MRZ

Introduction to CRRT - Definitions

CRRT

= Continuous Renal Replacement Therapy

Defined

as

y Any extracorporeal blood purification

therapy intended to substitute for impaired renal function over an extended period of time and applied for or aimed at being applied for 24 hours /day. *
y

* Bellomo R., Ronco C., Mehta R, Nomenclature for Continuous Renal Replacement Therapies, AJKD, Vol 28, No. 5, Suppl 3, November 1996

Modalities
   

The various CRRT treatment modalities are: SCUF: Slow continuous ultrafiltration CVVH: Continuous veno-venous hemofiltration CVVHD: Continuous veno-venous hemodialysis CVVHDF: Continuous veno-venous hemodiafiltration

Indications for CRRT

        

Renal Indications Non-obstructive oliguria (u/o<400 ml/24h) or anuria Severe acidemia (pH,<7.1) due to metabolic acidosis Azotemia(urea>30 mmol/l) Hyperkalemia Progressive severe dysnatremia Rhabdomyolysis (Crush Injuries) Hyperphosphatemia ARF in the context of MSOF

Indications for CRRT cont,d

Potential Non-Renal Indications Significant organ edema (especially lung) Sepsis SIRS (Systemic Inflammatory Response Syndrome) MSOF (Multi System Organ Failure) ARDS Fulminant hepatic failure Severe burns Cerebral edema Tumor lysis syndrome Coagulopathy requiring large amounts of blood products in patients at high risk of developing ARDS or pulmonary edema Cardiopulmonary bypass Suspected uremic organ involvement (percarditis) CHF (Congestive Heart Failure) Lactic acidosis Drug overdose with a toxin removable by extracorporeal therapy

CRRT Treatment Goals



Maintain fluid, electrolyte, acid/base balance. Prevent further damage to kidney tissue. Promote healing and renal recovery Allow other supportive measures; nutritional support

 

Therapy Options
Access Return Access
Return

Dialysate

Dialysate Access Return

I

Access Return Replacement

(pre or post dilution)

Replacement (pre or post dilution)

Effluent

Effluent

Effluent

Effluent

SCUF

CVVH

CVVHD

CVVHDF

Therapy Options
Access

SCUF
Slow Continuous Ultrafiltration

Return

Maximum Patient Fluid Removal Rate = 2000 ml/hr

Effluent

SCUF Slow Continuous Ultrafiltration

Primary therapeutic goal:

y Safe management of fluid removal

UF rate ranges up to 2 L/Hr No dialysate No replacement fluids Large fluid removal via ultrafiltration Blood Flow rates = 10-180 ml/min
9

Year/Legal owner

Therapy Options
Access

CVVH
Continuous Veno-Venous Hemofiltration
When prime with CVVH mode, Maximum Replacement Flow = 4500 ml/hr Maximum Patient Fluid Removal Rate = 1000 ml/hr

Return

Replacement
(pre or post dilution)

Effluent

CVVH Continuous VV Hemofiltration

Primary therapeutic goal:
convective solute removal and safe mgmt. of fluid volume

UF rate ranges 12-20 L/24 hours (>500 ml/hr) Requires replacement solution to drive convection No dialysate

Replacement Fluids

Access

Return Replacement

Pre-Dilution

Lowers HCT, decreases risk of clotting Higher UF UF chemistries do not reflect true plasma solute losses

Effluent

Year/Legal owner

12

Therapy Options

Dialysate

CVVHD
Continuous Veno-Venous Hemodialysis
S

Access Return

Maximum Patient Fluid Removal Rate = 1000 ml/hr Maximum dialysate flow = 2500ml/hr

Effluent

CVVHD Continuous VV Hemodialysis

Primary therapeutic goal:
Solute removal by diffusion Safe fluid volume management

Requires dialysate solution UF rate ranges 2-7 L/24 hours (~300 ml/hr) Dialysate Flow rate = 15-45 ml/min (~1-3 L/hr) Blood Flow rate = 10-180 ml/min No replacement solution Solute removal determined by Dialysate Flow rate.

Therapy Options

CVVHDF
Access

Continuous Dialysate Veno-Venous Hemodiafiltration

Maximum Pt. fluid removal rate = 1000 ml/hr

Return Replacement
(pre or post dilution)

Maximum Replacement Flow = 2000 ml/hr Maximum Dialysate Flow = 2500 ml/hr Effluent

CVVHDF Continuous VV Hemodiafiltration

Primary therapeutic goal:
Solute removal by diffusion and convection Safe fluid volume mgmt.

Combines CVVH and CVVHD therapies UF rate ranges 12-20L/24hr Uses dialysate solution Uses replacement solution Blood Flow rate = 10-180ml/min
Dialysate Flow rate = 15-45 ml/min

Therapy Options
Access

TPE
Therapeutic Plasma Exchange

Return

Plasma Maximum plasma exchange rate =2000ml/h Maximum patient plasma loss = 1000ml/h Effluent Replacement

Transport principle

Diffusive vs. Convective therapies

diffusion

convection

diffusion + convection

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