Introduction of Continuous Renal

Replacement Therapy
(CRRT)

Yohanes WH George

Acute Renal Failure in Critical Ill Patients

A) Mortality rate of acute renal failure
A) Mortality rate over 80% before intermittent hemodialysis
(HD)
B) Drop of mortality to 50% after HD
C) Mortality rate over 70% since 1980
B) Reasons for high mortality rate of ARF
A) Progressive in intensive care: antibiotics, hemodynamic
monitor, cardiovascular & respiratory support
B) Old age
C) Multiple organ failure

Acute Renal Failure in ICU

Goals for treatment
Intensivist

Nephrologist

Maintain tissue O2 deliveryFluid management

Increased cardiac output
Enhance ventilation
Maintain blood pressure
Solute control
Prevent hypermetabolism
Provide adequate nutrition
Treat primary process
Electrolyte balance
Acid -Base balance

Proposed Criteria for the Initiation of Renal Replacement

Therapy in Adult Critically Ill Patients

1. Oliguria (urine output<200 ml/12 hr)

2. Anuria/extreme oliguria (urine output<50 ml/12 hr)
3. Hyperkalemia ([K+]>6.5 mmol/liter)
4. Severe academia (pH<7.1)
5. Azotemia ([urea]>30 mmol/liter)
6. Clinically significant organ (especially lung) edema
7. Uremic encephalopathy
8. Uremic pericarditis
9. Uremic neuropathy/myopathy
10. Severe dysnatremia ([Na]>160 or<115 mmol/liter)
11. Hyperthermia
12. Drug overdose with dialyzable toxin
( KI 1998, R. Belloma and C. Ronco)

Renal Replacement Therapy for Acute Renal

Failure in Intensive Care Units

Intermittent therapies: Intermittent hemodialysis (IHD),

extended daily dialysis (EDD), slow low-efficiency
dialysis (SLED)
Peritoneal dialysis (PD)
Continuous renal replacement therapy (CRRT): SCUF,
CAVH, CAVHD, CAVHDF, CVVH, CVVHD, CVVHDF

Advantages of CRRT Compared with IHD

1. CRRT maintains consistent homeostasis through slow, gradual
shifts in volume status and serum osmolality
2. CRRT avoids hypotensive or dysequilibrium episode
3. CRRT permits continuous control of fluid balance and reduces
the need to restrict fluid administration
4. CRRT requires a lower volume of blood to be circulating outside
the body
5. CRRT has less effect on complement or leukocytes
6. CRRT does not require expensive equipment or extensive
training of personnel
7. CRRT has greater clearance of mid-molecular weight solute

History of CRRT (1)

1960 Scriber et al: The technique of continuous hemodialysis
1967 Henderson et al: Blood purification by ultrafiltration
and fluid replacement
1974 Silverstein et al: Treatment of severe fluid overloading
by ultrafiltration
1977 Peter Kramber et al: Continuous arteriovenous
hemofiltration (CAVH)
1979 CVVH was employed in Cologne
1979 Paganini et al: Slow continuous ultrafiltration (SCUF)
1982 FDA approval: CAVH in ICU patients
1984 October 7, Peter Kramber sudden death
1984 Geronemus et al: Continuous arteriovenous hemodialysis
(CAVHD)
1988 Tam et al: Continuous venovenous hemodialysis (CVVHD)

Definitions of CRRT

Any extracorporeal blood purification therapy intended to

substitute for impaired renal function over the extended
period of time and applied for, or aimed at being applied for
24 hours/day.

Continuous Renal Replacement Therapy (CRRT)

CAVH: Continuous arteriovenous hemofiltration
CAVHD: Continuous arteriovenous hemodialysis
CAVHDF: Continuous arteriovenous hemodiafiltration
CVVH: Continuous venovenous hemofiltration
CVVHD: Continuous venovenous hemodialysis
CVVHDF: Continuous venovenous hemodiafiltration
SCUF: Slow continuous ultralfiltration

CRRT: AV v.s VV
* Arteriovenous therapies (AV)
- Technique simplicity
- Required large-bore arterial catheter
- Blood flow dependent on MAP
* Venovenous therapies (VV)
- No arterial line
- Pump-assisted
- Blood flow independent of blood pressure

Further Definitions (1)

Ultrafiltration:
In the field of renal replacement therapy, this is a term
describing the process by which plasma water and ultrafiltrate
solutes are separated from whole blood, across a semipermeable
membrane in response to transmembrane pressue.
Ultrafiltrate:
The plasma water and ultrafiltered solutes produced during
ultrafiltration or hemofiltration of blood.
Dialysate:
The synthetic, uremic solute-free solution administered into the
ultrafiltrate-dialysate compartment of the hemofilter or hemodialyzer
in order to achieve diffusive solute clearance.

Further Definitions (2)

Arterio-venous (A-V) circuit :
A term describing the arterial and venous vascular access
cannulae or shunt and the associated tubing necessary to carry
blood into and out of the hemofilter, and back into the circulation.
Veno-venous (V-V) circuit:
A term describing the venous vascular access and associated
tubing carrying blood into and out of the hemofilter, and back into
the circulation.
Pre-dilution:
The administration of replacement fluid into the patients blood
prior to its entry into the hemofilter (pre-filter delivery).

Further Definitions (3)

Post-dilution:
The administration of replacement fluid into the patients blood
after its exit from the hemofilter (post-filter delivery).
Suction:
A technique whereby ultrafiltrate production is augmented by
applying negative pressure to the ultrafiltrate port of the
hemofilter.
Ultrafiltration control system:
A technique whereby ultrafiltrate production is controlled by a
volumetric pumps applied to the ultrafiltrate outflow tubing.

Circuit: CAVH CVVH with Post-dilution

CAVH
Qb= 50-100 ml/min
Qf: 8-12 ml/min

Vein

Artery

CVVH
Qb= 50-200 ml/min
Qf: 8-12 ml/min

Vein

Vein
UF

UF
Mechanisms of function

Membrane Reinfusion Diffusion

Convection

Circuit: CAVH CVVH with Pre-dilution

R

CAVH
Qb= 50-100 ml/min
Qf: 8-12 ml/min

Vein

Artery

CVVH
Qb= 50-200 ml/min
Qf: 8-12 ml/min

P
Vein

Vein
UF

UF

Mechanisms of function
Membrane Reinfusion Diffusion

Convection

Circuit: CAVHD - CVVHD

CAVHD
Artery
Dialout

Qb=50-100 ml/min
Qf = 1-3 ml/min
Qd 10-20 ml/min

Vein Vein
Dialin

CVVHD
P

Qb=50-200 ml/min
Qf = 1-5 ml/min
Qd 10-30 ml/min

Vein

Dialout

Mechanismsoffunction
MembraneReinfusionDiffusionConvection
Lowflux
No HighLow

Dialin

Circuit: CAVHDF -CVVHDF

Qb 50-100 ml/min
Qd 10-20 ml/min
Qf 8-12 ml/min

Artery

CAVHDF

CVVHDF

Vein

Qb 50-200 ml/min
Qd 20-40 ml/min
Qf 8-15 ml/min

Vein

P
Dialout+Uf
in

Dialin

Dialout+Uf

Mechanismsoffunction
Membrane
Highflux

Reinfusion Diffusion
Yes
High

Convection
High

Dial

Circuit: SCUF

Qb 50-100 ml/min
Qf 2-6 ml/min

A-VSCUF

Qb 50-200 ml/min
Qf 2-8 ml/min

V-VSCUF
P

V
VC

UF

UF

Mechanismsoffunction
Membrane Reinfusion DiffusionConvection
Highflux

No

Low

Low

Vascular Access for CRRT

* CAVH, CAVHD, CAVHDF: Femoral artery and vein
Advantages : simplest system to assemble and operate
Disadvantage: Required arterial puncture and cannulation
Required a second catheter
Risk of arterial embolization
Unreliable blood flow
* CVVH, CVVHD, CVVHDF: Femoral vein, internal jugular vein,
subclavian vein with double lumen catheter
Advantages : No arterial puncture or cannulation
Less systemic anticoagulation required
Only one puncture , Faster blood flow
More reliable blood flow
Disadvantage: Required extracorporeal blood pump

Commercially available filter for CRRT

Company
Amicon

Asahi Med.
Bellco
Fresenius
Gambro
Hospal
Renal Syst.
Sorin

Name
Diafilter 30
Diafilter 20
Diafilter 10
Minifilter
Minifilter Plus
Ultrafilter GS
BL 650
AV-400
AV-600
FH 66
FH22
Multiflow 60
PLATE
HF 500
HF 250
HFT 04
HFT 02

Membrane
Polysulphone
Polysulphone
Polysulphone
Polysulphone
Polysulphone
Polyacrylonitrile
Polysulphone
Polysulphone
Polysulphone
Polyamide
Polyamide
AN69S
AN 69S
Polysulphone
Polysulphone
Polysulphone
Polysulphone

Surface (m2 )
0.60
0.25
0.20
0.015
0.08
0.50
0.20
0.70
1.35
0.60
0.15
0.60
0.50
0.50
0.25
0.45
0.24

Factors Affecting Drug Removal During CRRT

* Drug properties
Protein binding
Molecular weight
Hydration radius
Molecular charge
* Ultrafilter membrane properties
Pore size
Membrane charge
Length and width of fiber
Filter surface area

Applications for CRRT

Renal Application vs Non-renal Application
Renal Application ( Renal replacement and Renal
support)
* Acute renal failure ( specifically complicated ARF with
multiple organ failure and cardiovascular failure)
* Oligouric ARF needs large amount of fluid or nutrition
* Acute renal failure with cerebral edema
* Acute renal failure with hypercatabolism
* An alternative to HD in the mass casualty situation
* Electrolytes and acid base disturbance

Applications for CRRT

Renal Application vs Non-renal Application
Non-renal Application
* Hepatic failure complicated with hepatic coma
* Congestive heart failure refractory to diuretics
* Overhydration during & after cardiac surgery ( CPB )
* Sepsis
* Life-threatening hyperthermia
* Lactic acidosis
* Cytokine removal: Acute respiratory distress syndrome
* Tumor lysis syndrome
* Crush injury
* Inborn errors of metabolism: maple syrup disease, urea cycle
disorder

Scheme for Selection of a Renal Replacement Therapy

in Intensive Care Units
Renal Failure requiring renal replacement therapy
Uni-Organ failure

Intermittent hemodialysis

Main problems:
biochemical/uremia

Multi-Organ failure
Hemodynamically
stable

Hemodynamically
unstable

Main problems:
fluid overload or cytokines

CRRT

Intermittent Hemodialysis
Untolerant

CRRT

Conclusions
* CRRT provide good supportive treatment in the
management of patients with multiple organ failure and
acute renal failure
* Maintenance of water, and electrolyte balance
* Removal of metabolic waste products
* Removal of inflammatory mediators of MOSF
* Facilitate full nutrition support
* Mortality of CRRT is non-significant difference as
compared with IHD, but severity of illness is more in
CRRT
* No particular form of CRRT has yet shown to be superior
of survival