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Dialysis and Replacement Solutions for CRRT

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  1. Dialysis and Replacement Solutions for CRRT Jordan M. Symons, MD University of Washington School of Medicine Children’s Hospital & Regional Medical Center Seattle, WA jordan.symons@seattlechildrens.org

  2. CRRT Solutions:Outline of the Talk • Purpose of solutions in CRRT • Goals for a CRRT solution • Description of solutions currently available for CRRT • Considerations in choosing a solution for CRRT

  3. First CAVH Circuit Kramer, P, et al. Arteriovenous haemofiltration: A new and simple method for treatment of over-hydrated patients resistant to diuretics. Klin Wochenschr 55:1121-2, 1977.

  4. CRRT Machines: Current Generation

  5. Convective Clearance To increase clearance by convection, increase ultrafiltration rate (will require more replacement fluids)

  6. D Diffusive Clearance To increase clearance by diffusion, increase dialysate flow rate

  7. Characteristics of the Ideal CRRT Solution • Physiological • Reliable • Inexpensive • Easy to prepare • Simple to store • Quick to the bedside • Widely available • Fully compatible

  8. Base in CRRT Solutions • Hemodialysis: first acetate, then bicarbonate • Peritoneal dialysis: lactate in North America; bicarbonate in Europe • CRRT: lactate or bicarbonate?

  9. Bicarbonate vs. Lactate in CRRT • Both can be used for base • Bicarbonate superior to acetate in HD • PD uses lactate due to technical issues Is bicarbonate preferable to lactate?

  10. Bicarbonate vs. Lactate in CRRT:Blood Lactate Levels Zimmerman et al, Neph, Dial & Transpl 1999 14:2387-2391

  11. Bicarbonate vs. Lactate in CRRT:Blood Lactate Levels in Children Maxvold et al, Blood Purif 17:#27, 1999 [abstract]

  12. Bicarbonate vs. Lactate in CRRT: Cardiovascular Events Bicarbonate Lactate Barenbrock M et al, Kid Int 58:1751-1757, 2000

  13. Options for CRRT Solutions • Peritoneal dialysate • Adapted pre-made solutions • Saline, Lactated Ringers • Multi-bag systems • Custom-made solutions • Local pharmacy; outsource • On-line dialysate • Commercially available CRRT solutions

  14. Baxter Hemofiltration Solution • Lactate buffered • 5 liter bag • Small amount of potassium • Contains calcium

  15. Chemical Content of Baxter Hemofiltration Solution

  16. Hemosol (Hospal) • 5 liter bag • “L” series (lactate) with variable K+, glucose • “B0” (bicarbonate) needs to be mixed • Not available in US

  17. Chemical Content of Hemosol

  18. Normocarb (DSI) • Bicarbonate buffered • Concentrate must be compounded • Final volume 3.24 liters (240ml concentrate added to 3 L bag)

  19. Chemical Content of Normocarb

  20. PrismaSate (Gambro) • Bicarbonate buffered • Small amount of lactate • 5 liter bag • 2 compartments to prevent precipitation • Two ionic formulations

  21. Chemical Content of PrismaSate

  22. Choosing a Solution: Issues to Consider • Anticoagulation • Cost • CRRT modality • Diffusion (CVVHD) • Convection (CVVH) • Both (CVVHDF) • Patient safety

  23. Anticoagulation and Solutions May need to consider Ca++ content if using citrate for anticoagulation

  24. CRRT Solutions: Costs Bunchman et al, Blood Purif 20: 2002 [abstract]

  25. D R R Modality May Have an Impact on Choice of Solutions • Diffusion requires the use of a dialysate • Convection requires the use of replacement fluids

  26. What’s the Difference BetweenDialysate and Replacement Fluid? Dialysate is a Device Replacement Fluid is a Drug

  27. FDA Approval Status of CRRT Solutions

  28. Normocarb as Replacement Fluid FDA Modernization Act of 1997: “The Act creates a special exemption to ensure continued availability of compounded drug products prepared by pharmacists to provide patients with individualized therapies not available commercially”. Bunchman et al, AJKD 42(6):1248-52, 2000

  29. Evaluation of Errors in Preparation of CRRT Solutions • Survey of 3 Pediatric Listserves: • Pediatric Critical Care • Pediatric Nephrology • Pediatric CRRT • 31 programs responded to query Bunchman et al, Blood Purif 22: 2004 [abstract]

  30. Prevalence and Consequences of Errors in Solution Preparation • 16/31 programs reported errors: • 7 errors in replacement solutions • 9 errors in dialysate solutions • Consequences of improper solutions • 2 deaths • 1 non lethal cardiac arrest • 6 seizures (hypo/hypernatremia) • 7 without complications Bunchman et al, Blood Purif 22: 2004 [abstract]

  31. Policy Changes Resulting from Errors in Solutions • Changed to Normocarb for either replacement or dialysate (11) • Changed to PrismaSate for dialysate (2) • Purchased TPN mixer for solutions (2) • Chemistry lab check of every bag (3) • Bag label check by at least 2 staff (10) Bunchman et al, Blood Purif 22: 2004 [abstract]

  32. CRRT Solutions: Summary • Solutions needed to maximize clearance • Bicarbonate seems superior to lactate • Pharmacy made solutions give greatest flexibility but have increased risks/costs • Several industry-made solutions; none currently approved for replacement • Still no perfect “solution” for this problem

  33. Thanks!