CRRT Continuous Renal Replacement Therapies

Oct 25, 2013 Dr. M.Susca 1/46
C R R T
Continuous Renal Replacement Therapies
Technical and Practical Aspects

Oct 25, 2013 Dr. M.Susca 2/47
continuous ambulatory peritoneal dialysis (CAPD)
continuous cyclical peritoneal dialysis (CCPD)
slow continuous ultrafiltration (SCUF)
continuous arterio-venous hemofiltration (CAVH)
continuous arterio-venous hemodialysis (CAVHD)
continuous arterio-venous hemodiafiltration (CAVHDF)
continuous veno-venous hemofiltration (CVVH)
continuous veno-venous hemodialysis (CVVHD)
continuous veno-venous high-flux dialysis (CVVHFD)
continuous veno-venous hemodiafiltration (CVVHDF)
intermittent peritoneal dialysis (IPD)
hemoperfusion (HP)
hemoconcentration
ther. plasmapheresis (PEX, PAP)
hemodialysis (HD)
hemofiltration (HF)
hemodiafiltration (HDF)
continuous
intermittent
Blood Purification Procedures in ICU

Oct 25, 2013 Dr. M.Susca 3/47
CRRT Indications in ICU
•
Acute renal failure, which often is a part of multi-organ failure

with complications such as shock, cardial and non-cardial
pulmonary edema, hemodynamic instability, bleeding,
hypercatabolism
•
diuretic-resistant fluid overload
•
parenteral nutrition in cases of oligoanuria
•
Hyperpotassiemia
•
hypernatriaemia
•
elimination of toxins and mediators (endotoxin, prostaglandin,
leukotrins etc.)

Oct 25, 2013 Dr. M.Susca 4/47
1977 Kramer et al. Report for the first time on
continuous arterio-venous hemofiltration
(CAVH)
1981 Bischoff develops a pump-driven
procedure as continuous veno-venous
hemofiltration (CVVH)
1985 Geronemus further develops continuous
arterio-venous hemodialysis (CAVHD)
1987 Uldall introduces continuous veno-venous
hemodialysis (CVVHD)
Historical Overview

Oct 25, 2013 Dr. M.Susca 5/47
Disadvantages

•
filtration dependes on
blood flow (low efficiency)
•
arterial access (bleeding,
clot formation)
Advantage
•
technically not
complicated
A
V
heparin
UF
h
i
g
h
-
f
l
u
x
CAVH Continuous arterio-venous hemofiltration

Oct 25, 2013 Dr. M.Susca 6/47
Disadvantages
•
filtration dependes on
blood flow (low efficiency)

•
arterial access (bleeding,
clot formation)
A
V
heparin
UF
R
Advantage
•
technically not
complicated
h
i
g
h
-
f
l
u
x
CAVH Continuous arterio-venous hemofiltration

Oct 25, 2013 Dr. M.Susca 7/47
heparin
Disadvantages
•
filtration dependes on
blood flow (low efficiency)
•

backfiltration
•
bad elimination of large
molecules
•
complex machinery
•
fluid balance complicated
•
arterial access (bleeding,
clot formation)
Advantage
•
better elimination of small
molecules
A
V
D
UF
D
l
o
w
-
f
l
u
x
CAVHD Continuous arterio-venous hemodialysis

Oct 25, 2013 Dr. M.Susca 8/47
A
V
R
heparin
D
UF
D
Disadvantages
•
filtration dependes on
blood flow (low efficiency)
•
backfiltration
•
complex machinery
•
fluid balance complicated
•
arterial access (bleeding,
clot formation)
Advantage
•
better elimination of small
and large molecules
h
i
g
h
-

f
l
u
x
CAVHDF Continuous arterio-venous hemodiafiltration

Oct 25, 2013 Dr. M.Susca 9/47
PA
heparin
Disadvantages
•
complex machinery
•
expensive
•
fluid balance complicated
Advantage
•
no arterial access
•
blood flow sufficient
•
good filtration
V
V
PV
UF
BLD
SAD
h

i
g
h
-
f
l
u
x
SCUF Slow continuous ultrafiltration

Oct 25, 2013 Dr. M.Susca 10/47
heparin
V
V
PV
PA
Disadvantages
•
complex machinery
•
expensive
•
fluid balance complicated
Advantage
•
no arterial access
•
blood flow sufficient
•
good elimination of large

molecules
•
good filtration
UF
BLD
SAD
R
heater
h
i
g
h
-
f
l
u
x
CVVH Continuous veno-venous hemofiltration

Oct 25, 2013 Dr. M.Susca 11/47
heparin
V
V
PV
PA
Disadvantages
•
complex machinery
•
expensive

•
fluid balance complicated
Advantage
•
no arterial access
•
blood flow sufficient
•
good elimination of small
molecules
•
good filtration
D
UF
D
BLD
SAD
heater
l
o
w
-
f
l
u
x
CVVHD Continuous veno-venous hemodialysis

Oct 25, 2013 Dr. M.Susca 12/47
R

heater
heparin
V
V
PV
PA
Disadvantages
•
complex machinery
•
expensive
•
fluid balance complicated
Advantage
•
no arterial access
•
blood flow sufficient
•
good elimination of small
and large molecules
•
good filtration
D
UF
D
BLD
SAD
h
i

g
h
-
f
l
u
x
CVVHDF Continuous veno-venous hemodiafiltration

Oct 25, 2013 Dr. M.Susca 14/47
heparin
V
V
PV
PA
Disadvantages
•
complex machinery
•
expensive
Advantage
•
no arterial access
•
blood flow sufficient
•
good elimination of
large molecules
•
exact filtration

UF
R
BLD
SAD
heater
h
i
g
h
-
f
l
u
x
CVVH Continuous veno-venous hemofiltration

Oct 25, 2013 Dr. M.Susca 15/47
heparin
V
V
PV
PA
Disadvantages
•
complex machinery
•
expensive
Advantage
•
no arterial access

•
blood flow sufficient
•
good elimination of
small molecules
•
exact filtration
D
UF
D
BLD
SAD
heater
l
o
w
-
f
l
u
x
CVVHD Continuous veno-venous hemodialysis

Oct 25, 2013 Dr. M.Susca 16/47
heparin
V
V
PV
PA
Disadvantages

•
complex machinery
•
expensive
Advantage
•
no arterial access
•
blood flow sufficient
•
good elimination of
small and large
molecules
•
exact filtration
R
D
UF
D
BLD
SAD
heater
h
i
g
h
-
f
l
u

x
CVVHDF Continuous veno-venous hemodiafiltration

Oct 25, 2013 Dr. M.Susca 17/47
heparin
V
V
PV
PA
Disadvantages
•
complex machinery
•
expensive
Advantage
•
no arterial access
•
blood flow sufficient
•
good elimination of small
and large molecules
•
exact filtration
D
UF
D
BLD
SAD
heater

h
i
g
h
-
f
l
u
x
CVVHFD Continuous veno-venous high flux dialysis

Oct 25, 2013 Dr. M.Susca 18/47
CVVHDF versus CVVHFD
CVVHFD ↔ CVVHDF

CVVHFD and CVVHDF are comparable (same
effect).

Diffusive and convective clearance in parallel

Adapted for elimilation low and middle molecular
substances.

CVVHFD is easier from techincal side, no 4
th
pump
necessary.

CVVHFD less cost – intensive, because of less
disposables and less solution.

Oct 25, 2013 Dr. M.Susca 19/47
Filter Substitution Sub./Dia. Flow Blood Flow
SCUF High-Flux --- --- 100-150 ml/min
CVVH High-Flux Lac./Bic. Sub. 500-2000 ml/h 100-150 ml/min
CVVHD Low-Flux Lac./Bic. as Dialysate Dia. 500-2000 ml/h 100-150 ml/min
CVVHDF High-Flux Lac./Bic. Both 500-2000 ml/h 100-150 ml/min
HF High-Flux Lac./Bic. Sub. < 5000 ml/h 200-300 ml/min
HD Low-Flux Lac./Bic. as Dialysate Dia. 200-300 ml/min 200-300 ml/min
HDF High-Flux Lac./Bic. Sub. < 5000 ml/h 200-300 ml/min
HP
Whole Blood
Adsorber
--- --- 100-150 ml/min
PEX
Plasma Filter
Albumin Sol., FFP,
Plasma Expander
30% of BF 60-150 ml/min
PAP Plasma Adsorber --- --- 60-150 ml/min
Filter? Substitution?