Renal Replacement Therapy 101

Frank Luo Renal Fellow

What we will go over today:

Understand the physiologic differences between hemodialysis and hemofiltration Understand what is CVVH, CVVHDF, PUF, SLED, SCUF Understand the elements of the dialysis prescription Review clinical trials comparing different dialytic modalities

Hemodialysis vs Hemofiltration

Hemodialysis

Hemodialysis

Diffusive clearance Removal of solutes depend on: - concentration gradient - size of molecule - surface area of membrane Highly efficient system for removing urea

Hemodialysis solute levels have sawtoothed fluctuations

UREA

TIME

Hemofiltration

Hemofiltration

Convective clearance Solute removal depends on: - ultrafiltration rate - size of molecule Exactly as shown, this is called PUF (pure ultrafiltration)

Continuous therapies

CVVH (Continuous Veno-venous Hemofiltration)

post-dilution

pre-dilution

CVVHDF (Continuous Venovenous HemoDiafiltration)

Dialysate

CVVH - solute levels are constant

UREA

TIME

The Equipment

We have come a long way

Our toys

Dialyzers

Dialyzers

The Prescription

The Prescription
Hemodialysis

CVVH

Blood speed (300-350ml/min) Dialysate flow (500-800ml/min) Time (3-4 hours) Fluid out Bath - Na+ - K+ - Ca2+ - HCO3-

Blood speed (150-250ml/min) Replacement fluid (15-30ml/min) - saline - saline + bicarb - saline + bicarb + K+ - Prismasate Net UF rate (even, -50, -100)

Theoretical advantages of CVVH over Hemodialysis

Hemodynamically better tolerated Better control of electrolytes and urea clearance Better middle molecule clearance Greater removal of excess fluid Allow simultaneous administration of large fluid volumes Ease of use

Overcoming BP Instability on Hemodialysis

Lower dialysate temperature (34-36) Slower UF rate, longer dialysis time Higher Na+ bath Higher Ca2+ bath Iso-volumetric connection

Is CVVH better than Hemodialysis?

Mortality

Meta-analysis 9 RCT Continuous vs Intermittent N=1403

Crit Care Med. 2008 Feb;36(2):610-7

Cochrane Review
15 RCT, 1550 patients, Continuous vs Intermittent

RR
In hospital mortality ICU mortality Dialysis free survival Hypotension Escalation of pressors 1.01 1.06 0.99 0.92 0.53

CI
0.92 - 1.12 0.90 - 1.26 0.92 - 1.07 0.72 - 1.16 0.26 - 1.08

Cochrane Database Syst Rev. 2007 Jul 18;(3):CD003773

Common Complications of Hemodialysis

Hypotension (20-30%) Cramps (5-20%) Nausea + vomiting Headache Chest pain Back pain Itch

Special Precautions about CVVH

Treatment interruptions Clotting risk - systemic anticoagulation: heparin - regional anticoagulation: sodium citrate Electrolyte imbalance - K+, Mg2+, PO4Amino acid losses Drug dose adjustments

Hemodialysis
Mechanism Treatment Solute clearance Dialyzer Pump speeds Complications Diffusion Intermittent Small > Large Large surface High volume Hypotension

CVVH
Convection Continuous Small Large Smaller surface Low volume Clotting

What about SLED and SCUF ?

SLED sustained low efficiency dialysis useful in unstable patients, CVVH not available SCUF slow continuous ultrafiltration useful in CHF who are difficult to diurese

More dialysis is better ?

VA/NIH ARF Trial Network

N Engl J Med 359:7, July 3, 2008

All Cause Mortality

Subgroup analysis

Summary

Hemodialysis and Hemofiltration have different mechanisms in solute clearance Hemofiltration (CVVH) has not been shown to be superior to intermittent hemodialysis More intensive renal replacement therapy in acute renal failure has not been shown to improve survival

Questions