CRRT
Uremic Toxins
Clearance
ULTRAFILTRATION
• Movement of fluid through a semi-permeable membrane along a pressure gradient.
• Positive pressure is generated on the blood side of the membrane
• Negative pressure is generated on the fluid side
CONVECTION
• One-way movement of solutes through a semi-permeable membrane with water flow.
• Solvent drag
• Efficient for both larger and smaller molecules
• The faster the substitution flow rate, the higher the clearance.
Continuous renal replacement therapy (CRRT)
• Therapy indicated for continuous solute removal and/or fluid removal in the critically ill
patient
• For slow and isotonic fluid removal
• Hemodynamic tolerance even in unstable patients with shock and severe fluid overload.
Continuous Therapies
• Continuous hemodialysis (C-HD)
• Continuous hemofiltration (C-HF)
• Continuous hemodiafiltration (C-HDF)
• Slow continuous ultrafiltration (SCUF)
• Intermittent Hemodialysis
• Prolonged Intermittent Therapies
• Sustained low efficiency hemodialysis, SLED
Continuous hemodialysis (C-HD)
• Dialysis solution is passed through the dialysate compartment of the
filter continuously and at a slow rate
• Diffusion is the primary method of solute removal.
Continuous hemofiltration (C-HF)
• No dialysate is used
• A large volume (about 25–50 L/day) of replacement fluid is infused
• Inflow or the outflow blood line (predilution or postdilution mode,
respectively)
• Volume of fluid that is ultrafiltered across the membrane is
• Replacement fluid and
• Excess fluid removed
• Fluid ultrafiltered much higher than with C-HD
Continuous hemodiafiltration (C-HDF)
• A combination of C-HD and C-HF
• Dialysis solution is used, and replacement fluid is also infused
• Volume of fluid that is ultrafiltered across the membrane is
• Replacement fluid infused plus
• Net volume removed
Slow continuous ultrafiltration (SCUF)
• Setup is similar to that for C-HD and C-HF
• Neither dialysis solution nor replacement fluid is used.
• Daily ultrafiltered fluid volume across the membrane is low (usually
about 3–6 L per day)
SCUF (Slow Continuous Ultrafiltration)
SCUF is a process by which excess fluid is removed with little or no change in blood
solute concentrations.
Very small amounts of urea and creatinine are removed passively along with the
ultrafiltrate.
SLED
• IHD using an extended (6- to 10-hour) session
• Reduced blood and dialysate flow rates.
• Qb are about 200 mL/min and
• Qd is 100–300 mL/min.
• Hemodialysis equipment supporting low blood and dialysate flow rates needed
Components
• Machine
• Hemofilter
• Access
• Anticoagulation
• Replacement Fluid
• Ultrafiltrate
VASCULAR ACCESS
Venovenous blood access
• A dual-lumen cannula inserted into a large (internal jugular or femoral) vein.
• The subclavian vein can be used but is not the site of first choice .
Arteriovenous blood access.
• AV blood access for CRRT is no longer widely practiced
• Usually the femoral artery
• Propel blood through the extracorporeal circuit by using the patient’s own
arterial pressure instead of a pump
• Blood is returned via any large vein
CRRT FILTERS
CRRT Dialyzers have high water permeability, and so will be in the
“high-flux” category
DIALYSATES AND REPLACEMENT SOLUTIONS
• Premixed as commercially prepared sterile solutions
• Packaged in 2.5-L or 5-L bags
• Supplied in bags with two compartments that need to be mixed immediately
prior to use.
Buffers
Lactate-based solutions.
• Pure lactate-based replacement fluid usually contains 40–46 mM of lactate
• Lactate is metabolized on a 1:1 molar basis to bicarbonate
Bicarbonate-based solutions.
• Two-compartment systems
• Base concentrations are typically 25–35 mM.
• Some solutions contain a small amount (3 mM) of lactate, left over from lactic
acid used to acidify the final solution
Citrate-based solutions.
• Attempts to merge the buffering and anticoagulation properties of citrate
• Citrate-based solutions at 18 mM
• Acid–base consequences have not been adequately studied
Dose of CRRT
• The suggested dose of CRRT in AKI is a delivered effluent volume of 20–
25 mL/kg per hour
• As per RENAL study and ATN study, the average serum urea nitrogen
achieved should be less than 45 mg/dL (16 mmol/L)
• Typical blood flow is 60 to 100 mL per minute
• Dialysate flow is generally set at 1 to 2 liters per
hour.
Advantages
• Hemodynamically well tolerated; smaller change in plasma osmolality.
• Better control of azotemia and electrolyte and acid–base balance;
• Highly effective in removing fluid (postsurgery, pulmonary edema, ARDS).
• Less effect on intracranial pressure.
SLED
• IHD using an extended (6- to 10-hour) session
• Reduced blood and dialysate flow rates.
• Qb are about 200 mL/min and
• Qd is 100–300 mL/min.
• Hemodialysis equipment supporting low blood and
dialysate flow rates needed
