Nomenclature c hd,c-hfc-hdf scuf sled clinical indications - copy

Different types of Dialysis, Continuous Renal Replacement therapies (CRRT) and Indications of CRRT.

1. Dr Irfan Elahi Assistant Professor Nephrology, KEMU Mayo Hospital 1) Nomenclature C-HD,C-HF,C-HDF, SCUF, SLED 2) Clinical Indications

2. One needs to understand. Hemodialysis. Hemofiltration. Hemodiafiltration. Difference between diffusive and convective clearance Before starting this topic

3. Hemodialysis It is a process in which composition of a solution “A”(blood) is altered by exposing it to another solution “B”(dialysate) via semipermeable membrane. The major principle of movement of solutes is diffusion.

4. Hemofiltration It is a process in which fluid is infused in to the blood compartment and ultrafiltration is done to remove this infused fluid to achieve convection. Diffusion is dependent on molecular size where as convection removes solutes independent of their size.

5. Hemodiafiltration When hemodialysis (diffusion based clearance) is added to hemofiltration (convection based clearance) the process is called Hemodiafiltration. This increases clearance of middle molecular size molecules.

6. Convective & Diffusive clearance As diffusion is dependent on molecular weight of substance and convection is independent of it. So convection increases clearance of larger molecules.

7. 1) Nomenclature of RRT

8. IRRT or IHD Intermittent renal replacement therapy Also called hemodialysis the process which is routinely done for 4 hours twice or thrice weekly. This is RRT most of ESRD patients receive routinely. IHD and IUF (isolated UF)

9. PIRRT (Hybrid) Prolonged intermittent renal replacement therapy. Done using same hemodialysis machine. But duration of therapy is increased and blood flows reduced. Types a) SLED b) SLEDF

10. PIRRT SLED Slow low efficacy hemodialysis Diffusive clearance Only dialysis is done and extra fluid is removed from body, no replacement fluid is given and no fluid is removed to achieve clearance SLED-F Slow low efficacy hemodiafiltration Diffusive clearance + convective clearance. Dialysis is done similar to SLED but in addition extra fluid in infused in to patient and excessive ultrafiltration done for clearance

11. So the difference in SLED & SLEDF The addition of process of hemofiltration in SLED to achieve additional convective clearance makes it SLEDF. SLED + HF = SLEDF

12. CRRT Continous Renal Replacement therapy

13. Vevovenous Access CVVHD CVVH CVVHDF Venovenous is catheter based therapy and it is used universally VV is not added CAVHD CAVH CAVHDF Arteriovenous access is not used for CRRT usually AV is not used Modalities of CRRT Arteriovenous Access

14. SCUF (Slow continuous ultrafiltration) It is done using CRRT machine. N o dialysate is used, so no diffusive clearance. No replacement fluid used, so no convective clearance. Only excessive fluid is removed from body.

15. CHF (Continuous hemofiltration) It is done using CRRT machine. No dialysate is used, so no diffusive clearance . Excessive replacement fluid used and ultrafiltration done, so convective clearance is the basic principle of solute removal.

16. Pre-dilution replacement fluid is given prior to dialyzer/ hemofilter CHF (Continuous hemofiltration) Post-dilution replacement fluid is given after dialyzer/ hemofilter

17. CHD (Continuous hemodialysis) It is done using CRRT machine. Dialysate is used, so diffusive clearance is the basic principle of solute removal. No replacement fluid used, so no convective clearance. .

18. CHDF (Continuous hemodiafiltration ) It is done using CRRT machine. Dialysate and replacement fluid both are used, so diffusive & convective clearance both principles of solute removal are working. CHF + CHD = CHDF

19. CRRT Continous Renal Replacement therapy

20. 2) Clinical Indications Two benefits over IHD. Lower rate of fluid removal ensuring hemodynamic stability. Enhanced control of azotemia

21. The 2012 KDIGO Guidelines for AKI suggest CRRT: A) For hemodynamically unstable patients. B) For patients with acute brain injury or other causes of increased intracranial pressure or generalized brain edema. Guidelines recognize that the use of PIRRT therapies such as SLED or SLED-F may be as useful to treat hemodynamically unstable patients as CRRT Indications of CRRT

22. When we compare PIRRT & CRRT PIRRT (SLED) Can be done with standard hemodialysis machine. Don’t need special training of staff. Less costly. Suitable where there are financial constrains and limited recourses. CRRT (CVVHD) Need special CRRT machine. N eed special training of staff. More costly . Suitable in ICU setups where lot of patients need them.

23. $ 7,000 (Rs 11,20,000) Cost comparison $ 17,500.00 (280,000,000)

24. Fluid overload Oliguria (urine output <200ml/12hr) Anuria (urine output <50ml/12hr) Hyperkalemia (K+>6.5mmol/l and rising) Severe acidemia (pH<7.1) Azotemia (urea>30mmol/l or creat >300umol/l) Pulmonary edema Indications for CRRT in Critically Ill Patients.

25. Uremic encephalopathy Uremic pericarditis Uremic myopathy or neuropathy Severe Dysnatremia (Na+>160 or <115mmol/l) Drug overdose with filterable toxins ( Lithium,Vancomycin,Procainamide etc.) Imminent / ongoing massive blood product administration Indications of CRRT

26. Significant Organ edema (especially Lung) Sepsis SIRS (Systemic Inflammation Response System) ARDS (Adult Respiratory Distress Syndrome) Hepatic failure Severe burns Non Renal Indications for CRRT

27. Cerebral edema Tumor lysis syndrome Cardiopulmonary bypass CHF Lactic Acidosis Drug overdose Non Renal Indications for CRRT