rrt choice

Renal Replacement Therapy Options for

ChildrenTimothy E. Bunchman, MD

Professor & Director Helen DeVos Children’s Hospital

Grand Rapids, MI

[email protected]

Questions?

Is there an optimal form of RRT in children independent of cause of AKI?

Are there studies comparing outcome randomized by RRT modality in children?

RRT Options(all are reasonable to use)

PD (continuous or intermittent) Acute, CAPD, CCPD

HD (intermittent) Standard vs High Flux

CRRT (continuous) CVVH, CVVHD, CVVHDF

Dialysis (diffusive)

PD vs. HD vs. CVVHD Works with solute clearance across a

semi-permeable membrane The greater the gradient the greater

the clearance The greater the solution exposure per

unit of time the greater the clearance

Diffusive Clearance

CVVHD/HD/PD Diffusive clearance Dialysate

Physiologic sterile solution that is infused countercurrent to the blood flow rate (Qd)

Replacement (Convective)

Due to mass transfer (push) of solute thru a semi-permeable membrane

The pore size of the membrane may effect clearance AN-69 membrane > Polysulphone

The greater the solution exposure per unit of time the greater the clearance

CVVH Convective

clearance Replacement

Solutions Physiologic sterile

solution that is either infused pre filter (NA) or post filter (outside of NA) that infused at a set rate (Qr)

Convective Clearance

CVVHDF Convective clearance

Replacement Solutions Diffusive clearance

Dialysis solution

Convective and Diffusive Clearance

Sieving Coefficients

Solute (MW) Convective Coefficient Diffusion Coefficient

Urea (60) 1.01 ± 0.05 1.01 ± 0.07

Creatinine (113) 1.00 ± 0.09 1.01 ± 0.06

Uric Acid (168) 1.01 ± 0.04 0.97 ± 0.04*

Vancomycin (1448) 0.84 ± 0.10 0.74 ± 0.04**

Calcium (protein bound) 0.67 + 0.1 0.61 + 0.07

Cytokines (large) adsorbed minimal clearance

*P<0.05 **P<0.01

Impact of urea Clearance CVVH vs CVVHD(Maxvold et al, Crit Care med. 2000 Apr;28(4):1161-5)

Study design Fixed blood flow rate-4 mls/kg/min HF-400 (0.3 m2 polysulfone) Cross over for 24 hrs each to

prefilter replacement fluid (CVVH) or Dx (CVVHD) flow at 2000 mls/hr/1.73 m2

Comparison of Urea Clearance: CVVH vs CVVHD(Maxvold et al, Crit Care med. 2000 Apr;28(4):1161-5)

U

rea C

leara

nce

(mls

/min

/1.7

3 m

2)

BFR = 4 mls/kg/minFRF/Dx FR = 2 l/1.73 m2/hrSAM = 0.3 m2

p = NS

Solute clearance vs UF

Solute Clearance/unit of time HD > HF > PD

(30-50 l/hr vs 2 l/hr vs 1-2 /hr Dx)

UF with regard to hemodyamics HF > PD > HD

(24 hrs/day vs 3-4 hrs/day or QO Day)

Dialysis Dose

0123456789

10W

eekly

std

Kt/

V

0.3 0.5 0.7 0.9 1.1 1.3 1.5

eKt/V each dialysis

234567

No. o

f Days/w

eek

EDDEDD

35ml/kg35ml/kg

45ml/kg45ml/kg

20ml/kg20ml/kg

Adapted from Gotch et al. Kidney Int 2000;58:S3-18Adapted from Gotch et al. Kidney Int 2000;58:S3-18

CRRTCRRT

PD

Dialysis Dose and OutcomeRonco et al. Lancet 2000; 351: 26-30

• Conclusions:– Minimum UF rates should be ~ 35

ml/kg/hr– Survivors had lower BUNs than non-

survivors prior to commencement of hemofiltration

425 patientsEndpoint = survival 15 days after D/C HF

146 UF rate 20ml/kg/hrsurvival significantly lower

in this group compared to the others

139 UF rate 35ml/kg/hrp=0.0007

140 UF rate 45ml/kg/hrp=0.0013

Relative Advantages (+) and Disadvantages (-) of CRRT, IHD, and PD

Variable CRRT IHD PD-----------------------------------------------------------------------------

-----------------

Continuous RRT + - +

Hemodynamic stability + - +

Fluid balance achievement + - -

Relative Advantages (+) and Disadvantages (-) of CRRT, IHD, and PD

Variable CRRT IHD PD----------------------------------------------------------------------------------------------Unlimited nutrition + - -

Superior metabolic control + - -

Continuous removal of toxins + - +

Simple to perform ± - +

Relative Advantages (+) and Disadvantages (-) of CRRT, IHD and PD cont.

Variable CRRT IHD PD-----------------------------------------------------------------------------------

----

Stable intracranial pressure + - +

Rapid removal of poisons - + -

Limited anticoagulation -/+ + +

Relative Advantages (+) and Disadvantages (-) of CRRT, IHD and PD cont.

Variable CRRT IHD PD---------------------------------------------------------------------------------------

-------Intensive care nursing support + - +

Hemodialysis nursing support ± + +

Patient mobility - + -

PATIENT MORTALITYP

erce

nt

of P

atie

nts

(%

)

Modality

(NS in mortality)

N=21 N=9 N=12

Fleming et al., J Thorac Cardiovasc Surg, 1995

CALORIC INTAKE

PD

CAVH *

CVVH *

Fleming et al., J Thorac Cardiovasc Surg, 1995

% C

han

ge F

rom

Bas

elin

e

Modality(* p < 0.05 compared to PD)

Renal Replacement Therapy in the PICU Pediatric Outcome Literature

122 children studied No PRISM scores Most common

diagnosis IHD: primary renal

failure CRRT: sepsis

31% survival Conclusion: patients

who receive CRRT are more ill

Maxvold NJ et al: Am J Kidney Dis 1997 Nov;30(5 Suppl 4):S84-8

Pediatric ARF: Modality and Survival

% S

urvi

val

Ped Neph 16:1067-1071, 2001

P<0.01

P<0.01

(ns)

Pediatric ARF: Modality and Survival

Patient survival on pressors (35%) lower than without pressors (89%) (p<0.01)

Lower survival seen in CRRT than in patients who received HD for all disease states

Ped Neph 16:1067-1071, 2001

Unique Situations-PD

Infants and Post Op Hearts Ease of fluid management

Chien et al Pediatr Neonatol 2009; 50:25-279

Ease of administration at bedside Bonillis-Felix PDI 2009 29 S183-185

Limited resources

The etiology of acute renal failure- Nigeria ( Anochie & Eke Peds Neph 2005:20 1610-1614)

EtiologyNumber (%, N=211)

Gastroenteritis 61 (28.9)

Septicaemia 32 (15.2)

With Tetanus 4 (5.3)

Acute glomerulonephritis 29 (13.7)

Plasmodium falciparum malaria 29 (13.7)

Birth asphyxia 27 (12.8)

Haemolytic uraemic syndrome 7 (3.3)

Malignancy 6 (2.8)

Leukaemia 4

Burkitt lymphoma 2

HIV related 3 (1.4)

Congenital malformation 10 (4.7)

Posterior urethral valves 6

Renal agenesis 4

Renal vein thrombosis 1 (0.5)

211 Patients with ARF over an 18 year period

Dialysis indicated in 108 patientsOnly 24 had PD– due to resource

availability and costPrimary causes of death-

uremia, infection, anemia, hypertension and

LACK of Dialysis

The etiology of acute renal failure- Nigeria ( Anochie & Eke Peds Neph 2005:20 1610-1614)

Unique Situations-HD (+/- CRRT)

Conditions when maximal solute clearance is needed with less concern on hemodynamic stability Auron and Brophy

Current opinions in Pediatrics 2010 22: 283-188

Quan and Quigley Current opinions in Pediatrics 2005 17:

205-209

Vancomycin clearance High efficiency dialysis membrane

Time of therapy

Vanc

level

(m

ic/d

l)

Rx Rx Rx

Rebound Rebound

Unique Situations-CRRT

When hemodynamic instability and highly catabolic conditions are present Sepsis Bone Marrow Transplantation

Goldstein SL Seminars in Dialysis 2009; 22; 180-184

Walters et al Pediatr Neph 2009 24; 37-38

Stem Cell Transplant: ppCRRT

51 patients in ppCRRT with SCT Mean %FO = 12.41 + 3.7%. 45% survival

Convection: 17/29 survived (59%) Diffusion: 6/22 (27%), p<0.05

Survival lower in MODS and ventilated patients

Flores FX et al: Pediatr Nephrol. 2008 Apr;23(4):625-30

Intensive vs non Intensive RRT HD and CRRT at 6 days per week and

35 mls/kg/hr daily Vs. HD and CRRT at 3 days per week and

20 mls/kg/hr daily Intensity of Renal Support in Critically Ill

Patients with Acute Kidney Injury The VA/NIH Acute Renal Failure Trial Network*

NEJM july 3, 2008 vol. 359 no. 1

The VA/NIH Acute Renal Failure Trial Network. N Engl J Med 2008;359:7-20

Enrollment, Randomization, and Follow-up of Study Patients

Intensive vs Conventional


Primary and Secondary Outcomes


Kaplan-Meier Plot of Cumulative Probabilities of Death (Panel A) and Odds Ratios for Death at 60 Days, According to Baseline Characteristics (Panel B)


Summary of Complications Associated with Study Therapy

Conclusion of ATN Study

Intensive renal support in critically ill patients with AKI did not decrease mortality, improve recovery of kidney function, or reduce the rate of non-renal organ failure as compared with less-intensive therapy involving a defined dose of IHD three times per week and CRRT at 20 ml per kilogram per hour.

Copyright restrictions may apply.

Lins, R. L. et al. Nephrol. Dial. Transplant. 2009 24:512-518; doi:10.1093/ndt/gfn560

Flow chart of the SHARF 4 study



Outcome in patients randomized to intermittent (IRRT) or continuous (CRRT) renal replacement therapy



Survival curves in patients randomized to intermittent (IRRT) or continuous (CRRT) renal replacement therapy investigating ICU mortality and hospital

mortality

Cost of Dialysis Equipment (in U.S. dollars)

Manual Peritoneal Dialysis

Device: Dialy-Nate Manual PD setManufacturer: Utah Medical

ProductsCost per Unit: $88.75 (New set Required

every 24-72 h)

Cost of additional Supplies: 1.5% Dineal (Baxter) $24.43/2.0L

Cost of Dialysis Equipment (in U.S. dollars) cont.

Manual Peritoneal Dialysis

Device: Ultra Set (Y-set)Manufacturer: BaxterCost per unit: $6.95 (New unit required

for each exchange)

Cost of additional Supplies: 1.5% Dianeal (Baxter) $24.43/2.0L


Automated Peritoneal Dialysis

Device: Freedom CyclerManufacturer: FreseniusCost per unit: $12,295.00Cost of additional supplies:

Pediatric Tubing set $32.00 each


Intermittent Hemodialysis

Device: C3Manufacturer: GambroCost per unit: $18,000.00Cost of additional Supplies: 100HG

dialyzer $50.00 each;pediatric bloodlines $11.40 each


Continuous HemofiltrationDevice: PrismaManufacturer: GambroCost per unit: $25,000.00Cost of additional supplies: M60

hemofilter set(includes filter and bloodlines) $160.00

Normocarb dialysate concentrate(Dialysis Solutions) $20.00/3.0L

Conclusion

RRT modality comparison shows that the dose of RRT and the choice of RRT may not effect survival

Indication to begin, end is still of question

Do what you do well and improve your care of patient with AKI

rrt choice

Documents

pd variable crrt ihd

solute clearance

pd continuous

dialysis diffusive pd

pd variablecrrtihdpd

mlkg crrt

replacement convective

caloricintake pd cavh