d) but not large molecules is the main determinant of solute removal during dialysis

Dialysis (....diffusion)
Solutes flow down an electrochemical gradient, across a membrane. Solute removal is proportional to dialysate flow rate Dialysate flows counter-current to blood

 Dialysate
is the fluid that is pumped into the filter canister, surrounding the hollow fibers The concentration of solutes in the dialysis fluid determines diffusion gradients The removal of surplus solutes from the blood is achieved by infusing dialysate fluid that contains a lower solute concentration than the serum concentration Eg: in renal failure, K+ is often high . Thus, may start with low K+ in the dialysate. Thus, there will be diffusion from high concentration (pts blood) to the low concentration(dialysate) in order to remove K+ fr pts blood.

 Dialysate
Eg: in renal failure, HCO3 is low. So, HCO3 is added to dialysate to facilitate diffusion from high concentration( dialysate) to low concentration(pts blood)

 Dialysate
The main composition are sodium chloride, sodium bicarbonate or sodium acetate, calcium chloride, potassium chloride, and magnesium chloride Thus, it is used to replace electrolytes

Electrolyte Composition of dialysate

CONVECTION
Is a one-way movement of solutes through a semipermeable membrane with a water flow. Sometimes it is referred to as solvent drag. (Water movement
drags solute across membrane)

Efficient in removing larger and smaller molecules The faster the substitution flow rate, the higher the clearance The ultrafiltratecontaining the solute should be replaced by substitution solutions Main principle for hemofiltration

Convection

ULTRAFILTRATION
Is the movement of fluid through a semipermeable membrane along a pressure gradient The ultrafiltration rate depends on the pressure applied to the filter, inside and outside the fibers It removes fluid

Principles of CRRT clearance

Small molecules easily pass through a membrane driven by diffusion and convection. Middle and large size molecules are cleared primarily by convection. Semi-permeable membrane remove solutes with a molecular weight of up to 50,000 Daltons. Plasma proteins or substances highly proteinbound will not be cleared.

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RRT techniques

MAJOR RRT TECHNIQUES

INTRACORPOREAL PERITONEAL DIALYSIS EXTRACORPOREAL
CONVENTIONAL IHD SLOW LOW EFFICIENCY DIALYSIS (SLED) CRRT
CVVH ( continuous venovenous hemofiltration) CVVHD ( cont veno-venous hemodialysis) CVVHDF ( cont veno-venous hemodiafiltration) SCUF (slow cont ultrafiltration)

Major Renal Replacement Techniques

Intermittent Hybrid Continuous

IHD
Intermittent haemodialysis

SLEDD
Sustained (or slow) low efficiency daily dialysis

CVVH
Continuous veno-venous haemofiltration

IUF
Isolated Ultrafiltration

SLEDD-F
Sustained (or slow) low efficiency daily dialysis with filtration

CVVHD
Continuous veno-venous haemodialysis

CVVHDF
Continuous veno-venous haemodiafiltration

SCUF
Slow continuous ultrafiltration

Anatomy of a Hemofilter
blood in
dialysate out Cross Section hollow fiber membrane

dialysate in

blood out

Outside the Fiber (effluent) Inside the Fiber

(blood)

Membrane types and characteristics

Hemofilter membrane are composed of:
High flux material Synthetic/biocompatible material

Structural design is characterized by:

High fluid removal Molecular cut-off weight of 30,000-50,000 Daltons.

The blood flows in one direction and the dialysate flows in the opposite
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Semi-permeable Membrane
The semi-permeable membrane provides: An interface between the blood and dialysate compartment. Biocompatibility minimizes: Severe patient reactions Decreases the complement activation

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CVVH

INTERMITTENT HEMODIALYSIS

INTERMITTENT HEMODIALYSIS
Technically similar to what ESRF pt on chronic HD undergo in the community dialysis centres. Uses high dialysate flows (300-400ml/min) and short period of time ( 3-4 hrs)

IHD
Medical requirements and indication:
Hemodynamically stable ( no more than 1 vasopressor agent at low doses preferably) Vascular access: AVF or temporary dual lumen veno-venous dialysis catheter Relative C/I in high ICP as IHD may increase brain water content ( cerebral edema)

Intermittent Therapies - PRO

(Relatively) Inexpensive Flexible timing allows for mobility/transport Rapid correction of fluid overload Rapid removal of dialyzable drugs Rapid correction of acidosis & electrolyte abnormality Minimises anticoagulant exposure

Intermittent Therapies - CON

Hypotension 30-60%
Limited therapy duration

Cerebral oedema

Renal injury & ischaemia

Gut/coronary ischaemia

SLED

SLED
More gentle form / hybrid technology of IHD Lower Qb (150-200ml/min) and lower Qd (100-300ml/min)

SLED
Indication:
Recent ACS , AMI and severe cardiac failure with low vent ejection fraction Unstable BP requiring at most one vasopressor agent As a prelude to IHD following recovery from major critical illness during CRRT was utilized Recent worsening in overall condition resulting in IHD being poorly tolerated and pt become frankly hypotensive but still maintain SBP>100 with low dose of a single inotropes

SLED : Hybrid therapy

Conventional dialysis equipment Excellent small molecule detoxification Cardiovascular stability as good as CRRT Reduced anticoagulation requirement 11 hrs SLED comparable to 23 hrs CVVH Decreased costs compared to CRRT Phosphate supplementation required

CONTINUOUS RENAL REPLACEMENT THERAPY

CRRT
Preferred dialytic modality in critically ill, hypercatabolic pt with unstable circulatory state ( with high doses of multiple vasopressor)

TYPES OF CRRT THERAPY

1) SLOW CONTINUOUS ULTRAFILTRATION ( SCUF) 2) CONTINUOUS VENO VENOUS HEMOFILTRATION (CVVH) 3) CONTINUOUS VENO VENOUS HEMODIALYSIS (CVVHD) 4) CONTINUOUS VENO VENOUS HEMODIALYSIS (CVVHDF)

CRRT
Indications:
Hemodynamically instability requiring 1or more inotropes at high doses and/or failure to tolerate IHD or SLED Catabolic state:
CRRT provides more optimal biochemical and metabolic control than IHD/SLED

Continuous Therapies - PRO

Hemodynamically stability stable and predictable in volume and chemistry control Relative safe use in high ICP and CVS instability May have an adjuvant therapy effect in sepsis Make space for TPN in anuric pt Probable advantage in term of renal recovery

Continuous Therapies - CON

Anticoagulation requirements

Higher potential for filter clotting

Increased bleeding risk

High heparin exposure

Expense fluids etc.

Immobility & Transport issues

SCUF(slow cont ultrafiltration)

This type of CRRT remove fluid only without the need for replacement fluids known as substitution solutions. This can help prevent or treat fluid overload in cases when waste products don't need to be removed, or the pH levels don't need to be corrected.

SCUF

CVVH
Most popular removes large volumes of fluids and waste from the patient. It then uses replacement fluids (also known as a substitution solution), which are devoid of toxins, to maintain electrolyte and acid base balance. Dialysate is not used

 Replacement fluids
Is used to replace any water that is removed during hemofiltration. Thus, it is able to prevent hypovolemia Any fluid removed during hemofiltration is given back to maintain a net neutral fluid balance Replacement fluid must be sterile intravenous fluids with concentrations of electrolytes similar to plasma.

CVVH

CVVH
Prescription based on Prisma CRRT machine algorithm: Qb: 150-220ml/min
A higher blood flow rate is needed if more intensive CVVH is performed

UFR(ultrafiltration rate) : >35ml/kg/h

Predilution 1/3 Postdilution 2/3

 Predilution of the blood prior to its entry in the dialyzer with replacement fluid can lead to decreased requirement of anticoagulation and also by maintaining the concentration gradient Postdilution means that the replacement fluid is returned to the blood after the filter Postdilution concentrates the blood in the filter, enhancing clearance.

CVVHD
This type of therapy primarily uses diffusion along with a cleansing fluid known as a dialysate solution to boost the removal of waste products Continuous diffusive dialysis Mostly small molecules are removed

CVVHD

CVVHDF
With CVVHDF, large volumes of fluids and waste are removed from the patient. Cleansing fluids (dialysate solution) and replacement fluids (substitution solution) are used to replace the dirty plasma with clean fluid. This allows for the removal of large volumes of toxinfilled plasma, while still maintaining electrolyte balance.

CVVHDF
Removal of small molecules by diffusion through the addition of dialysate solution. Removal of middle to large molecules by convection through the addition of replacement solution.

CVVHDF

SCUF Solute removal H20 removal

Replacement fluid ( to replace H2o)
Dialysate (to replace e- eg: ca, HCO3

CVVH convection Ultrafiltration

CVVHD Diffusion + convection Ultrafiltration

CVVHDF Diffusion + convection Ultrafiltration

minimal Ultrafiltration

No

yes

no

Yes

no

no

yes

yes

Advantage

Reduce volume overload

Volume and salute removal

Less susceptible to e- disorder d/t dialysate replacement Can treat both volume overload + azotemia

Less susceptible to edisorder d/t dialysate replacement Allow mech to increase convection solute removal while performing HD Useful for volume expanded pt with high solute load

disadvantage

Not much solute clearance Slow bl flow rate prone to get system thrombosis

Vulnerable for edisorder d/t large infusion of replacement fluid

Vascular Access
A veno-venous double lumen hemodialysis catheter or two single lumen venous hemodialysis catheters may be used.

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Access Location
Internal Jugular Vein
Primary site of choice due to lower associated risk of complication and simplicity of catheter insertion.

Femoral Vein
Patient immobilized, the femoral vein is optimal and constitutes the easiest site for insertion.

Subclavian Vein
The least preferred site given its higher risk of pneumo/hemothorax and its association with central venous stenosis.
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Choosing the right catheter

The length of the catheter chosen will depend upon the site used
Size of the catheter is important in the pediatric population.

The following are suggested guidelines for the different sites: RIJ= 15 cm French LIJ= 20 cm French Femoral= 25 cm French
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COMPLICATIONS

Complications
Vascular access Vascular spasm(initial BFR too high) Movement of catheter against vessel wall Improper length of hemodialysis catheter inserted Fluid volume deficit Excessive fluid removal without appropriate fluid replenishment

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Complications
Hypotension Intravascular volume depletion Underlying cardiac dysfunction Electrolyte imbalances High ultrafiltration rates (high clearance) Inadequate replenishment of electrolytes by intravenous infusion, Inadequate replenishment of bicarbonate loss during CRRT

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Complications
Acid/base imbalance Blood loss Ineffective anticoagulation therapy Clotting of hemofilter Inadvertent disconnection in the CRRT system Hemorrhage due to over-anticoagulation Blood filter leaks

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Complications
Air embolus Leaks or faulty connections in tubing Line separation. Cardiac arrest Hypotension/hypertension Air embolism Circulatory overload Arrhythmias

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OTHER ISSUES

Other issues
Hypothermia Coagulation Blood loss during CRRT Nutritional support Changes in medications dosage in RRT

1)HYPOTHERMIA IN CRRT
Hypothermia
Causes
Patients blood in extracorporeal circuit at room temperature Administration of large volumes of room temperature fluids (replacement and dialysate)

Signs and Symptoms

Hemodynamic instability Chilling, shivering Skin pallor, coolness and cyanosis

Treatment
Warming blanket

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2)COAGULATION IN CRRT
Blood contact to circuit tubing in CRRT leading to activation of coagulation cascade Result in clotting of filter or circuit Even the most biocompatible membranes gradually occluded by fibrin microthrombi

COAGULATION IN CRRT
Factors leading to clot formation
Poor or low flow rates through the dialyser circuit which is affected by vascular assess Areas of stagnant blood particularly where pumps join the circuit Air blood interfaces as in bubble traps ( the 1st sign of clotting usually occurs in the bubble trap and not the dialyzer) HCT plays a significant role in clotting of dialysis circuit and is exacerbated by high filtration rates Membrane material: till now, no membrane material is currently available that binds heparin permanently

COAGULATION IN CRRT
Anticoagulant therapy to prevent dialyzer clot formation
Most CRRT machines incorporate a pump that can infuse heparin into the dialyzer circuit b4 the blood pump is started
Doses btw 200 800 units per hour

Other anticoagulant:
LMWH, prostacyclin and sodium citrate

COAGULATION IN CRRT
If bleeding risk is high, the safest approach is no anticoagulant at all
Thus, saline flushing is used .
100ml of N/S is flushed thru the filter every hour to prevent clotting of dialysis circuit

3) Minimizing blood loss during CRRT

CRRT blood circuits can contain up to 250ml blood So, when CRRT is halted, effort must be made to return as much blood as possible to the patient
By perfusing blood circuit with saline

4)Nutritional support
RRT can cause additional protein losses
CVVH 10 15g/day IHD : 6- 8 g/day

Recommended protein supplement

CVVH: 1.1 2.5g/kg/day IHD: 1.1 1.2 g/kg/day

5)Changes in common ICU medications in RRT

CRRT VS. INTERMITTENT RENAL REPLACEMENT THERAPY

Intermittent renal replacement Unstable patient Pateint stable in and cannot hymodynamicall tolarate rapid y fluid and electrolyte CRRT

who?

CRRT

Why?

How?

Rapid change in electrolyes, pH, and fluid balance

Intermittent renal replacement To remove fluid, To remove fluid, electrolytes and Electrolytes and toxin slowly toxin rapidly Continuous Every 2 to 3 24hrs. days and last about 3 to 4 hrs. No yes

CRRT

Need to reduce Dosage of renal clearance drug Need to adjust administration times of renally cleared drugs Need to limit protein, KCL and fluid intake

Dependent on mode of therapy No

Intermittent renal replacement Yes

Yes

No

Yes

CRRT

Intermittent renal replacement yes

pH and electrolyte shift after therapy

Yes