Solute Clearance

MONIKA AGGARWAL, MD,MS,FASN

Outline

 Principles of clearance
 Factors
 Modalities

 Not Cover
 Measure
 Clinical outcomes
(KSolute)
 Dialysis Adequacy
 Drug Dosing
 Poisoning
 Intermittent Hemodialysis
 Nocturnal
 Home Hemodialysis
 Quotidian/TIW
 Sustained Low efficiency dialysis (SLED)
 Continuous Renal Replacement Therapies
 CVVH
 CVVHD
 CVVHDF
 SCUF
 Prolonged Intermittent Renal Replacement Therapies (PIRRT)

 Peritoneal Dialysis
 CAPD
 APD
B2microglobulin 11800
Surface Area
Flux (Pore Size)
Efficiency (Number of Pores)
Diffusion
 Solute
 Molecular Weight
 Volume of distribution
 Protein Bound
 Compartment
 Concentration

 Dialysis
 Time
 BFR
 DFR
 Dialyzer
 Pore numbers, Surface area, thickness
 KoA= Diffusive clearance of dialyzer
 High efficiency dialyzer KoA >800-1000 ml/min
Diffusive Clearance

 Maintain concentration Gradient

 Countercurrent
 Higher DFR
 Dialyzer (KoA)
 Higher BFR
 Time
 Number of treatments
 67-year-old male, ESRD, three times a week in-center HD.
 T=4 hours
 BFR=400 ml/min
 DFR =500 ml/min
 KoA=800 ml/min
 Weight 70 kg

Increase clearance of Urea(Kurea) per session :

1) Increase DFR to 800 ml/min
2) Change dialyzer to KoA = 1000 ml/min
3) Increase Time
4) Increase Number of sessions to 4 days a week
 65-year-old female, CKD 5
 BUN 200 mg/dl
 Creatinine 11 mg/dl
Risk for dialysis disequilibrium syndrome

Slow clearance of Urea(Kurea) :

1) Low BFR
2) Low DFR
3) Short session
4) Smallest Dialyzer
 55-year-old male, ESRD, three times a week HD
 Phosphorus =11 mg/dl
 Time =4 hours
 KoA =1200 ml/min
 DFR=800 ml/min
 BFR=400 ml/min

Increase Phosphorus Clearance:

1) Increase Time
2) Shorter More Frequent Dialysis
3) Increase DFR=1000 ml/min
4) Increase KoA =1400 ml/min
 35-year-old male : Hydroxychloroquine overdose after hearing about it on the news. You are called to
dialyze
 Molecular weight =336 Daltons
 Protein binding = 50%
 Vd= 200L/kg

Dialysis will be ineffective:

1) Large Vd
2) Molecular weight
3) Protein Binding
 Convection

 Solute
 Molecular weight
 Sieving Coefficient
 Ultrafiltration rate
 High flux membrane (larger pore size, thinner
membrane)
 Kuf=Convective clearance of
dialyzer=“leakiness”
 High flux dialyzer Kuf> 15-20 ml/hour/mm of
hg
 Sieving Coefficient

Solute (MW) Convective Coefficient Diffusion

Coefficient SC= D/P

Urea (60) 1.01 ± 0.05 1.01 ±

0.07
Creatinine (113) 1.00 ± 0.09 1.01 ±
0.06
Uric Acid (168) 1.01 ± 0.04 0.97 ±
0.04*
Vancomycin (1448) 0.84 ± 0.10 0.74 ±
0.04**
Cytokines (large) adsorbed minimal
clearance
Convective Clearance

 Dialyzer (KUF)
 UF (Replacement Fluid)
 60-year-old male with ESRD, three times a week HD. On Vancomycin 1 gram every other
dialysis for MRSA bacteremia. Vancomycin MW 1485 Da .
 Time=4 hours
 BFR=400 ml/min
 DFR=800 ml/min
 Dialyzer =Optiflux F16 (1.5 m2, Kuf 10 ,K0A 977)
 Optiflux F160 (1.5 m2, Kuf 61,K0A1167)

Vancomycin dosing :
1) No change as surface area same
2) More frequent dosing as K0A higher
3) More frequent dosing as Kuf increased
Modality Diffusive Convective
Hemodialysis (HD) Most Some
SLED Most Some
Nocturnal HD Most Some
Home HD Most Some
Hemodiafiltration (HDF) Yes Yes
CVVHD Most Some (depends on UF)
CVVH None All
CVVHDF Yes Yes
PIRRT Depends on Rx
Peritoneal Dialysis

 Diffusion (Solute)
 Convective (Solute)
 Osmosis (Water)
Diffusive Clearance

Surface Area
Solute size
Concentration gradient
Dwell Time(Modality & Membrane)
Dwell volume
Membrane Permeability

Copyrights apply
 Surface Area (pore numbers, type, vascularity)
 Hydrostatic pressure gradient
 Osmotic gradient
 Peritoneal Permeability
 High vs. Low transporter
 Type of dianeal (Icodextrin ,dextrose)
 Reflection coefficient

UF & Convective Clearance

 66-year-old female, APD at night, Slow Transporter, 10 hours
 5 exchanges
 90 minutes
 3000 ml

Increase Urea Clearance :

1) Add a daytime exchange
2) Increase Number of exchanges but decrease dwell time
3) Increase Dwell time and decrease number of exchanges
4) Increase Dwell Volume