sicu combine meeting 2012-4-26 蔡壁如. case presentation 56yr, male: cad s/p pobas with icmp s/p...

SICU Combine meeting

2012-4-26蔡壁如

Case Presentation

• 56yr, Male: CAD s/p POBAS with ICMP s/p heterotopic heart transplantation in 2004

• Hypertension • Gout • CRI• Current Medication:

Burinex 1 mg/tab 1 tab BID SR Diltelan SR 120 mg/cap 1 capFolic Acid 5 mg/tab 1 tab QD PO Allopurinol 100 mg/tab 1 tab BID PO Colchicine 0.5 mg/tab 1 tab BID PO Sandimmun Neoral 25 mg/cap 2 cap BID POCellCept 250 mg/cap 2 cap BID PO

ER 2012-1-25

• At ER, afebrile but SpO2 93% with short of breath. • EKG monitor showed intermittent VT. • Cardiac echo showed poor recipient heart with

LVEF:23% • LV systolic function is normal with LVEF:61.6%.• BUN, Cre and potassium was 118, 6.06 and 7.9(H9). • Under the impression of acute kidney injury,

suspected rejection or infection-related

2012-1-26 start RRT

• AKI Cause – Sepsis ?– Rejection ?– Both? Acute on chronic ?

問題一：重症透析的人工膜選擇5008HF

Stenotrophomonas maltophilia 1/30, 2/8, 2/10, 2/15

問題二：急性腎損傷透析液的選擇

Unveiling Current Controversies inAcute Kidney Injury

Kellum JA, Ronco C, Vincent J- L (eds): Controversies in Acute Kidney Injury.Contrib Nephrol. Basel, Karger, 2011, vol 174, pp 1–3

Dialyzer membranes for RRT in AKI

2012 KDIGO guideline for AKI

Dialyzer membranes for RRT in AKI

Hemodialysis-membrane biocompatibility and mortality of patients with dialysis-dependent acute renal failure: a

Prospective randomized multicenter trial

人工膜 :1.2m2

Low-Flux vs High Flux Synthetic Dialysis Membrane in Acute Renal Failure : Prospective Randomized Study

• In conclusion, no significant differences were found in the results of low-flux versus high-flux synthetic membrane dialyzer treatment in patient in terms of survival rate, recovery of renal function, …….

• Low-flux synthetic polysulphone dialyzer (1.3 m2) vs High-flux synthetic AN-69(1.3m2)

Artif Organs, Vol 25, No. 12, 2001

Membranes for Dialysis and Hemofiltration --- 7.3

• Management of Acute Kidney Problems – D. H. Krieter and C. Wanner. 2010

• Materials : Synthetic membrane √• Low-flux vs High-flux • Size

High-flux vs Low-flux

• The Hemodialysis (HEMO) study – not find a difference between low- and high-flux

membranesEffects of high-flux hemodialysis on clinical outcomes: Results of the HEMO Study. J Am Soc Nephrol 2003 14:3251-3263.

• MPO study ( Membrane Permeability Outcome)– High-flux benefits in DM and low serum albumin

levels ( < 4 g/dl) – No significant survival benefitMembrane Permeability Outcome (MPO) Study Group Effect of membrane permeability on survival of hemodialysis patients. J Am Soc Nephrol 2009 20:645-654

• No study was able to demonstrate differences in survival between low- and high-flux membranes.

• Is the choice of membrane important for patients with acute renal failure requiring hemodialysis? 1995 Artif Organs 19:391-394.

• Patient survival and renal recovery in acute renal failure: randomized comparison of cellulose acetate and polysulfone membrane dialyzers. 2000 Mayo Clin Proc 75: 1141- 1147.

• Comparison of cellulose diacetate and polysulfone membranes in the outcome of acute renal failure. A prospective randomized study. 2000 Nephrol Dial Transplant 15:224- 230

• Low-flux versus high-flux synthetic dialys is membrane in acute renal failure: prospective randomized study. 2001 Artif Organs 25:946-950.

• Only with respect to the recovery of renal function that a possible advantage of high- over low-flux membranes.

• (2000) Patient survival and renal recovery in acute renal failure: randomized comparison of cellulose acetate and polysulfone membrane dialyzers. Mayo Clin Proc 75: 1141- 1147.

• Biocompatible hemodialysis membranes for acute renal failure. 2008 Cochrane Database Syst Rev 23:CD005283

Modality of ARRT with Efficiency Defined

Marshall MR, Golper TA:Semin Dial 24:142-148,2011

Low-Efficiency Acute Renal Replacement Therapy : Role in Acute Kidney Injury

• PIRRT effect of urea disequilibrium on time concentration profiles inbound and rebound

• 1.8 m2 low-flux(QB200, QD100, 12HR) 4% rebound• 1.8 m2 low-flux (QB200, QD500, 8hr) 17% rebound

– High-efficiency PIRRT – Unacceptable Disequilibrium

Mark R. Marshall*† and Thomas A. Golper

• Seminars in Dialysis—Vol 24, No 2 (March–April) 2011 pp. 142–148


three major ways in which solute disequilibrium affects the clinical care of patients: ARRT dosedialysis disequilibrium syndromehemodynamic instability

solute disequilibrium

• Symptoms of headache, disorientation and nausea at its mildest, delirium, myoclonus ⁄ seizures and coma at its most severe.

• The pathogenesis is incompletely understood although it is clearly attributable to cerebral edema from water influx as the final common pathway

Ronco C, Bellomo R, Kellum J. Critical Care Nephrology. 2009:1079–1083


• Prosaic Use of Lower-Efficiency ARRT– Low-flux membrane– Lower-efficiency

Case Presentation

• 52yrs, AMI with ventricular septal rupture status post repairmen of ventricular septum on 2012/01/07,

• Tachypnea and agitation were noted around 8PM on 2/19, and desaturation to 90% was found. CXR showed pulmonary edema, r/o pneumonia, and BW gain>7Kg , metabolic acidosis with dopamine infusion, he was transferred to ICU. And start CRRT.

• 2/20 5008HF(standard setting), BUN/Cre:283/5.79 2/23 BUN/Cre :33/1.83

• solute disequilibrium ??? • 停止透析 :2012/3/4

Case Presentation

• 35yrs, DCMP with congestive heart failure and lung edema s/p ECMO support(2012/3/22), s/p LVAD support (2012/03/26)

• 3/28 septic shock start RRT (SLED 2hr due to BUN/Cre:174/4.91, prevent disequilibrium?)

• 3/28 night profound acidosis 5008HF • 3/29 Expired

超過濾係數 Ultrafiltration Coefficient

水份的移除 (Hydraulic

Permeability)

超過濾係數 Kuf

(ml/mmHg/hour)

• Low (Standard) Flux

UFcoefficient 2-9 ml/mmHg/hour

• Intermediate FluxUFcoefficient 10-19 ml/mmHg/hour

• High FluxUFcoefficient 20-80 ml/mmHg/hour

Categories for HD membranes

Vicken J. Membranes in Haemodialysis in ； Peinemann KV, Pereira Nunes SP, (eds) Membranes for Life Sciences. Wiley Co, 2007 ； 1-48.

血液透析器設計理念血液過濾器設計理念血液透析過濾器 for SLEDD-f

血液透析器 for IHD

200 µm 40 µm

Chronic Filter

High-flux DialyzerWall thickness (µm) 40Inner lumen (µm) 200

具高生物相容性具良好的中大分子篩濾與清除效果抗凝劑需要量越低越好最少可連續使用 24 小時

“ 理想的 " 血液過濾（ Hemofilter ）

“ 理想的 " 血液過濾器

Function Membrane permeability

– Diffusion Low flux and High flux– Convention High flux

Filter and Fiber Geometry Adapted for low blood flow

– Large ID ： short Biocompatibility

Membrane geometry adapted to special needs in CRRT

• Decreased wall thickness– increased diffusive clearance

• Increased inner lumen– less shear-stress– lower thrombogenicity– lower heparin need

血液過濾器 – 中空纖維特性

220 µm

Acute Filter35 µm

HemofilterWall thickness

(µm) 35

Inner lumen (µm) 220

high-flux dialyzer is required to SLEDD-f

• A high-flux dialyser is required to perform SLEDD-f– A dialysis membrane with high hydraulic

permeability, high solute permeability and large surface exchange• Moderate transmembrane pressures (< 300mmHg)• Simultaneously avoid or minimal albumin loss• Highly biocompatible membrane is particular

importance

010 100 1000 10000 100000

Vit.B 12 Albuminß2-M

0 , 2

0,4

0,6

0,8

1,0

InulinUrea Creatinine

Siev ing C oef f icient

M o le cu lar W e ig ht [ Dalto n ]

P o l y su lf o n e Ultra- F lu x K id n e ySta n da rd m em bra ne

The cut off of the membrane is ~ 30.000 Dalton.

Membranes for Dialysis and Hemofiltration --- 7.3

Dialysis membranes should have ：• high diffusive and convective clearances for the

removal of a wide range of toxins.• the best possible biocompatibility to avoid undesirable

interactions with blood components• adequate hydraulic permeability for use in intermittent

or continuous renal replacement therapy modes• the highest pyrogen retention capability for the use

with non-ultrapure dialysate.

Membrane Size

• 早期 : 1.2 m2

• 近期 : 1.4 ~ 1.8 m2

SICU Dialysis indication2009(209)

2010(242)

2011(260)

Shock 63 (30.1%) 85 (35.1%) 108 (41.5%)

Sepsis 109 (52.1%) 101 (41.7%) 138 (53.0%)

ESRD 67 85 68

Others 2 2 3

SICU Dialysis method2009 2010 2011

CAVHCVVH

365 450 340

IHD 925 988 931

SLED 304 428 335

SLED-f 371 304 322

選一種人工腎臟：兼顧 PIRRT and IHD ？CRRT:1.4 m2 AV-600

台大 AK

AN-69 : Bradykinin release syndrome

J Am Soc Nephrol 20: 645–654, 2009

sicu combine meeting 2012-4-26 蔡壁如. case presentation 56yr, male: cad s/p pobas with icmp s/p...

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