Renal Replacement Therapy What

the Non-Nephrologist Should Know

Kidney Disease is a Public

Health Problem
Trends in Kidney Disease
Burden

Prevalence of CKD Stages in US Adults Aged

20 Years or Older:
NHANES 1988-1994 and NHANES 1999-2004

Coresh, J. et al. JAMA 2007;298:2038-2047

ESRD Prevalence The Forecast

Projected growth overall ESRD prevalence (5% / yr)
Number of patients (millions)
3.0

2.2 million
(60% diabetic)

2.0
618,160 pts
(2011)
1.3 million

1.0
0.7 million
0
1978

0.4 million
2000

2010
Year

2020

2030
Gilbertson et al. JASN 2003

Objectives
Describe treatment options for renal
replacement therapy
Understand the general principles of
dialysis modalities & compare their
outcomes
Importance of residual renal function
Describe kidney transplantation process

Case Presentation (I)

39 y/o AA man
PMHx: none
Routine physical exam:
BP 142 / 100
LE edema
4+ proteinuria (dipstick)

Case Presentation (II)

Initial Nephrology Clinic Visit
PE:

Unremarkable, except:
Weight 230 lbs (BMI 33)
BP 138 / 85
2+ LE edema

Treatment:
ACE inhibitor
Thiazide diuretics

Case Presentation (III)

Initial Laboratory Data
Labs:
12.3
7490

333
41.0

141

107

18

3.6

28

2.4

95

Albumin 2.5
eGFR 37 cc/min/1.73m2
T. cholesterol 398 mg/dL
Serology w-u (-)
UA: protein 4+, 0-2 RBC, 0-2 WBC
Spot u. prot. / creat. 413 mg/dL / 41 mg/dL 10

CKD Progression ESRD

Uremic
ESRD

40
30
20 Kidney Bx: FSGS
eGFR cc/min/1.73m2
10
0

Dates

Initial presentation:
HTN, CKD, proteinuria

RRT

Indications for Renal Replacement Therapy

Hyperkalemia
Metabolic acidosis
Fluid overload (recurrent CHF admissions)
Uremic pericarditis (rub)
Other non specific uremic symptoms:
anorexia and nausea, impaired nutritional
status, increased sleepiness, and decreased
energy level, attentiveness, and cognitive
tasking,

What are the Treatment Options for Renal

Replacement Therapy for our Patient?

ESRD Treatment Options

ESRD

Comfort Care

Peritoneal Dialysis

Hemodialysis

Kidney Transplant

ESRD Treatment Options

ESRD

Hemodialysis

Comfort Care

Peritoneal Dialysis

Kidney Transplant

Dialysis options
Dialysis

Hemodialysis
In-Center HD (3 x week)
Home HD (short daily, nocturnal)

Peritoneal Dialysis
CAPD
CCPD

Home

Incident Patient Counts (USRDS)

by 1st Modality

USRDS 2013 ADR

CKD Education

CKD Progression ESRD

40

CKD
Education

Uremic
ESRD

30
20
eGFR cc/min/1.73m2
10
0

Dates

Initial presentation:
HTN, CKD, proteinuria

RRT

CKD Education
Refer patients early, when eGFR < 30 cc/min
Education about types of renal replacement therapy:
Hemodialysis (vascular access +++)
Peritoneal Dialysis (QOL advantage +++)
Kidney Transplantation
Refer when eGFR <20
Living kidney transplant (family, friends)
Build time on list before dialysis initiation
Even transplant before dialysis initiation (preemptive)

Early Vaccination for Hepatitis B!

Patients with ESRD have response to vaccination
(2ary to general suppression of immune system)

After Hepatitis B vaccination in ESRD patients:

50 60 % develop antibodies, compared to >
90% in patients without renal failure
Have Lower titers
Have protective levels for shorter duration

Stevens CE et al. NEJM 1984; 311: 496

Buti M et al. Am J Nephrol 1992; 112: 144

Early Vaccination for Hepatitis B!

Patients with ESRD have response to vaccination
(2ary to general suppression of immune system)

After Hepatitis B vaccination in ESRD patients:

50 60 % develop antibodies, compared to >
90% in patients without renal failure
Have Lower titers
Have protective levels for shorter duration

Stevens CE et al. NEJM 1984; 311: 496

Buti M et al. Am J Nephrol 1992; 112: 144

Hemodialysis (HD)

Principle of Hemodialysis
Vein
Artery

Hemodialysis Filter (Dialyzer)

Hemodialysis Filter (Dialyzer)

Hemodialysis Vascular Access

Polytetrafluoroethylene

Arteriovenous (AV) Fistula

Question 1
Which type of vascular access is associated
with better outcomes in hemodialysis
patients? (choose one answer):
1.Central venous cuffed catheter
2.Arteriovenous graft
3.Arteriovenous fistula
4.Temporary central venous catheter

Which Vascular Access and When

Should It Be Placed?

CKD Progression
Vascular
Access (AVF)

40
30
20
eGFR cc/min/1.73m2
10
0

Dates

Initial presentation:
HTN, CKD, proteinuria

HD

Adjusted* Relative Risk of Death

by Type of Vascular Access
Diabetes

No Diabetes

Cohort: 5,507 patients, followed for 2 years

*Adjusted for age, race, gender, BMI, history of smoking, PVD, CAD, CHF, neoplasm, ability to
ambulate and education level.
Prevalent diabetic pts: CVC vs. AVG (P = 0.42). Incident diabetic pts: CVC vs. AVG (P = 0.48).
Prev. nondiabetic pts: CVC vs. AVG (P < 0.0001). Inc. nondiabetic pts: CVC vs. AVG (P = 0.82).
Dhingra RK et al. Kidney Int 2001; 60: 14431451

Adjusted* Relative Risk of Death due to

Infection by VA Type and Diabetes Status

Cohort: 5,507 patients, followed for 2 years

*Adjusted for age, race, gender, BMI, history of smoking, PVD, CAD, CHF, neoplasm, ability to
ambulate and education level.
Prevalent diabetic pts: CVC vs. AVG (P = 0.81)
Prevalent nondiabetic pts: CVC vs. AVG (P < 0.13)
Dhingra RK et al. Kidney Int 2001; 60: 14431451

Patients who started using an AV access by

timing of first referral to a nephrologist

N=356 hemodialysis patients

Astor B. et al. Am J Kidney Dis 2001; 38 (3): 494-501

VASCULAR ACCESS GUIDELINES

Arm veins suitable for placement of vascular access
should be preserved, regardless of arm dominance.
Arm veins, particularly the cephalic veins of the nondominant arm should not be used.
Dorsum of the hand could be used for IV.
A Medic Alert bracelet should be worn to inform
hospital staff to avoid IV cannulation of essential
veins.
Subclavian vein catheterization should be avoided
for temporary access in all patients with CKD
( stenosis preclude use of ipsilateral arm for
vascular access)

SAVE the Non-Dominant ARM

for Vascular Access
When GFR < 30 mL/min
No BP measurement
No IV
No Blood Draws

On Non-Dominant
Arm

Place vascular access within a year of hemodialysis anticipation

Peritoneal Dialysis (PD)

Principle of PD Treatment

Abdominal cavity is lined by peritoneal membrane

which acts as a semi-permeable membrane
Diffusion of solutes (urea, creatinine, ) from blood
into the dialysate contained in the abdominal cavity
Removal of excess water (ultrafiltration) due to
osmotic gradient generated by glucose in dialysate

Types of PD Catheters

Overall PD catheter survival : +/- 90% at 1 year

No particular catheter is superior

Placement of Peritoneal Dialysis Catheter

Placement of PD Catheter

Exit Site

PD Catheter Exit Site

Peritoneal Dialysis (PD)

PD

Continuous

Intermittent

Continuous PD Regimens
Multiple sequential exchanges are performed during the day
and night so that dialysis occurs 24 hours a day, 7 days a week

CAPD: Continuous
Ambulatory PD

CCPD: Continuous
Cyclic PD

Intermittent PD Regimens
PD is performed every day but only during certain hours

DAPD: Daytime
Ambulatory PD.

Multiple manual exchanges

during waking hours

NPD: Nightly PD.

Performed while patient

asleep using an automated
cycler machine.
Sometimes,
1 or 2 day-time manual
exchanges are added to
enhance solute clearances

CCPD Treatment Setup

Question 2
What is the most common cause of
technique failure in peritoneal dialysis?
(choose one answer):
1.Ultrafiltration failure
2.Malnutrition
3.Peritonitis
4.Non-adherence to the treatment regimen

Cumulative percentage of PD patients by

time from 1st dialysis to 1st switch to HD

25% of PD
patients
switched to HD
within 5-7 years

Jaar BG et al. BMC Nephrol 2009; 10: 3

Causes of PD Technique Failure

(Switching from PD to HD)
Psychological Issues
4%
Abdominal Surgery

15%
46%
Malnutrition

Peritonitis

15%

19%
Ultrafiltration Failure
Jaar BG et al. BMC Nephrol 2009; 10: 3

Which Dialysis Modality Provides the

Best Outcomes?

Factors Influencing Dialysis Choice

Contraindications

Survival

Quality of Life

Treatment Satisfaction

Other Factors:
Late Referral,

Dialysis Modality

Absolute contraindications for PD

Documented loss of peritoneal function or
extensive abdominal adhesions (previous abd.
Surgeries) limit dialysate flow
Uncorrectable mechanical defects
(e.g., diaphragmatic hernia)
In the absence of a suitable assistant, a patient
who is physically or mentally incapable of
performing PD.
NKF K/DOQI Guidelines 2000

Peritoneal Adhesions

Factors Influencing Dialysis Choice

Contraindications

Survival

Quality of Life

Treatment Satisfaction

Other Factors:
Late Referral,

Dialysis Modality

Best Study Design to Compare Dialysis Modalities

Prospective, randomized, clinical trial

Significant barriers to performing this type of study1
We are left with the analysis of observational data
from well-conducted prospective studies

Quinn RR et al. 2011 (I)

Country:
Enrollment Years:
Follow-Up:

Ontario, Canada
7-1-1998 to 3-31-2006
8 years

Population Type:

Incident Elective Outpatient

(databases @ Institute for Clinical
Evaluative Sciences)

Sample Size:
Switching Modality:

HD: 4,538 PD: 2,035

No

Model(s)

Intention-to-Treat (baseline
modality)
Quinn RR et al. J Am Soc Nephrol 2011; 22: 1534-1542

Adjusted Survival between PD and HD, (received > 4

months of predialysis care and Started as outpatient)

Adjusted HR: 0.96, p = 0.44

Quinn RR et al. J Am Soc Nephrol 2011; 22: 1534-1542

Biases
Residual confounding: limited adjustment for known
factors associated with mortality (e.g., comorbidities,
lab data [albumin, ])
Short follow-up (1-2 years) in some studies
Lead-time bias: baseline GFR
Selection bias: patient characteristics
Statistical Methodology:
Center Effect: confounding by clinic as patient
characteristics varied by center and treatment
How to handle modality switching: As-Treated vs
Intention-to-Treat
No causal relationship, just association!

Other Issues: PD vs HD
Beyond Survival

In considering choice of dialysis technique,

other issues must be considered

Factors Influencing Dialysis Choice

Contraindications

Survival

Quality of Life

Treatment Satisfaction

Other Factors:
Cost of Care,
Late Referral,

Dialysis Modality

CHOICE - Quality of Life:

PD vs HD (I)
PD patients reported better QOL then HD patients
in the following domains:
Bodily pain
Travel
Diet restrictions
Dialysis access
Financial well-being
Physical functioning (only at baseline, not at 1
year)
Wu A et al. JASN 2004; 15: 743-753

CHOICE - Quality of Life:

PD vs HD (II)
At one year,
HD patients improved more on aspects of
general health-related QOL than patients on
PD
HD patients had greater improvement on:
Physical functioning
Sexual functioning
General health perceptions
Wu A et al. JASN 2004; 15: 743-753

Factors Influencing Dialysis Choice

Contraindications

Survival

Quality of Life

Treatment Satisfaction

Other Factors:
Late Referral,

Dialysis Modality

CHOICE - Treatment Satisfaction: PD vs HD

PD patients were significantly more likely to give
excellent ratings of dialysis care overall compared to
HD patients (85% vs 56%).
Also PD patients were more likely to give excellent
ratings for specific aspects of care:
information on choosing a dialysis modality
information on fluid removal
staff and nephrologist availability
coordination with other physicians
caring of nurses or staff

Rubin HR et al. JAMA 2004; 291: 697-703

Implications
Each modality has distinct advantages or disadvantages
Physicians should be as explicit as possible in describing specific
tradeoffs and attempt to elicit individual preferences at start of dialysis
Although there is no conclusive evidence that the choice of PD or HD
provide a specific survival advantage:
Better selection of PD patients (PD underutilized)
PD patients should be monitored closely after the 2 nd or 3rd year of dialysis
Consider a timely transfer to HD (if or when PD problems arise)

What is the best long-term treatment?

1.

PD

2.

HD in-center

3.

HD home/
self-care

Ask the nephrology providers which dialysis modality they would select if they had
ESRD?

What is the best long-term treatment?

Opinion vs Reality

1.

PD

2.

HD in-center

3.

HD home/
self-care

Ledebo I., Ronco C. NDT Plus 2008; 6:403-408

Question 3
Which one of the following patients characteristic
or comorbidity is associated with better overall
outcome on dialysis (choose one answer):
1.Diabetes Mellitus + end-organ damage
2.BMI > 30
3.Residual urine output of > 500 cc / day
4.Colon cancer
5.Early initiation of dialysis (eGFR > 15)

Is Timing of Dialysis Initiation

Important in ESRD Patients?

(Controversial)

IDEAL Study: KM Curves for Time to the

Initiation of Dialysis & for Time to Death

Between July 2000 & November

2008
Australia / New Zealand
828 adults
Early start:
eGFR 10-14 cc/min
Late start:
eGFR 5-7 cc/min
mean age 60.4 years
542 men & 286 women
355 with diabetes
Median follow-up 3.6 years

Cooper BA et al. N Engl J Med 2010;363:609-619

Implications
A total of 75.9% of the patients in the late-start group
started dialysis when eGFR was > 7.0 cc/minute, owing
to the development of symptoms!
In this study, planned early initiation of dialysis in
patients with stage V CKD was not associated with an
improvement in survival or clinical outcomes (QOL)
OK to delay initiation of dialysis (eGFR < 7-10 cc/min)
Dialysis initiation should be based upon clinical
factors (symptoms) rather than eGFR alone
Cooper BA et al. N Engl J Med 2010;363:609-619

Why is Residual Renal Function

Important in Dialysis Patients?

Why is baseline residual renal function

important?
Remaining GFR at start of dialysis make a
significant contribution to the removal of potential
uremic toxins
Also facilitates regulation of fluid, electrolytes, and
may enhance nutritional status and QOL
Offers survival advantage in both HD and PD
Suda T et al. Nephrol Dial Transplant 2000; 15: 396
Shemin D et al. Am J Kidney Dis 2001; 38: 85
Szeto C et al. Nephrol Dial Transplant 2003; 18: 977

Cumulative Incidence of All-Cause Mortality in 579

HD Patients by Urine Status at 1 Year (CHOICE)
Adjusted Hazard Ratio: 0.70 (0.52-0.93) p = 0.02

Shafi T., Jaar B., et al. Am J Kidney Dis. 2010;56:348-58

Implications
Try to preserve residual renal function in
dialysis patients!
Less dietary restriction
Better quality of life
Better survival
Try to avoid nephrotoxins if your dialysis
patient still makes urine!

Kidney Transplantation

Principle of Kidney Transplantation

Iliac Fossa

Question 4
Which one of the following statements is
correct? (choose one answer):
1.CKD patients can be referred to a transplant
center when their GFR is < 20 cc/min/1.73m2
2.Pre-emptive and live kidney transplants are
associated with better graft survival
3.Most common cause of kidney transplant loss is
death with a functional transplant
4.All of the above

Trends in Transplantation:
age 20 years & older

patients

USRDS ADR 2012

Adjusted Relative Risk of Death among 23,275

Recipients of a 1st Cadaveric Transplant

Wolfe RA et al. N Engl J Med 1999;341:1725-1730

K-M Estimates of Allograft Survival According to

the Use or Nonuse of Long-Term Dialysis before
Kidney Transplantation from a Living Donor
Adjusted Rate Ratio (95% CI): 0.16 (0.070.35)

P = 0.009

Mange K et al. N Engl J Med

Acute Rejection within

the 1st Year Post-Transplant

Patients age 18
& older with a
functioning
graft at
discharge.

USRDS ADR 2012

Cumulative incidence of
post-transplant diabetes

Patients
receiving a
first-time,
kidney-only
transplant,
20032007
combined.
USRDS ADR 2012

Causes of Death in Kidney Transplant

Patients with Functioning Graft 20062010

First-time,
kidney-only
transplant
recipients,
age 18 &
older, 2006
2010, who
died with
functioning
graft.
USRDS ADR 2012

Posttransplant Malignancy
Risk is 4X to 100X compared rates of malignancy in
the general population
No comprehensive reporting system
Available data suggesting 2- to 3-fold under-reporting
The precise rate is UNKNOWN
Accounts for 10% of deaths in kidney recipients with
functioning graft
SCREENING is KEY!

Immunization for Kidney Transplant

Recipients

Recommended
Influenza types A and B
(yearly)
Pneumovax (every 3-5
years)
Diphteria-PertussisTetanus
Haemophilus influenza B
Hepatitis A and B
Inactivated polio
Meningococcus

Not Recommended

Varicella zoster
Intranasal influenza
BCG
Live oral typhoid
Measles, Mumps, Rubella
Oral polio
Yellow fever
Smallpox
Live Japanese B
encephalitis vaccine

Key Concepts (I)

Kidney transplantation is the most cost-effective
modality of renal replacement
Transplanted patients have a longer life and
better quality of life
Early transplantation (before [pre-emptive] or
within 1 year of dialysis initiation) yields the best
results
Living donor kidney outcomes are superior to
deceased donor kidney outcomes

Key Concepts (2)

Early transplantation is more likely to occur in
patients that are referred early to nephrologists
Refer for transplant evaluation when eGFR < 20
cc/min/1.73m2
Success of transplantation results from a delicate
balance between the suppression of the immune
system to prevent rejection and the long-term
side-effects of immunosuppression

Key Concepts (3)

The most common cause of transplant loss is
death with a functional transplant due to
Heart disease +++
Infections
Malignancies

Immunosuppressants are essential to prevent

immunological loss of the transplant but side
effects can also lead to transplant loss

What are the Costs of the Different Renal

Replacement Therapy Modalities?

Costs (in Billion) of Medicare and ESRD

Programs in 2010

ESRD Cost
$32.9 (6.3%)

Total Medicare
$522.8
488,938 ESRD patients representing
less than 1% Medicare population

USRDS ADR 2012

Total Medicare ESRD expenditures

per person per year, by modality
$87,561

$66,751

$32,914

Period prevalent ESRD patients

Patients with Medicare as secondary payor are excluded

USRDS ADR 2012

What About No Renal Replacement

Therapy Option?

Starting Dialysis in the ElderlyOr Not?

Among patients > 75 yrs with stage 5 CKD who
chose NOT to start dialysis:
Overall, more likely to die over next 1-2 years
But if they had ischemic heart disease or other
significant comorbidity NO DIFFERENCE in
survival
Active disease management and supportive care
may be appropriate without starting dialysis in the ill
elderly
Must have end-of-life discussions!
Murtagh, et al. Nephrol Dial Transplant. 2007; 22(7): 1955-1962

The Future

 Regenerative Medicine
Stem Cell Therapy
Wearable Artificial Kidney

Thank You !
QUESTIONS?

RENAL REPLACEMENT THERAPHY

Where are we - too many questions?

What therapy should we use?

When should we start it?
What are we trying to achieve?
How much therapy is enough?
When do we stop/switch?
Can we improve outcomes?
Does the literature help us?

Overview

AKI classification systems 2: AKIN

Stage

Creatinine criteria

Urine output criteria

1.5 - 2 x baseline (or rise >

26.4 mol/L)

< 0.5 ml/kg/hour for > 6

hours

>2 - 3 x baseline

< 0.5 ml/kg/hour for > 12

hours

> 3 x baseline (or > 354

mol/L with acute rise > 44
mol/L)

< 0.3 ml/kg/hour for 24

hours or anuria for 12 hours

Patients receiving RRT are Stage 3 regardless of creatinine or urine output

Acute Kidney Injury in the ICU

AKI is common: 3-35%* of admissions

AKI is associated with increased
mortality
Minor rises in Cr associated with worse
outcome
AKI developing after ICU admission (late)
is associated with worse outcome than
AKI at admission (APACHE
underestimates ROD)
AKI requiring RRT occurs in about 4-5%
Brivet, admissions
FG et al. Crit Care Medand
1996; 24:
192-198
of ***ICU
is
associated with
Metnitz, PG et al. Crit Care Med 2002; 30: 2051-2058
worst mortality risk **

Mortality by AKI Severity (1)

75
60
45
ICU Mortality

30
15
0

Clermont, G et al. Kidney International 2002; 62: 986-996

Hospital Mortality

Mortality by AKI Severity (2)

70

53

35

18

Bagshaw, S et al. Am J Kidney Dis 2006; 48: 402-409

RRT for Acute Renal Failure

There is some evidence for a

relationship between higher therapy
dose and better outcome, at least up
to a point
This is true for IHD* and for CVVH**
There is no definitive evidence for
superiority of one therapy over
another, and wide practice variation
exists***
Accepted indications for RTT vary
*Schiffl,
H et
al. NEJM 2002; 346: 305-310
** Ronco, Con
et al. timing
Lancet 2000;
No
definitive
evidence
355: 26-30
*** of
Uchino,
S. Curr Opin Crit Care 2006; 12: 538-543
RRT

Outcome with IRRT vs CRRT (2)

No mortality difference between

therapies
No renal recovery difference between
therapies
Unselected patient populations
Majority of studies were unpublished

Tonelli, M et al. Am J Kidney Dis 2002; 40: 875-885

Proposed Indications for RRT

Oliguria < 200ml/12 hours

Anuria < 50 ml/12 hours
Hyperkalaemia > 6.5 mmol/L
Severe acidaemia pH < 7.0
Uraemia > 30 mmol/L
Uraemic complications
Dysnatraemias > 155 or < 120
mmol/L
Hyper/(hypo)thermia
Drug overdose with dialysable
drug
Lameire, N et al. Lancet 2005; 365: 417-430

Implications of the available data

The Ideal Renal Replacement

Therapy
Allows
Allows control
control of
of intra/extravascular
intra/extravascular volume
volume
Corrects
Corrects acid-base
acid-base disturbances
disturbances
Corrects
Corrects uraemia
uraemia &
& effectively
effectively clears
clears
toxins
toxins
Promotes
Promotes renal
renal recovery
recovery
Improves
Improves survival
survival
Is
Is free
free of
of complications
complications
Clears
Clears drugs
drugs effectively
effectively (?)
(?)

Solute Clearance - Diffusion

Small (< 500d)
molecules cleared
efficiently
Concentration gradient
critical
Gradient achieved by
countercurrent flow
Principal clearance mode
of dialysis techniques

Solute Clearance Ultrafiltration &

Convection (Haemofiltration)

Water movement drags

solute across membrane
At high UF rates (> 1L/hour)
enough solute is dragged to
produce significant clearance
Convective clearance
dehydrates the blood passing
through the filter
If filtration fraction > 30%
there is high risk of filter
clotting*
Also clears larger molecular
weight
substances (e.g. B12,
* In post-dilution haemofiltration
TNF, inulin)

Major Renal Replacement

Techniques
Intermittent

Hybrid

Continuous

IHD

SLEDD

CVVH

IUF

SLEDDF

CVVHD

Intermittent
haemodialysis

Isolated
Ultrafiltration

Sustained (or
slow) low
efficiency daily
dialysis

Sustained (or
slow) low
efficiency daily
dialysis with
filtration

Continuous venovenous
haemofiltration

Continuous venovenous haemodialysis

CVVHDF
Continuous venovenous
haemodiafiltration

SCUF

Slow continuous
ultrafiltration

Intermittent Therapies - PRO

Intermittent Therapies - CON

Intradialytic Hypotension: Risk Factors

LVH with diastolic dysfunction or LV systolic
dysfunction / CHF
Valvular heart disease
Pericardial disease
Poor nutritional status / hypoalbuminaemia
Uraemic neuropathy or autonomic dysfunction
Severe anaemia
High volume ultrafiltration requirements
Predialysis SBP of <100 mm Hg
Age 65 years +
Pressor requirement

Managing Intra-dialytic Hypotension

Dialysate temperature modelling
Low temperature dialysate

Dialysate sodium profiling

Hypertonic Na at start decreasing to 135 by end
Prevents plasma volume decrease

Midodrine if not on pressors

UF profiling
Colloid/crystalloid boluses
Sertraline (longer term HD)
2005 National Kidney Foundation K/DOQI GUIDELINES

Continuous Therapies - PRO

Continuous Therapies - CON

SCUF

High
High flux
flux membranes
membranes
Up
Up to
to 24
24 hrs
hrs per
per day
day
Objective
Objective VOLUME
VOLUME control
control
Not
Not suitable
suitable for
for solute
solute
clearance
clearance

Blood
Blood flow
flow 50-200
50-200 ml/min
ml/min
UF
UF rate
rate 2-8
2-8 ml/min
ml/min

CA/VVH
Extended
Extended duration
duration up
up to
to
weeks
weeks
High
High flux
flux membranes
membranes
Mainly
Mainly convective
convective
clearance
clearance
UF
UF >
> volume
volume control
control
amount
amount
Excess
Excess UF
UF replaced
replaced
Replacement
Replacement prepre- or
or postpostfilter
filter
Blood
Blood flow
flow 50-200
50-200 ml/min
ml/min
UF
UF rate
rate 10-60
10-60 ml/min
ml/min

CA/VVHD
Mid/high
Mid/high flux
flux membranes
membranes
Extended
Extended period
period up
up to
to
weeks
weeks
Diffusive
Diffusive solute
solute
clearance
clearance
Countercurrent
Countercurrent dialysate
dialysate
UF
UF for
for volume
volume control
control
Blood
Blood flow
flow 50-200
50-200 ml/min
ml/min
UF
UF rate
rate 1-8
1-8 ml/min
ml/min
Dialysate
Dialysate flow
flow 15-60
15-60
ml/min
ml/min

CVVHDF
High
High flux
flux membranes
membranes
Extended
Extended period
period up
up to
to
weeks
weeks
Diffusive
Diffusive &
& convective
convective
solute
solute
clearance
clearance
Countercurrent
Countercurrent dialysate
dialysate
UF
UF exceeds
exceeds volume
volume
control
control
Replacement
Replacement fluid
fluid as
as
required
required
Blood
Blood flow
flow 50-200
50-200 ml/min
ml/min
UF
UF rate
rate 10-60
10-60 ml/min
ml/min

SLED(D) & SLED(D)-F : Hybrid therapy

Conventional dialysis equipment

Online dialysis fluid preparation
Excellent small molecule
detoxification
Cardiovascular stability as good
as CRRT
Reduced anticoagulation
requirement
11 hrs SLED comparable to 23 hrs
CVVH
Fliser, T & Kielstein JT. Nature Clin Practice Neph 2006; 2: 32-39
Berbece,
AN & Richardson,
RMA. Kidney
International
Decreased
costs
compared
to2006; 70: 963-968

Uraemia Control

Liao, Z et al. Artificial Organs 2003; 27: 802-807

Large molecule clearance

Liao, Z et al. Artificial Organs 2003; 27: 802-807

Comparison of IHD and CVVH

John, S & Eckardt K-U. Seminars in Dialysis 2006; 19: 455-464

Common Antibiotics and CRRT

These effects will be even more dramatic with HVHF

Honore, PM et al. Int J Artif Organs 2006; 29: 649-659

Towards Targeted Therapy?

Non-septic ARF

Septic ARF

Daily IHD

Daily IHD?

Daily SLEDD

Daily SLEDD?

Cathecholamin
e resistant
septic shock

HVHF 60-120
ml/kg/hour
for 96 hours

CVVHD/F ? dose
CVVH @
35ml/kg/hour

CVVH >
35ml/kg/hour
? 50-70
ml/kg/hour

PHVHF 60-120
ml/kg/hour
for 6-8 hours
then CVVH >
35 ml/kg/hour

Cerebral oedema
Honore, PM et al. Int J Artif Organs 2006; 29: 649-659

EBT