1. CRRT (Continuous Renal Replacement Therapy)
 Dr. Sree Bhushan Raju
MD,DM(AIIMS),DNB,MBA,FICP, FISN, FIACM Professor & Head Dept of Nephrology,  Nizam's Institute of Medical Sciences,  Hyderabd

2. Definition of CRRT
“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 24hours/day”
Bellomo R, Ronco C, Mehta R; Nomenclature for CRRT; AJKD 1996

5. Use of CRRT worldwide
First-choice RRT in ICUs throughout Australia, Japan and Europe
Best Kidney study
Treatment of AKI in 1,738 patients in 54 ICUs on five continents
CRRT- most common choice of initial RRT treatment, with 80% of patients
CRRT- used first in 100% of ICUs in Australia
IHD used as initial therapy in 30–40% of patients, restricted to North and South America

7. Comparision of different RRT modalities

8. Rt.jugular > Femoral > Lt.jugular > subclavian

9. Modes of CRRT

10. Solute and water transport in CVVH vs CVVHD

12. Indications of CRRT Haemodynamic instability
Disrupted fluid balance due to cardiac failure or multiorgan failure
Increased catabolic states (e.g., rhabdomyolysis)
Sepsis
Severe fluid overload
Cerebral oedema

13. ADV. vs DISADV. Advantages of CRRT More haemodynamic stability
No worsening of cerebral oedema
Easier fluid removal
Optimal flexibility
User-friendly machines may be operated by ICU nurses
Disadvantages of CRRT
Patient immobilization
Continuous anticoagulation
Treatment should be interrupted for patient transport
Higher ‘in-hospital’ costs
Slow removal of toxins

14. Pre-dilution vs Postdilution
Advantages of pre-dilution
Advantages of postdilution
Improved filter survival due to reduced haemoconcentration and membrane fouling
Reduced filter costs
Increased thermal losses
Increased solute clearances (for similar replacement rate)
Reduced requirement for replacement fluids (for similar clearance)
Reduced fluid costs

15. Advantages of CRRT over IHD
Allows adequate volume of nutrition without compromising fluid balance
Decreased vasopressor requirements during fluid removal
Increased hemodynamic stability
Optimizes fluid balance in lung injury
Continuous control of fluid balance

16. RCT on CRRT vs IHD

17. RCT on Dose of CRRT

18. Prescribed vs Delivered dose
ATN study
RENAL study
Prescribed dose low (mL/kg/hr) 20 25
Delivered dose low (mL/kg/hr)
17.5 22
Prescribed dose high (mL/kg/hr) 35 40
Delivered dose high (mL/kg/hr)
27.1
33.4

19. Dose of CRRT
The currently recommended dose for CRRT in critically ill patients with AKI is an actually delivered effluent flow of 20–25 mL/kg/hour
In order to account for the discrepancy between prescribed and delivered dose, it is recommended to prescribe an effluent flow of 25– 30 mL/kg/hour

20. Timing of RRT - Controversial!

21. Unresolved issues Timing of CRRT Modality of CRRT
Effect of CRRT on renal recovery and other patient centred outcomes

22. Thank u