1. Dialysis and Replacement Solutions for Pediatric CRRT
Jordan M. Symons, MD
University of Washington School of Medicine
Children’s Hospital & Regional Medical Center
Seattle, WA

2. CRRT Solutions: Outline of the Talk
Purpose of solutions in CRRT
Goals for a CRRT solution
Description of solutions currently available for CRRT
Considerations in choosing a solution for CRRT

3. First CAVH Circuit
Kramer, P, et al. Arteriovenous haemofiltration: A new and simple method for treatment of over-hydrated patients resistant to diuretics. Klin Wochenschr 55:1121-2, 1977.

4. CAVH: Good for Fluid Balance, Not So Good for Metabolic Balance
CAVH removes all molecules slowly
Good for BP stability (slow UF)
Not so good for metabolic control
Need method to increase molecular clearance without increasing UF rate

5. Small molecules diffuse easily Larger molecules diffuse slowly
Diffusion
Small molecules diffuse easily
Larger molecules diffuse slowly
Dialysate required
Concentration gradient
Faster dialysate flow increases mass transfer

6. Small/large molecules move equally Limit is cut-off size of membrane
Convection
Small/large molecules move equally
Limit is cut-off size of membrane
Higher UF rate yields higher convection but risk of hypotension
May need to Replace excess UF volume
Neg Press
H2O
H2O
H2O
H2O

7. Solutions in CRRT Address Molecular Control Issues
Improved mass transfer using diffusion, high-grade convection, or combination
CVVH: a pure convection modality
CVVHD: a diffusion modality
CVVHDF: combined convection/diffusion
Permits correction of metabolic abnormalities
Provides “complete” renal replacement

8. Characteristics of the Ideal CRRT Solution
Physiological
Reliable
Inexpensive
Easy to prepare
Simple to store
Quick to the bedside
Widely available
Fully compatible

9. Options for CRRT Solutions
Peritoneal dialysate:
Pre-made IV solutions:
Saline, Lactated Ringers
Multi-bag systems:
Custom-made solutions:
Local pharmacy; outsource
Commercially available CRRT solutions NO
MAYBE
UNNECESSARY
RARELY

10. Commercial Solutions for CRRT: Several Companies, Multiple Options
Previously: limited options
No bicarbonate-based solutions
US regulations re: “drug” vs. “device”
Currently: multiple manufacturers each offering a variety of formulations
Bicarbonate as primary or only base
The Choice: may depend on local policy, vendors, economic pressures

11. Normocarb (DSI) Bicarbonate buffered Concentrate must be compounded
Final volume 3.24 liters (240ml concentrate added to 3 L bag)

12. Chemical Content of Normocarb
Ion
Concentration After Mixing (mEq/L)
Sodium
140
Potassium
Chloride
107
Bicarbonate 35
Calcium
Magnesium
1.5

13. Normocarb HF (DSI) Bicarbonate buffered Concentrate must be compounded
Final volume 3.24 liters (240ml concentrate added to 3 L bag)
2 ionic formulations
Normocarb HF 25
Normocarb HF 35

14. Chemical Content of Normocarb HF
Ion (mEq/L)
HF 25
HF 35
Sodium
140
Potassium
Chloride
116.5
106.5
Bicarbonate 25 35
Calcium
Magnesium
1.5

15. PrismaSate (Gambro) Bicarbonate buffered Small amount of lactate
5 liter bag
2 compartments to prevent precipitation
Six ionic formulations

16. Chemical Content of PrismaSate
Ion (mEq/L)
BK0/3.5
BGK2/0
BGK4/0/1.2
BGK4/2.5
B22GK4/0
BK2/0
Sodium
140
Potassium 2 4
Chloride
109.5
108
110.2
113
120.5
Bicarb 32 22
Lactate 3
Calcium
3.5
2.5
Magnesium 1
1.2
1.5
Gluc(mg/dL)
110

17. PrismaSol (Gambro) Bicarbonate buffered Small amount of lactate
5 liter bag
2 compartments to prevent precipitation
Seven ionic formulations

18. Chemical Content of PrismaSol
Ion (mEq/L)
BK 0/3.5
BGK 2/0
BGK 2/3.5
BGK 4/2.5
BGK 4/0
BGK 0/2.5
BK 0/0
Sodium
140
Potassium 2 4
Chloride
109.5
108
111.5
113
110.5
109
106.5
Bicarb 32
Lactate 3
Calcium
3.5
2.5
Magnesium 1
1.5
Gluc(mg/dL)
100

19. Accusol (Baxter) Bicarbonate buffered No lactate 2.5 liter bag
2 compartments to prevent precipitation
Five ionic formulations

20. Chemical Content of Accusol
Ion (mEq/L)
5B9248
5B9249
5B9250
5B9251
5B9252
Sodium
140
Potassium 4 2
Chloride
113.5
111.5
109.5
116.3
Bicarb 35 30
Lactate
Calcium
3.5
2.8
Magnesium 1
1.5
Gluc (mg/dL)
100

21. Duosol (B.Braun) Bicarbonate buffered No lactate 5 liter bag
2 compartments to prevent precipitation
Three ionic formulations

22. Chemical Content of Duosol
Ion (mEq/L)
4450
4451
4452
Sodium
136
140
Potassium 2
Chloride
107
109
111
Bicarb 25 35
Lactate
Calcium 3
Magnesium
1.5 1
Gluc (mg/dL)
100

23. NxStage PureFlow (NxStage)
Part of NxStage System One for acute care
5 liter bags
Choice of buffers
Lactate: 3 formulations; single-chamber bag
Bicarbonate: 5 formulations; dual-chamber bag

24. Chemical Content of NxStage PureFlow (1)
Ion (mEq/L)
Lactate Buffer
RFP-204
RFP-205
RFP-207
Sodium
140
Potassium 1 3
Chloride
105
112
100
Bicarbonate
Lactate 40 35 45
Calcium
Magnesium
Glucose (mg/dL)

25. Chemical Content of NxStage PureFlow (2)
Ion (mEq/L)
Bicarbonate Buffer
RFP-400
RFP-401
RFP-402
RFP-453
RFP-454
Sodium
140
130
Potassium 2 4
Chloride
111
113
109
108.5
110.5
Bicarbonate 35 25
Lactate
Calcium 3
Magnesium 1
1.5
Gluc (mg/dL)
100

26. Choosing a Solution: Issues to Consider
Cost
Anticoagulation
Patient safety
CRRT modality
Diffusion (CVVHD)
Convection (CVVH)
Both (CVVHDF)

27. Anticoagulation and Solutions
May need to consider Ca++ content if using citrate for anticoagulation
Solution
Calcium?
Normocarb HF No
Accusol
4 Yes; 1 No
PrismaSate
2 Yes; 4 No
PrismaSol
4 Yes; 3 No
Duosol
2 Yes; 1 No
NxStage PureFlow
6 Yes; 2 No

28. Evaluation of Errors in Preparation of CRRT Solutions
Survey of 3 Pediatric Listserves:
Pediatric Critical Care, Nephrology, CRRT
16/31 programs reported solution compounding errors
Consequences of improper solutions
2 deaths
1 non lethal cardiac arrest
6 seizures (hypo/hypernatremia)
7 without complications
Barletta et al, Pediatr Nephrol. 21(6):842-5, 2006 Jun

29. FDA Approval Status of CRRT Solutions
FDA Label
Normocarb HF
Replacement
PrismaSate
Dialysate
PrismaSol
Accusol
Duosol
NxStage PureFlow

30. Putting it All Together: One Approach
CRRT with citrate regional anticoag R
DIALYSATE: commercial bicarb-based solution D
REPLACEMENT: normal saline
Adjust blend, change saline if indicated

31. On-Line Dialysate with SLED: An Alternative to Solutions in CRRT
Extended sessions using standard dialysis equipment
Dialysate made on-line from concentrates
Simple, convenient, MUCH cheaper
Dialysate is not sterile

32. Citrasate (Advanced Renal Technologies)
“A” concentrate for dialysis
Liquid or bulk powder
Citrate used as acidifying agent
Local anticoagulation greatly reduces need for heparin

33. CRRT Solutions: Summary
Solutions needed to maximize clearance
Bicarbonate has superseded lactate
Industry-made solutions are available including some approved for replacement
Pre-mixed, sterile solutions for CRRT are simple, safe, may be costly
On-line dialysate for SLED is clean (not sterile), simple, cheap
The best “solution” may still be pending

34. Thanks!