Convection (CVVH) is Better! Timothy E Bunchman MD Professor & Director Pediatric Nephrology

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Presentation transcript:

Convection (CVVH) is Better! Timothy E Bunchman MD Professor & Director Pediatric Nephrology

Convective Clearance To increase clearance by convection, increase ultrafiltration rate (will require more replacement fluids) CVVH

D Diffusive Clearance To increase clearance by diffusion, increase dialysate flow rate HD, PD, CVVHD, SLED

Sieving Coefficients Solute (MW)Convective Coefficient Diffusion Coefficient Urea (60)1.01 ± ± 0.07 Creatinine (113)1.00 ± ± 0.06 Uric Acid (168)1.01 ± ± 0.04* Vancomycin (1448)0.84 ± ± 0.04** Calcium (protein bound) Cytokines (large)adsorbedminimal clearance *P<0.05 **P<0.01

Comparison of Urea Clearance: CVVH vs CVVHD (Maxvold et al, Crit Care med Apr;28(4):1161-5) Urea Clearance (mls/min/1.73 m2) BFR = 4 mls/kg/min FRF/Dx FR = 2 l/1.73 m2/hr SAM = 0.3 m2 p = NS

 51 patients in ppCRRT with SCT  Mean %FO = %.  45% survival  Convection: 17/29 survived (59%)  Diffusion: 6/22 (27%), p<0.05  Survival lower in MODS and ventilated patients Stem Cell Transplant: ppCRRT Flores FX et al: Pediatr Nephrol Apr;23(4):625-30

 40 patients with Sepsis/ARF at 4 ppCRRT centers  Randomized crossover design  24 hours of CVVH or CVVHD, then crossover  2500 ml/hr/1.73m2 clearance  Dialysis/Replacement fluid with [HC03]=35mmol/l  Citrate ACG  Serum collection at 0,1, 24, 25 and 48 hours  TNF-alpha  IL-1 beta  IL-6, IL- 8, IL-10, IL-18  Six hours of effluent for CK’s for clearance estimation Prospective Pediatric Study

 10 patients enrolled to date  6 male, 4 female  Mean age years  Mean weight kg  PELOD  Mean =  Median = 22 (range 11-42) ppCRRT Sepsis Study

CytokineConvectionDiffusionp TNF-alpha IL-1 beta IL IL IL IL PELOD ppCRRT [Cytokine] % Change: Convection vs. Diffusion

 Convection is equal to diffusion for small molecules but superior for cytokines and inflammatory mediators  Why not give your child the best treatment! Summary

Rebottled slide to follow

Dr. Carcillo is dancing around the question