1. 血液透析原理及臨床適應症
台大醫院 外科部護理師
蔡壁如

2. Evolution of Renal Replacement Therapy
Kramer, 1977
First CRRT (CAVH)
1994
Automated CRRT
CRRT or SLEDD?
Abel, 1913
First dialysis of animal
Kolff, 1945
First dialysis in human
Teschan, 1950s
Daily dialysis in Korean war
Since 1960s
Chronic, intermittent hemodialysis (IHD) ( 24hrs q.w hrs b.i.w hrs t.i.w. )
Daily dialysis?
Contrib Nephrol. 2004; 145: 1-9

3. Basic Principle of Renal Replacement Therapy
Diffusion
Solute from higher concentration to lower concentration
Ultra-filtration
Fluid trough semi-permeable membrane driven by pressure gradient
Convection
Solute and fluid (Depending on molecular weight and size) by ultra-filtration
Adsorption
Molecular adhesion to inner surface of semi-membrane
NEJM 336:

4. Diffusion

5. Ultra-filtration

6. Convection

7. Adsorption

8. Molecular weights

9. Molecules sizes

10. Molecules Size

11. Low-Flux Membrane

12. High Flux Membrane

13. IL-6, TNF-α 20000 Molecular weights cut-offs <30000> IL-1, IL-8
IL-1, IL-8, TNF-a

14. Clearance = QF x SC QF= filtration amount SC=sieving coefficients

15. Hemodialysis
NEJM 336:

16. Hemofiltration
NEJM 336:

17. Component of renal replacement therapy
Membrane
Vascular access
Anti-coagulant
Dialysate
Renal replacement fluid

18. Choice of membrane Substituted cellulose dialyzers :
hydroxyl group
Cellulose acetate, diacetate, triacetate
Synthetic dialyzers :
Polysulfone (PS)
Polyamide (PA)
Polyacrylonitrile (PAN)
Polymethylmethacrylate (PMMA)
American Journal of Kidney Disease, Vol 35, NO 5(May), 2000:pp

19. Choice of membrane
Biocompatible membrane (activate less complement and greater higher 2-microglobulin clearance, greater hydraulic permeability.low and high-flux synthetic membranes)
Hypotension and prolongation of ARF in biocompatible membranes
Adsorptive vs. nonadsorptive membrane in CRRT
American Journal of Kidney Disease, Vol 35, NO 5(May), 2000:pp

20. Vascular access Grade C : avoided subclavian in adults
Grade D : avoided femoral vein in neonates and young (femoral vein thrombosis is a significant problem)
Grade C : Internal jugular vein
Level II and III studies : Ultrasound guidance
Re-circulation is likely to be significant for blood flow in excess of 200 c.c/min, but depending on catheter design and location
The first international consensus conference on CRRT, 2002

21. Double lumen : Re-circulation rate
under 250cc/min blood flow
Subclavian , internal jugular vein < 3%
Catheter length
Femoral vein 24cm : 10%, cm : 18%
Blood flow
400 cc/min : 38% in the femoral vein
American Journal of Kidney disease , 1996

22. Anticoagulation Standard protocol
Initial bolus unit/kg of heparin
Infusion unit/kg to target
ACT : seconds or
PTT: 2 X
N.J.Maxvold, T.E. Bunchman/Crit Care Clin (2),

23. Ideal replacement fluid/dialysate
Principle: remove waste, supply lost
Nearly plasma water
Supply inadequate component
Individualized
Different disease

24. Dialysate (透析液) Na K Ca Mg GB +No8 140 2.0 3.5 1.0 GB +No9 137 2.5 Cl
Acetate
HCO3-
GB +No8
107 5 -
GB +No9
106 39
Units: mEq/L

25. Replacement Fluid (補充液)Na Ca Mg Cl
HCO3-
mEq/L
CVVH A 液
147
5.2
2.8
155 -
CVVH B 液
137 71 33
A+B
142
2.6
1.4
113
CVVH B 液 = H/S 2760ml + Rolikan 250ml

27. Hybrid therapies in ICU
CRRT (Continuous Renal Replacement Therapy )
EDD ( Extended daily dialysis )
SLEDD ( Slow Low-efficient Daily Dialysis )
SLEDD-f (Sustained Low-efficiency Daily Diafiltration )
IHD ( Intermittent Hemo-dialysis )

28. CRRT
iHD

29. Hybrid or Prolonged Intermittent Renal Replacement Therapies
CRRT
iHD

30. EDD: Extended Daily Dialysis
Fresenius 2008H delivery system
Double lumen
Toray 2.0 m2 dialyzer
Duration : 6 ~ 8 hrs
Blood flow : 200 ml/min
Dialysate flow rate : 300 (500) ml/min
Dialysate potassium concentration 4 meq/L
Dialysate bicarbonate concentration : 30 ~ 35meq/L
American Journal of Kidney Disease, Vol 36, No 2 (August), 2000: pp

31. SLEDD ( Slow Low-efficiency Daily Dialysis )
Fresenius 2008H delivery system
Double lumen
Duration : 6 ~ 12 hrs
Blood flow : 200 ml/min
Dialysate flow rate : 300 ml/min
Dialysate bicarbonate concentration : 30 ~ 35meq/L
American Journal of Kidney Disease, 2000

32. SLEDD-f Sustained Low-efficiency Daily Diafiltration
Fresenius 4008S
Double lumen
Duration : 8 ~ 12 hrs
Blood flow : 200 ml/min
Dialysate flow rate : ml/min
High Flux Dialyzer
Online replacement fluid
Nephrol Dial Transplant :

33. Nomenclature

35. HD treatment in ICU depend
Treatment behavior
Availability of treatment methods
Organization of the unit
Knowledge and experience of nurses
Existence of nephrological unit in the hospital
Cost
Individual doctor must therefore know the advantages and disadvantage of different treatment options
Kidney Blood Press Res2003;26:

36. Daily hemodialysis and the outcome of acute renal failure
ARF require CRRT is related high mortality and uremic damage to other organ systems
Intensive hemodialysis reduces mortality without increasing hemodynamically induced morbidity.
Survival was the primary endpoint of the study
Mortality rate : 28% Vs. 46% (daily H/D Vs. Alternate H/D )
N Engl J Med 2002;346:305-10

37. IHD vs CVVH IHD CVVH Diffusion Low-flux membrane High dialysate flow
A few hours per day
Technically demanding
Less labor intensive
Convection
High-flux membrane
Low dialysate flow
Theory continuously
Technically less demanding
Labor intensive
Journal of the American Society of Nephrology, 2001

38. IHD vs CVVH IHD CVVH Advantages Short duration Cheap
Less labor-intensive
Hemodynamic stability
Better removal of cytokines
Disadvantages
Rapid hemodynamic change
Technically sophisticated
Continuous anticoagulation
Patient immobility
Intensive nursing requirement
Increased expense

39. What is SLEDD-f ?? Sustained Low-Efficient Daily Diafiltration
A conceptual and technical hybrid of continuous veno-veno hemofiltration(CVVH : convection) and intermittent hemodialysis (IHD : diffusion )

40. Advantage of SLEDD-f Patient mobility ↑ Anticoagulation ↓
hemodynamic stability – or ↑
Nursing labor ↓
Professional ↑
Cost ↓
American Journal of Kidney Disease, 2000

41. The predominant potential advantages of continuous renal replacement therapy
Hemodynamics stability correction of hypervolemia and metabolic acidosis
Better solute removal
Recovery of renal function
Biocompatibility
Correction of malnutrition
Better removal of cytokines
Overall outcomes ?
Kidney Blood Press Res2003;26:
Journal of the American Society of Nephrology, 2001

42. Potential disadvantages of CRRT
Need for continuous anticoagulation
More difficult drug dosing
Low efficiency interims of unit/ time ( e.g. Severe hyperkalemia)
Nonselective solute removal : depletion syndrome with prolonged use of high Qf ?
The Netherlands Journal of Medicine
August 2003

43. Sustained low-efficiency dialysis in the ICU: Cost, anticoagulation, and solute removal
Treatment parameters for current and previous SLED studies
Author (reference)
Kumar
et al4
Marshall
et al5
This study
Treatment name
EDD
SLED
SLEDD-f
Hours/day
7.5 12 8
Days/week
6-7
4-7 6
Blood flow (ml/min)
200
100
300
Dialysate flow (ml/min)
350
Replacement fluid (ml/min) － 17
KI (2006) 70,

44. Sustained low-efficiency dialysis in the ICU: Cost, anticoagulation, and solute removal
Measures of small solute removal
CRRT
SLED
P-valve
Morning serum creatinine after day 3 (μmoL/l)
136±49
120± 55
0.06
Time-average serum creatinine (μmoL/l)
95±49
0.03
Weekly Kt/V
7.1±2.1
8.4±1.8
<0.001
EKR ( ml/min)
31±10
31±7 NS
EKR (ml/min)
28±9
29±6
KI (2006) 70,

45. Daily and weekly cost of SLED and CRRT
Sustained low-efficiency dialysis in the ICU: Cost, anticoagulation, and solute removal
Daily and weekly cost of SLED and CRRT
SLED($)
CRRT citrate ($)
CRRT heparin ($)
Supply cost/day
69.75
402.8
334.95
HD RN cost/day
168.75a
37.5
Total cost /day
238.5
440.3
372.45
Total cost / week
1431
3089
2607
KI (2006) 70,

46. Dialysis guideline in NTUH SICU
Dominant and responsibility by Intensivist
Hybrid Therapies in NTUH SICU
Setting up and performing by Technician and NP

47. Guideline in CVVH Indication： Setting:
(1). Cerebral edema：Mannitol ≧ q12hr in use frequency
(2). Prevention of post-dialytic “ rebound” intoxication
Setting:
Double lumen: 14Fr，儘量打在right neck vein
blood flow: 200mL/min
hemofiltration: 35mL/kg/hr
dialyzer: PAN 10
HF-400 CVVH：pre-dilution : post-dilution＝ 50%:50%
Replacement fluid：信東A＋(B＋Rolikcan)，若病人「K+」低，則每袋B液加KCl (20 meq)一支

48. Guideline in IHD (1). IHD (4 hr)：病況穩定時使用之
(2). EDD (4 ~ 6hr)：stable hemodynamics，但預計脫水超過2L，為了增加脫水量而延長H/D時Initial H/D setting for patients with double lumen
Blood Flow：200c.c/min
Dialyzer：FK-18C (EVAL 1.8m2)
Dialysate：IHD、EDD set 500c.c/min，SLEDD set 300c.c/min
Net UF rate: max 500c.c/hr, 若須更多的脫水，則延長透析時間 (EDD)
Dialysate Temp.：37℃
Dialysate：信東No 9＋GB solution

49. Guideline in SLEDD、 SLEDD-f
Indication: 取代CVVH
blood flow: 200mL/min
Dialysate: 300mL/min，Dialysate Temp. : 38℃
Portable RO機使用
Dialyzer: FX60 (FMC, Helixone 1.4m2)
Duration：8 ~ 12hr
Replacement fluid：UF rate : 35c.c/kg/min
Dialysate：信東No 9＋GB solution

50. Guideline in heparin use
Priming solution：2000 unit/1000c.c N/S
以下情況不用Heparin：
Major operation  48 hr
Bleeding tendency：INR＞2.0 or PTT > 50sec or Plat  50000
Active bleeding：e.g. GI bleeding, Surgical bleeding, etc
其他情形使用heparin
Heparin solution concentration: 2c.c heparin (10000 unit)/20c.c N/S
Dosage：30 unit/Kg/hr
H/D結束前1小時，停止Heparin infusion
Reference: Journal of Nephrology 2003:6;

57. SLEDD-f

58. 新型洗腎機:5008