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Continuous Renal Replacement Therapy Kelly Monaghan, DVM Small Animal Internal Medicine August 28, 2009.

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Presentation on theme: "Continuous Renal Replacement Therapy Kelly Monaghan, DVM Small Animal Internal Medicine August 28, 2009."— Presentation transcript:

1 Continuous Renal Replacement Therapy Kelly Monaghan, DVM Small Animal Internal Medicine August 28, 2009

2 Indications Toxins/drugs Leptosporosis Oliguric/anuric renal failure Acute kidney injury that is not responsive to traditional management Acute kidney injury in critically ill patients SIRS, sepsis?

3 Benefits More closely approximates normal kidney function Slower blood and dialysate flow rates – Smaller patients Less dramatic changes/shifts Cage-side system Less maintenance required for machine

4 Basic Principles Blood is diverted from the patient to the unit Anticoagulants are added to the blood before the filter Uremic toxins are removed and electrolytes normalized Blood is returned to the patient

5 Diffusion BUN and creatinine diffuse freely into dialysate through semipermeable membrane Limited by the size of the membrane pores Substances in dialysate also diffuse into blood

6 Convection Blood traveling within semipermeable membrane is exposed to a positive transmembrane pressure Pressure pushes fluid out of the blood (with toxins and electrolytes) and across the semipermeable membrane Ultrafiltrate is removed from the dialyzer and disposed of as effluent Larger molecules are more effectively cleared by this process than by diffusion

7 Adsorption Molecules adhere to the dialysis membrane and are removed from circulation May be of benefit for SIRS/sepsis – Potentially requires more frequent filter changes Membrane

8 The Machine Dialyzer Four pumps – Blood pump – Dialysis solution pump – Replacement solution pump – Effluent pump Solutions are continuously weighed by machine

9 Modes of Operation SCUF CVVH CVVHD CVVHDF Filtration = Convection Dialysis = Diffusion

10 SCUF Slow Continuous UltraFiltration Least complex and most rapid (few hours) Purely convection Ultrafiltrate is not replaced in this modality Congestive heart failure, fluid overload

11 SCUF

12 CVVH Continuous Veno-Venous Hemofiltration Similar to SCUF (convection) but removed fluids are replaced with sterile, balanced electrolyte replacement solution to prevent hemoconcentration Effective at removing uremic toxins through convection only

13 Pre / Post Filter Replacement Pre-filter Replacement – Replacement solution mixed with blood before passing through the filter – Decreased risk of filter clotting due to hemodilution – Decreased overall efficiency Post-filter Replacement – Replacement solution is mixed with blood leaving the filter – Higher risk of filter clotting due to relative hemoconcentration within the filter – Improved efficiency

14 CVVH

15 CVVHD Continuous Veno-Venous HemoDialysis Primarily diffusive therapy Similar to intermittent hemodialysis Toxins diffuse across membrane into dialysate Beneficial substances diffuse into blood from dialysate

16 CVVHD

17 CVVHDF Continuous Veno-Venous HemoDiaFiltration Primary modality for our patients = CVVH (convection) + CVVHD (diffusion) Diffusion guides movement of uremic toxins and electrolytes Convection causes movement of fluid and molecules out of blood

18 CVVHDF

19 Pathophysiology (Ronco and Ricci. Intensive Care Med 2008) CRRT requires continuous contact of patients blood with foreign surfaces which activates the coagulation and complement cascade, leukocytes, and platelets Activated leukocytes release inflammatory mediators and induce oxidative stress, transforming lipids and proteins and contributing to endothelial injury Activated platelets aggregate and stimulate thrombin generation Bio-incompatibility of RRT materials potentially enhances coagulation and inflammation pathways that are already triggered in the critically ill patients and that RRT is used to treat

20 Complications Clotting of dialyzer/circuit (blood loss) Hemorrhage Thromboembolic events Sepsis Dialysis dysequilibrium (not reported in CRRT)

21 Anti-coagulation HEPARIN Requires systemic anti- coaulation Less intensive monitoring required Reported shorter filter life (Kutsogiannis et al. Kidney Intl. 2005) Heparin-induced thrombocytopenia (people) CITRATE Decreased risk of hemorrhage Requires calcium supplementation Risk of iatrogenic hyper/hypocalcemia Risk of metabolic alkalosis as it is metabolized More intensive monitoring

22 Veterinary Literature Only one paper by Diehl et al. JVECC 2008 – Retrospective on 17 dogs and 16 cats that received CVVHDF – Regional citrate anticoagulation was performed – Median duration of CRRT in dogs was 16.3 hours and in cats was 11.5 hours (until values normalized) – UOP was not consistently monitored and therefore not reported – Complications: hypokalemia, CNS signs, hyper/hypocalcemia, hypothermia, alkalosis, filter clotting, chronic kidney disease – 41% of dogs and 44% of cats survived to discharge

23 Intermittent HD versus CRRT Which is the better choice for our patients?

24 Evidence-Based Medicine No veterinary studies in this area Several human papers that try to compare To date, there is no clear answer

25 Theory of Practice Intermittent HDCRRT

26 Literature Ricci and Ronco. Crit Care Med 2008 – Review article – 80% of centers use CRRT, 17% use IHD – Studies comparing the modalities have found conflicting results – Surviving Sepsis Campaign concluded that they should be considered equivalent in AKI – Problem in all of the studies is that despite attempts at randomization, CRRT population has significantly greater severity of illness scores and despite improved fluid balance and azotemia control, still had higher mortality in some studies – Metaanalysis by Kellum et al in 2002 found that after stratifying 1400 patients according to disease severity, CRRT was associated with a significant decrease in the risk of death when similar patients were compared – Metaanalysis by Tonelli et al in 2002 found no difference between the techniques – Concluded that the most important point with either is achieving an adequate dose

27 Literature Bell et al. Intensive Care Med 2007 – Concluded that there was better renal recovery for patients receiving CRRT than those that got IHD but no difference in mortality – Study does not discuss dose, time on machine, or severity of illness for each population – Metha et al 2001 had similar results

28 Literature Lins et al. Nephrol Dial Transplant (2009) – Randomized controlled trial stratified for disease severity – No difference between IHD and CRRT was observed in duration of ICU stay or hospitalization – Renal recovery at the time of discharge was comparable between groups – No difference in mortality between groups – Cross-over was allowed between groups

29 Literature Rauf et al. Intensive Care Med (2008) – Evaluated costs and outcomes associated with each modality – Patients in CRRT group had higher severity scores, higher incidence of sepsis and respiratory disease Significantly longer hospitalization stays Less likely to have chronic renal insufficiency – RRT method did not affect the likelihood of renal recovery, in-hospital survival, or survival during 1 year follow-up – Mean adjusted cost through hospital discharge was $93,611 for IHD patients and $140,733 for CRRT patients

30 How do we apply this? General consensus that CRRT may be better for cardiovascularly unstable patients Veterinary dialysis patients tend to correlate with the most critically ill and often, cardiovascularly unstable human patients

31 Future Directions IHD for toxins, transient insults CRRT for critical patients and follow-up IHD if needed Consider use in septic AKI

32 Use in Sepsis / SIRS Ronco et al. Artificial Organs (2003) – Peak-concentration theory: cutting peaks of soluble mediators – CRRT non-selectively removes peak concentrations of pro- and anti-inflammatory mediators – Non-selective adsorption produced in excess may improve survival – May require higher doses of CRRT as compared with renal injury alone Peng et al. Burns (2005) – CVVHDF given to burn patients with sepsis – Plasma level of endotoxin, TNF-α, IL-1β, IL-6, and IL-8 significantly lower than pre-treatment or control – Endotoxin not present in effluent – No significant differences in median hospitalization or mortality Joannidis M. Seminars in Dialysis (2009) – Review – Use of standard CRRT in absence of AKI did not demonstrate changes in levels of cytokines or complement at standard doses (DeVriese et al 1999) – High adsorption hemofiltration (changing filter q3h in CVVH) showed significant reduction in IL-8 and IL-10 as well as faster reduction in vasopressor requirements (Haase et al 2007) – High volume hemofiltration used to increase convection and adsorption utilizing filtration rates up to 215ml/kg/h showed improved hemodynamic stability and survival

33 Cost ~$1100 per day for treatment Estimate $10,000-15,000 Owner should be prepared for at least hours of treatment

34 For More Info or Questions Anyone on dialysis team Happy to consult, talk with owners or RDVMs Personal contact info – – Pager: (508) – Cell: (225) – Home: (508)

35 QUESTIONS?


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