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Renal Replacement Therapy

Talk on various types of RRT, made for GICU
by

Richard Kirkdale

on 19 January 2013

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Transcript of Renal Replacement Therapy

Renal
Replacement
Therapy Timing Intermittent Continuous Mode Site Blood source Dialysis Filtration Peritoneal Extra-corporal Fistula Venous Line GICU Line Site Anticoagulation Fluid content Membrane ...is complicated IHD
IAPD CAPD
SCUF
CVVHF
CVVHD
CVVHDF Long term RRT
Older population
Risk of Sclerosing Peritonitis! Dialysis or filtration
Bridge to transplant
Long term RRT for CKD
Short term RRT for AKI
Other indications Take time to create
Arterial supply
Lower infection risk Quicker
TESIO vs VasCath
Only allows Veno-venous Internal Jugular Femoral Subclavian CVVHD
(IHD) CVVHF CVVHDF Dialysis vs Filtration Dialysis depends on the process of DIFFUSION Diffusive solute removal down a concentration gradient Gradient is maintained by counter-current flow of dialysate Control of removal of various molecules by relative composition of dialysate Smallest molecules removed best CVVHD Blood flow 50-200ml/hr
Dialysate 1-2.5L/hr
small>middle>large molecules
=Urea>Creatinine Filtration depends on the process of ULTRAFILTRATION Convective solute removal down a pressure gradient "solute drag" Gradient is maintained by maintaining pressure in the blood circuit Removes all molecules within filter range equally CVVHF Blood flow 100-200ml/min
Effluent is replaced with physiological fluid, pre- or post-filter
Heparin efficiently cleared
Most effective at middle sized molecules (inc inflammatory cytokines) Pre-filter replacement
increased pressure to drive convection
dilutes blood therefore decreases solute clearance by <15%

Post-filter replacement
causes haemoconcentration which causes clogging in filter CVVHDF Blend of HF & HD
Combined convection & diffusion
Theoretical better removal of small & large molecules
Removal of up to 1L/hr! Heparin Citrate PGE2 or PGI2 "Physiological" solutions
Usually low/no K & PO4
No HCO3, but often lactate or acetate buffered
Different for Citrate anticoagulation Membrane pore size dictates what is filtered
usual is 30-50kDa
Seiving coefficients: 1=free passage, 0=blocked
Na 0.94
K 1.0 Creat 1.0
Alb 0.0 CVVHDF Heparin or Flowlan (Citrate) Prismasol 30:70 Pre-:Post- filter replacement Blood flow ~180ml/min dose ~35ml/kg/hr dialysate ~1000ml/hr Int Jugular (15cm R vs 20cm L)
Femoral (20cm)
Subclavian M100 or M150 filters
both ?65kDa pore (higher in special circumstances) Clotting vs Clogging Activation of coagulation pathway
Decreased blood flow
Decreased access pressure

Needs more anticoagulation Debris filling the pores of the membrane
Increased TMP



Increase pre-filter replacement
Bigger filter (more SA
Full transcript