1. Excessive fluid is not needed: So why is Dr. Durward so wasteful? Timothy E Bunchman MD Professor & Director Pediatric Nephrology tbunchman@mcvh-vcu.edu pedscrrt@gmail.com www.pcrrt.com

2. Comparison of Urea Clearance: CVVH vs CVVHD (Maxvold et al, Crit Care med. 2000 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

3. Dialysis Dose and Outcome Ronco et al. Lancet 2000; 351: 26-30 Conclusions: –Minimum UF rates should be ~ 35 ml/kg/hr –Survivors had lower BUNs than non-survivors prior to commencement of hemofiltration 425 patients Endpoint = survival 15 days after D/C HF 146 UF rate 20ml/kg/hr survival significantly lower in this group compared to the others 139 UF rate 35ml/kg/hr p=0.0007 140 UF rate 45ml/kg/hr p=0.0013

4. Intensive vs non Intensive RRT  HD and CRRT at 6 days per week and 35 mls/kg/hr daily  Vs.  HD and CRRT at 3 days per week and 20 mls/kg/hr daily  Intensity of Renal Support in Critically Ill Patients with Acute Kidney Injury The VA/NIH Acute Renal Failure Trial Network*  NEJM july 3, 2008 vol. 359 no. 1

5. The VA/NIH Acute Renal Failure Trial Network. N Engl J Med 2008;359:7-20 Kaplan-Meier Plot of Cumulative Probabilities of Death (Panel A) and Odds Ratios for Death at 60 Days, According to Baseline Characteristics (Panel B)

6. Copyright restrictions may apply. Lins, R. L. et al. Nephrol. Dial. Transplant. 2009 24:512-518; doi:10.1093/ndt/gfn560 Survival curves in patients randomized to intermittent (IRRT) or continuous (CRRT) renal replacement therapy investigating ICU mortality and hospital mortality

7. Meta Analysis-8 Studies ( Clin J Am Soc Nephrol 5:956-963, 2010)  Intensity of Dialysis result in the following  No difference in death rate  No difference in outcome based upon APACHE score  No difference in renal recovery  No difference in outcome based upon weight

8.  Look at data on nutritional loss!  Look at data on drug loss! Wasteful

9. Comparison of Total Amino Acid losses: CVVH vs CVVHD (Maxvold et al, Crit Care Med 2000 Apr;28(4):1161-5 ) Amino Acid Losses (g/day/1.73 m2) NS

10. Sieving Coefficients Solute (MW)Convective Coefficient Diffusion Coefficient Urea (60)1.01 ± 0.051.01 ± 0.07 Creatinine (113)1.00 ± 0.09 1.01 ± 0.06 Uric Acid (168)1.01 ± 0.04 0.97 ± 0.04* Vancomycin (1448)0.84 ± 0.10 0.74 ± 0.04** Calcium (protein bound)0.67 + 0.10.61 + 0.07 Cytokines (large)adsorbedminimal clearance *P<0.05 **P<0.01

11. Rebottled slide to follow

12. Why not save on resources?