CRRT with Prismaflex slides renal replacement.pdf

CRRT

1. Continuous Renal Replacement
Therapy (CRRT)
with Prismaflex System
15
th
-16
th
January 2024
HSIS Serdang

2. Overview
•CRRT Modalities
•CRRT with Prismaflex®
•Components
•CRRT Initiation
•Optimal Dose for CRRT

3. CRRT Modalities

4. Continuous Renal Replacement Therapy
Different types of CRRT:
SCUF - Slow Continuous Ultrafiltration
CVVH - Continuous Veno-VenousHemofiltration
CVVHD-Continuous Veno-VenousHemodialysis
CVVHDF-Continuous Veno-VenousHemodiafiltration
Reference:
Kellum et al. 2010. Continuous Renal Replacement Therapy. New York, Oxford University Press.
25

5. In a nutshell -Therapies of CRRT
SCUF CVVH CVVHD CVVHDF
Principal Transport
Mechanism
Ultrafiltration
Ultrafiltration
Convection
Ultrafiltration
Diffusion
Ultrafiltration
Convection
Diffusion
26

6. Slow Continuous Ultrafiltration
Slow Continuous Ultrafiltration
27

7. Ultrafiltration
Ultrafiltration is the movement of fluid
through a semi-permeable membrane drive
by a pressure gradient
Ultrafiltration is the movement of fluid through a semi-
permeable membrane driven by a pressure gradient
Reference:
Kellum et al. 2010.
Continuous Renal
Replacement
Therapy. New
York, Oxford
University Press.
Ultrafiltration
28

8. Continuous VenoVenous Haemofiltration
Continuous Veno-Venous Hemofiltration
29

9. Convection
Reference:
Kellum et al. 2010.
Continuous Renal
Replacement Therapy. New
York, Oxford University
Press.
Convection is the movement of solutes with fluid flow, also
known as solute drag. This movement of fluid is consequence
of transmembrane pressure (TMP) gradient.
Convection
30

10. Pre vs. Post Filter Dilution
Pre Dilution
Reduces risk of filter clotting
May prolonged filter life
Reduces effective clearance
Reference:
Kellum et al. 2010.
Continuous Renal
Replacement Therapy. New
York, Oxford University
Press.

11. Pre vs. Post Filter Dilution
Post Dilution
Increases risk of filter clotting.
Increased need of anticoagulant
No reduction of effective clearance
Reference:
Kellum et al. 2010.
Continuous Renal
Replacement Therapy. New
York, Oxford University
Press.
32

12. Continuous VenoVenous Haemodialysis
Continuous Veno-Venous Hemodialysis
33

13. Diffusion
Reference:
Kellum et al. 2010.
Continuous Renal
Replacement Therapy. New
York, Oxford University
Press. Diffusion is the movement of solutes
from higher to lower concentration
Diffusion
34

14. Dialysis Compartment
Diffusion
35

15. Continuous VenoVenous Haemodiafiltration
Continuous Veno-Venous Hemodiafiltration
36

16. Diffusion vs. Convection
CVVHD CVVH
The AN 69 membrane cut
off point is 30 kDaltons
1
Reference:
1. Vriese et al. Cytokine Removal during
Continuous Hemofiltration in Septic Patients.
J Am Soc Nephrol 10: 846–853, 1999
37

17. |

18. CRRT with Prismaflex
®

19. Prismaflex
®
System
•User friendly system for
individualized CRRT
prescriptions
•Versatility to facilitate use of a
wide range of treatment
strategies
•Patients’ safety in mind
•Leading in development of
extracorporeal blood purification
and fluid management

20. Why choose Prismaflex
®
system?
1. Slow, gentle and continuous
–Well tolerated by hemodynamically unstable patient
–Prevent further damage to kidney tissue
2. Removes small molecules (urea and creatinine) and larger molecules
(beta 2 microglobulin & inflammatory mediators)

3. More control of electrolytes & acid-base balance
4. Removes large amounts of fluid and waste products over time
–Allow other supportive measures, i.e. nutrition
Reference:
1.Bellomo, Ronco. Continoushemofiltration in the intensive care unit. Crit Care, 2000; 4(6) ): 339–345.
2.Schneider, et al. Choice of renal replacement therapy modality and dialysis dependence after acute kidney injury: a systematic review and meta-analysis.
Intensive Care Medicine. Published online: 27 February 2013

21. System Components

22. System Flow Path

24. High-flow kidney-shaped
lumen design with 18% larger
arterial lumen, may ease
arterial pressure
Staggered double lumen tip
configuration free of side holes
may reduce risk of clotting
1,2
Reference:
1. Huriaux L, et al. Hemodialysis catheters in the intensive care unit, Anaesth Crit Care Pain Med. 2017;36:313-319.
2. Twardowski ZJ, et al. Side holes at the tip of chronic hemodialysis catheters are harmful, J Vasc Access. 2001;2:8–16.
The optimal dialysis
catheter in ICU is the
Cycle C design with a
shotgun tip
1

26. Purpose
The main functional unit of the CRRT circuit, where blood is
processed for solute and/or fluid removal
49

27. Haemofilter
50
AN69 Membrane
Microporous asymmetric membranes, ie
Polysufone / PAES.
Symmetrical hydrogel structure. ie. AN69
Reference:
J. Chanard, et al. New insights in dialysis membrane biocompatibility: relevance of adsorption properties and heparin binding. Nephrol Dial Transplant, 2003
PAES Membrane
CRRT (especially CVVH) with the AN 69 membrane, provide more adsorptive
capability as compared to other microporous asymmetric membranes; because
the entire breadth of the membrane is in contact with the blood compartment and
thus more accessible for adsorption.
Adsorption enables the removal of inflammatory cytokines.
CRRT Therapy Set – Prismaflex M Sets

28. Transport Mechanism -Adsorption
51
Adsorptionis molecular adhering to surface or interior of a semi
permeable membrane
Reference:
Kellum et al. 2010. Continuous Renal Replacement Therapy. New York, Oxford University Press.

29. `
52
Prismaflex
M60
Prismaflex
M100
Prismaflex
oXiris
Blood flow range
(ml / min)
50 –180 75–400 0 –450
Minimum patient weight
(kg)
11 30 30
Blood volume in set ±10
%
(ml)
93 152 189
CRRT Therapy Set – Prismaflex M Sets
Specification

30. 53
Heparin coating reduces membrane
thrombogenicity
PEI surface treatment adsorbs
endotoxin
AN 69 base membrane adsorbs
cytokine and toxins whilst providing
continuous renal support. Cytokine
adsorption occurs throughout the
entire membrane thickness
oXiris The only set for 3-in-1 CRRT-Sepsis Management

31. 55
oXiris - Observational Studies and Improved Outcome

33. Bicarbonate solution
57
CRRT Bicarbonate Solution
•Two-compartment bag in polyolefin material (PVC-free)
•Bicarbonate is separated from calcium and magnesium
to prevent carbonate precipitation during storage
•5 Litresper bag, 18-month shelf life
•Self-sealing Luerlock connector with valve and spike
connector
•Overwrap is made of several layers of different materials
which are gas and water barriers

35. CRRT -Anticoagulation
Types of
Anticoagulation
Systemic
Anticoagulation
Regional Citrate
Anticoagulation
•Heparin
•Low Molecular
Weight Heparin
•Prostacyclin
Anticoagulate both extracorpereal
circuit & patient
Anticoagulate extracorpereal
circuit only
59

36. Regional Citrate Anticoagulation
Calcium ion will be chelated by
citrate – initialing anti
coagulation effect.
CRRT –Regional Citrate Anticoagulation
60
Citrate Calcium complexed will
be metabolized – ceasing anti
coagulation effect.

37. CRRT Initiation

38. 62
Renal Replacement Therapy
1
(excretory function only)
Renal Support Therapy
2
Life threatening changes
Initiate emergently
•Immune modulation in sepsis
•Fluid balance •Volume balance in multi organ dysfunction / failure
•Electrolyte control •Nutritional support
•Acid–base regulation •Volume removal in refractory Congestive Heart Failure
Patient medical condition
Preference to initiate with
CRRT
•Alleviate ARDS induces respiratory acidosis
•Hemodynamically unstable
•Acute brain injury
•Generalized brain edema
•Increased intracranial pressure
Reference:
1.Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for AcuteKidney Injury. Kidney
inter., Suppl. 2012; 2: 1–138.
2.Kellum et al. 2010. Continuous Renal Replacement Therapy. New York, Oxford University Press.
Indications for Renal Replacement Therapy

39. Criteria for CRRT initiation
RENAL Trial
Reference:
Bellomo R et al. Intensity of Continuous Renal-Replacement Therapy in Critically Ill Patients. N Engl J Me 2009;361:1627-38
65

40. Optimal Dose for CRRT

41. Optimal Dose of CRRT
Reference:
1. Prowle et al. Clinical review:
Optimal dose of continuous renal
replacement therapy in acute
kidney injury. Critical Care 2011,
15:207
67

42. RENAL Trial
68
Study Design
1508 Patients
Multicenter
Randomized
High Intensity Group
40 ml/kg/hr
747 patients
Low Intensity Group
25 ml/kg/hr
761 patients
Reference:
Bellomo R et al. Intensity of Continuous Renal-Replacement Therapy in Critically Ill Patients. N Engl J Me 2009;361:1627-38
Primary End Point: 90 days mortality

43. RENAL Trial
90 days results show:
• No significant mortality difference between the high and low dose CRRT
• 55% survival
• 94% renal recovery
Results:
Reference:
Bellomo R et al. Intensity of Continuous Renal-Replacement Therapy in Critically Ill Patients. N Engl J Me 2009;361:1627-38
69

44. RENAL Trial
Description Parameter
CRRT modality CVVHDF
Replacement fluid 100% post dilution
Dialysate : Replacement fluid ratio 1:1
Effluent flow rateLower intensity 25ml / kg body weigh / hr
Higher intensity 40ml / kg body weigh / hr
Blood flow rate > 150 ml / min
Hemofilter membrane AN 69
Bicarbonate solution Prismasol
Reference:
Bellomo R et al. Intensity of Continuous Renal-Replacement Therapy in Critically Ill Patients. N Engl J Me 2009;361:1627-38
70

45. Effluent Dose
71
•The concept of CRRT dose is based on effluent flow rate.
1
•Effluent Dose is calculated as ml / kg body weight / hour
•Hence it is important to individualized effluent dose based on patient’s body
weigh.
Replacement Flow Rate
+ Dialysis Flow Rate
+ Patient Fluid Removal Rate

Effluent Dose
Current guideline on effluent dose:
5.8.4: We recommend delivering an effluent volume of 20–25 ml/kg/h for
CRRT in AKI (1A).
2
Reference:
1.Kellum et al. 2010. Continuous Renal Replacement Therapy. New York, Oxford University Press.
2.Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney
inter., Suppl. 2012; 2: 1–138.

46. Prescribed vs Delivered Effluent Dose
Target dose =
25ml / kg body
weight / hr
Hence, 25 - 30ml/ kg body
weight / hr is
recommended to prevent
under dialysis
Lead to 20%
reduction in
prescribed
dose
Reference:
1. Kellum et al. Results of RENAL—what is the optimal CRRT target dose? Nature Reviews. Vol.6. Apr
2010: 191-192
72

47. Calculation of Dialysis & Replacement FlowRate
73
Effluent Dose =
Patient weight x 30ml / hr
60kg x 30ml / hr
1800ml / hr
Replacement Dose =
900 ml / hr
Pre Dilution(50%)
(Pre Blood Pump) =
450 ml / hr
Post Dilution (50%)
(Replacement Pump Post) =
450 ml / hr
Dialysate Dose =
900 ml / hr
Dialysate Dose
(Dialysis Pump) =
900 ml / hr
Prescription
Calculation
Prescription on Prismaflex System

48. CRRT Prescription Form
74

49. CRRT2U website
76
https://www.baxterglobal.com/CRRT_2U_MY/

50. Making Possible Personal