IE 3: Renal Replacement Therapy

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53 Terms

1

What do kidneys do? What are they a major component of?

  • Filter the blood to maintain water, electrolytes, waste, and balance acids and bases

  • Major component of metabolism and excretion of certain medications

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2

What is renal failure defined as? What are the 2 types of renal failure?

  • Partial or complete loss of kidney function

    • Inability to maintain fluid, electrolytes, waste or acid-base

    • Accumulation of medications renally excreted

  • Two types of renal failure

    • Acute Kidney Injury (AKI)

    • Chronic Kidney Disease (CKD)

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3

How should you treat AKI?

  • Address underlying causes of AKI

  • Think of possible meds responsible

  • Consider external support while trying to achieve recovery of kidneys

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4

How should you consider treating CKD?

  • There is NO cure for CKD as kidneys become progressively injured and lose function over time

  • Two options:

    • External support

    • Kidney transplantation

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5

What does Renal Replacement Therapy act as?

  • As an artificial kidney to replicate lost functions

    • Optimize fluid balance

    • Prevent or treat electrolyte and acid-base disturbances

    • Elimination of medications

    • Avoid hemodynamic or nephrotoxic-related kidney injury

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6

How does dialysis work?

  • Blood is pumped out of patient into blood line

  • Heparin is added to prevent clotting

  • Blood sent to dialyzer where excess fluids, electrolytes and wastes are removed (effluent)

  • Cleaned blood is removed of air bubbles and returned to patient

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7

How is dialyzed blood accessed by?

  • Arteriovenous fistula (AVF)

  • Arteriovenous graft (AVG)

  • Central venous catheter (CVC)

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8

In terms of dialysis access what is the differences in AVF, ABG, and CVC?

  • AVF

    • Time to mature/use: 2-6 months

    • Maintenance: minimal

    • Infection risk: low

    • Thrombosis risk: low

  • AVG

    • Time to mature/use: 2-4 weeks

    • Maintenance: frequent (patency)

    • Infection risk: medium

    • Thrombosis risk: medium

  • CVC

    • Time to mature/use: immediate

    • Maintenance: frequent (exchange)

    • Infection risk: high

    • Thrombosis risk: high

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9

What does a hemodialysis dialyzer contain? What does it remove?

  • Dialyzer contains semipermeable membrane that blood passes through

  • Removes solutes (waste and electrolytes) without removing important components of blood


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10

What does a dialysate fluid contain?

  • Contains electrolytes and buffer

    • Waste removal while normalizing plasma composition


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11

Dialysis occurs through which. main ways of filtration?

  • Diffusion (requires dialysate)

  • Convection (requires pressurized blood)

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12

What impacts RRT removal? What is the mode of removals?

  • Molecular weight impacts RRT removal

  • Mode:

    • Large molecules: convection or adsorption (nothing above 50k is cleared)

    • Middle: convection better than diffusion

    • Small: diffusion better than convection

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13

What are the indications for RRT?

  • “AEIOU”

  • Acidosis/azotemia

  • Electrolyte imbalance

  • Intoxication/drugs

  • Overload of fluids

  • Uremia

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14

What is Azotemia and when is it seen? What does it lead do and what may it progress to?

  • Elevation of nitrogen waste products in blood (including urea)

    • Seen when kidney function worsens

    • Leads to elevation of BUN and SCr

  • May progress to uremia (urea in blood

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15

What are the toxic medications removed by RRT?

  • Acetaminophen

  • Barbiturates (phenobarbital)

  • Carbamazepine

  • Ethylene glycol

  • Gabapentin / Pregabalin

  • Lithium

  • Metformin

  • Methanol

  • Phenytoin

  • Salicylates

  • Theophylline

  • Valproic acid

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16

What are the different modalities of RRT?

  • Intermittent → IHD (intermittent hemodialysis), SLEDD (slow low efficiency daily dialysis)

  • Continuous → CRRT (continuous renal replacement therapy)→ CVVH (continuous venovenous hemofiltration), CVVHD (continuous venovenous hemodialysis), CVVHF (continuous venovenous hemodiafiltration)

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17

What is the duration of intermittent hemodialysis? What does it remove, what risk if made? When can it be performed?

  • Shortest dialysis procedure

    • 4-6 hours

    • Performed 3 times per week

  • Removes the most solute and fluid

    • Risk of hypotension

  • Can be performed both inpatient and outpatient

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18

What are the IHD (intermittent) outpatient options?

  • Dialysis clinics

    • Fixed time slot

    • Availability of healthcare professionals

  • Home hemodialysis

    • Option for higher frequency

    • More flexibility


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19

What is the process of peritoneal dialysis?

  • Waste products cross the semipermeable membrane into the peritoneal space with the dialysate

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20

What is sustained low efficiency dialysis? What does it have less risk of? What is limited and who is it only performed in?

  • Hybrid between IHD and CRRT

    • 6-12 hours

  • Less risk of hypotension compared to IHD

  • Limited drug clearance data

  • Only performed in critically-ill patients


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21

How long is continuous RRT ran over? What is characteristic of the removal of solutes and fluid? Who is it only performed in?

  • Run over 24 hours

  • Slower removal of solutes and fluid

    • Closer to physiologic kidney function

    • Lower risk of hypotension

  • Only performed in critically-ill patients


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22

In continuous RRT, what is the differences in CVVH, CVVHD, and CVVHDF?

  • CVVH:

    • Mechanism of solute clearance → convection

    • Dialysate? → no

    • Replacement fluid? → yes

    • Solute size removed → small to large

    • Effluent → fluid removed + replacement fluid

  • CVVHD:

    • Mechanism of solute clearance → diffusion

    • Dialysate? → yes

    • Replacement fluid? → no

    • Solute size removed → mostly small

    • Effluent → fluid removed + dialysate

  • CVVHDF:

    • Mechanism of solute clearance → diffusion and convection

    • Dialysate? → yes

    • Replacement fluid? → yes

    • Solute size removed → small to large

    • Effluent → fluid removed + replacement fluid + dialysate

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23

Why is replacement fluid used? What are the buffer agents?

  • Replace fluids lost during CRRT

    • Containing electrolytes and buffer to return blood closer to physiologic state

  • Buffer agents:

    • Lactate

    • Bicarbonate

    • Acetate

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24

In Lactate, what does it convert to in physiologic conditions? When is it not used?

  • Bicarbonate

  • Not used in liver failure > lactic acidosis

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25

In Bicarbonate, what is known about its usage? What change does it make to arterial pressure? Where is it preferred? What are the precipitation concerns?

  • Most commonly used

  • Little change in arterial pressure

  • Preferred in liver failure

  • Precipitation concerns with calcium and magnesium

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26

In acetate, what is known about the use? What can it cause?

  • Historical use, though poor control of acid-base balance

  • Can cause hyperacetatemia and vasodilation

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27

What are complications of RRT?

  • Infection

  • Thrombosis

  • Electrolyte abnormalities

  • Metabolic alkalosis

  • Hemodynamic shifts

  • Medication clearance


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28

What is the infection risk in RRT? What are some signs of possible access site infection?

  • Increased risk from frequent bloodstream access

  • Differing risk based on access

  • Signs of possible access site infection:

    • Redness or swelling of site

    • Drainage or pus along site

    • Fever

    • Chills

    • Malaise

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29

Rank the bloodstream infection risk?

  • Fistula (lowest risk) → Graft → Central Venous Catheter (highest)

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30

When is management of infection in RRT only in?

  • Only for ACUTE infection

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31

In management of infx in RRT, what is antibiotic therapy duration?

  • 4-6 weeks of therapy

  • Lower duration possible

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32

In management of infx in RRT, what is source control?

  • Removal of catheter

    • Culture catheter tip

  • Surgical removal of graft

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33

WHat is a primary issue in CRRT?

  • Clotting

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34

Clotting in CRRT circuit can lead to what?

  • Anemia due to blood lost in circuit

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35

How do you minimize clotting in CRRT circuit anticoagulation and what are the options?

  • Provide anticoagulation to the circuit to minimize clotting

  • Options:

    • Heparin

    • Trisodium Citrate

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36

What are advantages and disadvantages in UFH and Citrate?

  • UFH: easily reversible, inexpensive → increased bleeding risk HIT

  • Citrate: lower bleeding risk → hypocalcemia

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37

In Trisodium citrate related hypocalcemia, what does it bind with? What do we need?

  • Binds with calcium, forming chelated complexes

  • Calcium prevented from activating clotting pathways

  • Need calcium replacement


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38

When not in use, what can happen in RRT catheter? What can prevent this?

  • Clotting

  • Prevented by either a saline flush or by a citrate “lock”

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39

If occluded in RRT catheter, what can we do?

  • If occluded, may instill tissue plasminogen activator (tPA; Cathflo) in catheter for 30 minutes

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40

What is the comparison between IHD vs SLED vs CRRT?

  • IHD

    • Duration → 4-6 hrs

    • Blood flow rate → >300 mL/min

    • Dialysate flow rate → 500-750 mL/min

    • Fluid removal → fluid removed + replacement fluid

  • SLED

    • Duration → 6-12 hrs

    • Blood flow rate → 200 mL/min

    • Dialysate flow rate → 100-200 mL/min

    • Fluid removal → fluid removed + dialysate

  • CRRT

    • Duration → 24 hrs

    • Blood flow rate → <200 mL/min

    • Dialysate flow rate → <50 mL/min

    • Fluid removal → fluid removed + replacement fluid + dialysate

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41

Is there always requirement for long term RRT? What are reasons for stoping RRT?

  • Not all patients will require long-term RRT

  • Possible reasons for stopping RRT

    • Recovery of kidney function (AKI)

    • Removal of lines due to infection

    • Withdrawal of supportive measures


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42

The clearance of meds is dependent on what?

  • PK profile and size of pores in hemofilter

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43

What causes increased medication clearances in dialysis?

  • Hydrophilic

  • Neutral charge (non-ionic)

  • Molecular weight <500 Daltons

  • Low volume of distribution

  • Low protein binding

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44

Medication clearance changes with what? What is preferred, PK dat or guideline recs?

  • with worsening renal function and dialysis

  • PK data>guideline recs

    • Dosing adjustments via drug databases

    • Recs per facility protocols

  • Loading vs maintenance doses

  • Loading doses not impacted * check recording for rest

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45

What is vancomycin?

  • A glycopeptide antibiotic used in hospital settings for management of moderate to severe infections

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46

What is dosing based on in vancomycin? What is vancomycin typically seen with in terms of doses?

  • Dosing based on trough / area under the curve (AUC) targets

  • Typically seen with standing doses with regular intervals

    • Ex: q8 hours, q12 hours, q24 hours


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47

In AKI and CKD, vancomycin’s PK profile does what? Which is more stable in clearance?

  • In AKI and CKD, vancomycin's pharmacokinetic profile changes, especially in its clearance

    • CKD should have a stable clearance > able to calculate a standing dose

    • AKI (or AKI on CKD) is more unstable > spot dosing

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48

Dosing strategies is dependent on what? In CRRT patients can use what?

  • Dosing strategies will be dependent on which modality is used and whether the patient has oliguria or anuria

    • In CRRT, patient should have steady removal, can use a standing dose

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49

For vancomycin in IHD, when do you check serum vanc levels? What is the goal serum level?

  • Check serum vancomycin level before and/or after HD

  • Goal serum level:

    • 20-25 prior to dialysis

    • 15-20 after dialysis

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50

What do you calculate for vanc in IHD?

  • Calculate dialysis clearance

    • Around 30-40% cleared in HD

  • Calculate a dose to give

    • Based on patient's volume of distribution (Vd)

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51

What is the volume of distribution in Vanco?

  • Vd(L) ~ 0.7x Actual Body Weight (kg)

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52

For Vanco in IHD, what is the change in serum level needed?

  • Desired level (mcg/mL) – current level
    (mcg/mL

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53

For Vanco in IHD, what is the change in serum Vanco level?

  • Vanco Dose (mg) / Vd = needed change in serum level

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