solute mass transfer in crrt garred et al., ajkd 1997
DESCRIPTION
Post-Dilution CVVH. CVVHD. Q r. Q b. Q b. Q eff. Q eff. Q d. Q r. Q r. Q b. Q b. Q eff. Q eff. Q d. Pre-Dilution CVVH. CVVHDF. Solute Mass Transfer in CRRT Garred et al., AJKD 1997. Mechanisms of Solute Removal: IHD vs CRRT Clark and Ronco, Kidney Int 1998. IHDCRRT - PowerPoint PPT PresentationTRANSCRIPT
Solute Mass Transfer in CRRTGarred et al., AJKD 1997
Post-Dilution CVVH CVVHD
Pre-Dilution CVVH CVVHDF
Qb
Qb Qb
Qb
Qeff Qeff
QeffQeff Qd
Qd
Qr
Qr
Qr
Mechanisms of Solute Removal: IHD vs CRRTClark and Ronco, Kidney Int 1998
IHD CRRT
Small Solutes Diffusion* Diffusion** (CVVHD)(mw < 300) Convection (CVVH)
Middle Molecules Diffusion Convection(mw 500-5,000) Convection Diffusion
LMW Proteins Convection Convection(mw 5,000-50,000) Diffusion Adsorption
Adsorption
Large Proteins Convection Convection(mw > 50,000)
* Determinants: flow rates, membrane thickness** Determinants: effluent dialysate flow rate
Solute Clearance in CRRT
• CVVHD
K = E . QD
• Post-Dilution CVVH
K = S . QUF
• Pre-Dilution CVVH
K = S . QUF .
E =
S =
Concentration in effluent dialysate
Concentration in blood
Concentration in blood
Concentration in filtrate
(
(
)
)
QP
QP + QR
( )
Dialytic Solute Removal Mechanisms
• Diffusion
– transmembrane solute movement in response to a concentration gradient
– importance inversely proportional to solute size
• Convection
– transmembrane solute movement in association with ultrafiltered plasma water (“solvent drag”)
– mass transfer rate determined by ultrafiltration rate (pressure gradient) and membrane sieving properties
– importance directly proportional to solute size
Urea Clearance in Pre-Dilution CVVHBrunet et al., AJKD 1999
= -15%
QUF (mL/h)
28.7
33.9
Cle
ara
nce
(m
L/m
in)
Effect of Dialysate Flow Rate onSmall Solute Clearances in CVVHD
Bonnardeaux et al., AJKD 1992
0
20
40
60
80
0 16.7 33.3 50 66.7
Cle
ara
nce
or
Flo
w R
ate
(m
L/m
in)
Creatinine
Urea
Inlet QD (mL/min)
Ultrafiltration
Dialysate Out
Effect of Dialysate Flow Rate onSolute Equilibration in CVVHD
Bonnardeaux et al., AJKD 1992
0.5
0.6
0.7
0.8
0.9
1.0
1.1
0 16.7 33.3 50 66.7
D/P
Ra
tio
Creatinine
Urea
Inlet QD (mL/min)
Solute Equilibration in CVVHDBrunet et al., AJKD 1999
QE (mL/h)
Cle
ara
nce
(m
L/m
in)
Components of Small Solute Clearance in CRRTSigler et al., AJKD 1987
0
5
10
15
20
25
30
35
0 1 2 3 4 5 6 7 8 9 10 11 12 13
Ure
a c
lea
ran
ce, c
c/m
in
Ultrafiltration, (QF)cc/min
Urea and Creatinine Kinetic Parameters in ARF Patients
Leblanc et al., AJKD 1998
nPCR (gm/kg/d) 1.75 ± 0.82
Creatinine Index (mg/kg/d) 13.7 ± 4.7
LBM (kg) 38.3 ± 11.9
LBM/BW (%) 49.5 ± 14.0
Effect of Solute Molecular Weight on EquilibrationJeffrey et al., Artif Organs 1994
Solute (MW) Sieving Coefficient (HF) Diffusion Coefficient (HD)
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**
*P<0.05 vs sieving coefficient**P<0.01 vs sieving coefficient
Factors Influencing RRT Dose in ARF
Factor CRRT vs IHD
K . t Favors CRRT (due to “t”)
Anticoagulation Favors IHD
Hypotension Favors CRRT
Compartment Effects Favors CRRT
Access Recirculation Favors CRRT
“Down-Time” Favors IHD
Defined Target Favors Neither
Prescribed vs Delivered RRT in ARF
• CRRT
– “Down-time”: procedures, filter changes
– Decline in filter performance: SC or CDo/CBi, UFR
– Access recirculation
• IHD
– Failure to achieve prescription (QB, time)
– Compartment effects (rebound)
– Access recirculation
Effect of CVVH on Hemodynamic Parametersin Septic Patients
De Vriese et al., JASN 1999
Time (hours)
Ca
rdia
c o
utp
ut (
l/min
)a
nd P
AO
P (
mm
Hg)
Syste
mic V
ascula
r Re
sistance
(dyn
e.s/cm
5)
Effect of Filter Pore Size on Survivalin Experimental SepsisLee et al., Crit Care Med 1998
8
7
6
5
4
3
2
1
0
120 24 36 48 60 72 84 96 108 120 132 144 156 168 180 192
Nu
mb
er o
f A
nim
als
Aliv
e
Survival Time (hr)