【持續(xù)性腎臟替代治療CRRT英文課件】Treatment-Related-Factors

TreatmentRelatedFactorsCatheterperformance

QBtendsberoughlycomparableforFEandR)sidedSCandIJlinesMaximumachievableQB

tendstobelowerby~100mL/mininL)sidedSCandIJlines

ARtendstobehighestinshortFElines,intermediateinlongFElines,andlowestinSCandIJlinesDialyzerandfilterperformanceOliveretal,SeminDial,Vol14,pp432-435,2001Littleetal,AJKD,Vol36,pp1135-1139,2000Margettsetal,JASN,Vol10,pp211A,19991TreatmentRelatedFactorsCatheLittleetal,AJKD,Vol36,pp1135-1139,20002Littleetal,AJKD,Vol36,ppA-IJcatheterwithnorecirculation;B-20cmFEcatheterassumedtohave

ARof0%at150mL/min,8.5%at250mL/minand17%at350mL/min;C-

15cmFEcatheterassumedtohaveARof5%at150mL/min,20%at250

mL/minand30%at350mL/min

(iHDtreatmentsaremodelledunderthefollowingconditions;duration240mins,dialysateflow500mL/min,hemodialyzermasstransfercoefficient911mL/min,V40L,nPCR0.8g/kg/day)3A-IJcatheterwithnorecircu【持續(xù)性腎臟替代治療CRRT英文課件】Treatment-Related-Factors【持續(xù)性腎臟替代治療CRRT英文課件】Treatment-Related-FactorsTreatmentRelatedFactorsCatheterperformanceFilter(CRRT)performanceDowntimeduetofilterclottingisthemajorreasonforreducedCRRTdose6TreatmentRelatedFactorsCath77TreatmentRelatedFactorsCatheterperformanceFilter(CRRT)performance

DowntimeduetofilterclottingisthemajorreasonforreducedCRRTdose

Concentrationpolarization

reducesfiltrationrateandthefiltrateconcentrationsofvariousmedium/largesizedproteins

Highfiltrationfraction

(highUF+lowQBorpostdilution)isassociatedwithbothofabove

Pre-dilution

versuspost-dilution8TreatmentRelatedFactorsCatheTreatmentRelatedFactors9TreatmentRelatedFactors9TreatmentRelatedFactorsForiHD,longcathetersshouldbeusedforfemoralangioaccess,andadjustdoseprescriptioninanticipationofincreasedARForiHD,canadjustforsolutecompartmentalization

usingtheDaugirdas,Garred,orTattersallrateequationsForbothiHDandCRRT,optimizeanticoagulationandadjustdoseprescriptionintheadventofdialyzerandfilterclotting10TreatmentRelatedFactors10TreatmentRelatedFactorsForCRRT,avoidhighfiltrationfraction

byhigherbloodflowratesandpre-dilutiontominimizeconcentrationpolarizationandhemoconcentrationExceptusingRegionalCitrateAnticoagulationwithpost-dilutionreplacementForCRRT,adjustprescriptionforpredilution

witheitheraFUN/BUNratiooranempirical15%forlower-doseprescriptions(~2L/hr)and30-40%forhigher-doseprescriptions(>4L/hr)11TreatmentRelatedFactorsForCOverviewRevisitingofdoseandoutcomesPatientandtreatmentrelatedfactorsaffectingdoseprescriptionanddeliveryTherapy-specificdose-outcomedataApproachtoprescriptionandquantificationofacuteRRTdose12OverviewRevisitingofdoseandDose-OutcomeData

CRRT

13Dose-OutcomeData

CRRT 131414TableI–ClinicalDiagnosisofstudypatientsNoofPatientsMultipleinjury 12Aorticrupture 2Osteomyelitis 1Abdominalaorticaneurysmrepair 22*Thoracicaorticaneurysmrepair 4Othervascularprocedures 11Bronchialcarcinoma 3Otherthoracicprocedures 4Necrotisingpancreatitis 10Gastriccancer 9Peritonitis/intestinalperforation 7Diseasesofgallbladder 6Ileus 5Perforatedulcer 3Otherabdominaloperations 17*Emergencyin18,electivein415TableI–ClinicalDiagnosiso*NotRandomized16*NotRandomized161717181819192020212122222323Dose-OutcomeData(CRRT)Doseisquantifiedaseffluent(filtration)rateindexedtobodysizeAdoseof35mL/kg/hr

inpost-dilutionmodeisreportedasgivingthebestresultsStartingacuteRRTearlierratherthanlaterissuggestedasgivingthebestresults24Dose-OutcomeData(CRRT)24Dose-OutcomeData

iHD25Dose-OutcomeData

iHD25262627272828292930303131323233333434353536363737Dose-OutcomeData(iHD)Doseisquantifiedasclearanceindexedtosolutepoolsize(singlepoolKt/V)Adoseof>1.0

isreportedasgivingthebestresults

DailyiHDisreportedasgivingbetterresultsthatalternatedayiHD38Dose-OutcomeData(iHD)Doseis3939Phuetal.70patientswithsepsisrandomizedtoCVVHorCAPDAverageweight53kgMostcommondiagnosisfalciparummalariaCVVH25L/daypre-dilutionlactatebasedsubstitutionfluidrate,Ku25L/dayCAPD70L/daydialysateexchanged,Ku28L/day40Phuetal.70patientswithsepCAPDprovidedunsatisfactorycontrolofcidosis,longerdurationofARF,poorersurvival41CAPDprovidedunsatisfactorycOverviewRevisitingofdoseandoutcomesPatientandtreatmentrelatedfactorsaffectingdoseprescriptionanddeliveryTherapy-specificdose-outcomedataApproachtoprescriptionandquantificationofacuteRRTdose42OverviewRevisitingofdoseandCRRTPrescriptionForallCRRT,aimfor>85%delivery

ofprescribeddoseForallCRRT,aimforeffluentrateof>35mL/kg/hr,withappropriateadjustmentsfortheeffectofpre-dilution,andaccountingforpatientandtreatmentrelatedbarriers43CRRTPrescription43CRRTPrescriptionItisunlikelyCVVHcanachieveaneffluentrateof35mL/kg/hrwithouthighbloodflowrate+/-pre-dilutionExceptthepatientissmall/pediatric,ornotparticularlysickorUsingRegionalCitrateAnticoagulation+post-dilutionTheadequacyofaneffluentrateof35mL/kg/hrisunclearforCVVHD(F)

sincethisdoseappliestodialysategeneratedbydiffusionratherthanfiltrategeneratedbyconvection44CRRTPrescriptionItisunlikeliHDPrescriptionItisunlikelythatiHDcandeliveranadequatedoseoutsideofadailyornear–dailyregimen

unlessthepatientisunlessthepatientissmall/pediatric,ornotparticularlysickFordailyiHD,aimforadeliveredsinglepoolKt/Vofatleast>1.0,accountingforpatientandtreatmentrelatedbarriers(?prescribe1.3)45iHDPrescriptionItisunlikelyiHDPrescriptionThemostpracticalexpressionofiHDdoseissinglepoolKt/V,andismostaccuratelyachievedbyformalUKMThemostrealisticexpressioniHDdoseisequilibratedKt/V,andismostaccuratelyachievedbyadjustingsinglepoolKt/VusingtheDaugirdas,Garred,orTattersallrateequations46iHDPrescriptionThemostpractPDPrescriptionItisevenlesslikelythatPDcandeliveranadequatedoseoutsideofcontinuousflow

PD

unlessthepatientissmall/pediatric,ornotparticularlysick47PDPrescriptionItisevenlessDoseandTherapyChoiceIfiHDisnotdeliveringadequatedosedespiteoptimizingallfactors,tryHybridTherapyorCRRTIfCRRTisnotdeliveringadequatedosedespiteoptimizingallfactors,tryHybridTherapyoriHDThereareincreasingdatasuggestingthatdelaying

acuterenalreplacementtherapyincriticallyillpatientsisunwise48DoseandTherapyChoiceIfiHDIsthereanexpressionofacute

RRTdosethatwillallowusto

reconcilethesedifferent

recommendationsforiHDand

CRRT?49IsthereanexpressionofacutStandardKt/V(stdKt/V)

Units:week-150StandardKt/V(stdKt/V)

Units51515252stdKt/VRequiresasolutesteadystateforcalculationExpressesacuteRRTdoseasanewlessintuitiveparameterBasedonpeak-concentration

hypothesis,whichcanreconcileKt/VstandardsforCAPDandiHDdoseintheoutpatientsetting,butisarbitraryanddifficulttodefineinthecriticallyill53stdKt/VRequiresasolutesteadCorrectedEquivalentRenal

UreaClearance(EKRc)

Units:mL/min54CorrectedEquivalentRenal

Ure

=G/TACorJ/TAC55

=G/TACorJ/TAC55AcomparisonofBUNtime-concentrationprofilesbetweentwo

intermittenthemodialysisregimensdeliveringacEKRof24ml/min.The

solidlinereflectssoluteremovalover3treatmentsperweek,thedotted

soluteremovalover7treatmentsperweek.56AcomparisonofBUNtime-conceEKRc(1stGeneration)AnalogoustoGFR,conceptuallysimple

sinceitexpressesacuteRRTdoseasmL/minIscorrectedforbodysize

(a70kgpersonwithaVof40LorBSAof1.73m2)Isbasedontime-averagedBUN,whichiseasiertodefineandlessarbitrarythanpeakBUN57EKRc(1stGeneration)Analogous5858595960606161EKRjc(2ndGeneration)62EKRjc(2ndGeneration)62EKRjc(2ndGeneration)Isvalidduringsolutenon-steadystate,andisinsensitivetovariationinV

andGDoesnotrequirepreciseknowledge

ofV,GofKdCanbecalculatedonasimpleExcelspreadsheetwithinputofpatients’estimatedV

andBUN

bothpreandpostiHDforsequentialdialysiscyclesCanusepost-iHDCeq(Tattersall)63EKRjc(2ndGeneration)Isvalid646465656666DialysisDoseandPrescription67DialysisDoseandPrescription/68/6869697070/ct/show/NCT00221013AugmentedvsNormalRenalReplacementTherapyinAcuteRenalFailure71/7272HowshouldoneprescribeanddoseacuteRRTtooptimizepatientoutcomes?Individually,accordingtotherequirementsofthepatient73HowshouldoneprescribeanddTreatmentRelatedFactorsCatheterperformance

QBtendsberoughlycomparableforFEandR)sidedSCandIJlinesMaximumachievableQB

tendstobelowerby~100mL/mininL)sidedSCandIJlines

ARtendstobehighestinshortFElines,intermediateinlongFElines,andlowestinSCandIJlinesDialyzerandfilterperformanceOliveretal,SeminDial,Vol14,pp432-435,2001Littleetal,AJKD,Vol36,pp1135-1139,2000Margettsetal,JASN,Vol10,pp211A,199974TreatmentRelatedFactorsCatheLittleetal,AJKD,Vol36,pp1135-1139,200075Littleetal,AJKD,Vol36,ppA-IJcatheterwithnorecirculation;B-20cmFEcatheterassumedtohave

ARof0%at150mL/min,8.5%at250mL/minand17%at350mL/min;C-

15cmFEcatheterassumedtohaveARof5%at150mL/min,20%at250

mL/minand30%at350mL/min

(iHDtreatmentsaremodelledunderthefollowingconditions;duration240mins,dialysateflow500mL/min,hemodialyzermasstransfercoefficient911mL/min,V40L,nPCR0.8g/kg/day)76A-IJcatheterwithnorecircu【持續(xù)性腎臟替代治療CRRT英文課件】Treatment-Related-Factors【持續(xù)性腎臟替代治療CRRT英文課件】Treatment-Related-FactorsTreatmentRelatedFactorsCatheterperformanceFilter(CRRT)performanceDowntimeduetofilterclottingisthemajorreasonforreducedCRRTdose79TreatmentRelatedFactorsCath807TreatmentRelatedFactorsCatheterperformanceFilter(CRRT)performance

DowntimeduetofilterclottingisthemajorreasonforreducedCRRTdose

Concentrationpolarization

reducesfiltrationrateandthefiltrateconcentrationsofvariousmedium/largesizedproteins

Highfiltrationfraction

(highUF+lowQBorpostdilution)isassociatedwithbothofabove

Pre-dilution

versuspost-dilution81TreatmentRelatedFactorsCatheTreatmentRelatedFactors82TreatmentRelatedFactors9TreatmentRelatedFactorsForiHD,longcathetersshouldbeusedforfemoralangioaccess,andadjustdoseprescriptioninanticipationofincreasedARForiHD,canadjustforsolutecompartmentalization

usingtheDaugirdas,Garred,orTattersallrateequationsForbothiHDandCRRT,optimizeanticoagulationandadjustdoseprescriptionintheadventofdialyzerandfilterclotting83TreatmentRelatedFactors10TreatmentRelatedFactorsForCRRT,avoidhighfiltrationfraction

byhigherbloodflowratesandpre-dilutiontominimizeconcentrationpolarizationandhemoconcentrationExceptusingRegionalCitrateAnticoagulationwithpost-dilutionreplacementForCRRT,adjustprescriptionforpredilution

witheitheraFUN/BUNratiooranempirical15%forlower-doseprescriptions(~2L/hr)and30-40%forhigher-doseprescriptions(>4L/hr)84TreatmentRelatedFactorsForCOverviewRevisitingofdoseandoutcomesPatientandtreatmentrelatedfactorsaffectingdoseprescriptionanddeliveryTherapy-specificdose-outcomedataApproachtoprescriptionandquantificationofacuteRRTdose85OverviewRevisitingofdoseandDose-OutcomeData

CRRT

86Dose-OutcomeData

CRRT 138714TableI–ClinicalDiagnosisofstudypatientsNoofPatientsMultipleinjury 12Aorticrupture 2Osteomyelitis 1Abdominalaorticaneurysmrepair 22*Thoracicaorticaneurysmrepair 4Othervascularprocedures 11Bronchialcarcinoma 3Otherthoracicprocedures 4Necrotisingpancreatitis 10Gastriccancer 9Peritonitis/intestinalperforation 7Diseasesofgallbladder 6Ileus 5Perforatedulcer 3Otherabdominaloperations 17*Emergencyin18,electivein488TableI–ClinicalDiagnosiso*NotRandomized89*NotRandomized169017911892199320942195229623Dose-OutcomeData(CRRT)Doseisquantifiedaseffluent(filtration)rateindexedtobodysizeAdoseof35mL/kg/hr

inpost-dilutionmodeisreportedasgivingthebestresultsStartingacuteRRTearlierratherthanlaterissuggestedasgivingthebestresults97Dose-OutcomeData(CRRT)24Dose-OutcomeData

iHD98Dose-OutcomeData

iHD2599261002710128102291033010431105321063310734108351093611037Dose-OutcomeData(iHD)Doseisquantifiedasclearanceindexedtosolutepoolsize(singlepoolKt/V)Adoseof>1.0

isreportedasgivingthebestresults

DailyiHDisreportedasgivingbetterresultsthatalternatedayiHD111Dose-OutcomeData(iHD)Doseis11239Phuetal.70patientswithsepsisrandomizedtoCVVHorCAPDAverageweight53kgMostcommondiagnosisfalciparummalariaCVVH25L/daypre-dilutionlactatebasedsubstitutionfluidrate,Ku25L/dayCAPD70L/daydialysateexchanged,Ku28L/day113Phuetal.70patientswithsepCAPDprovidedunsatisfactorycontrolofcidosis,longerdurationofARF,poorersurvival114CAPDprovidedunsatisfactorycOverviewRevisitingofdoseandoutcomesPatientandtreatmentrelatedfactorsaffectingdoseprescriptionanddeliveryTherapy-specificdose-outcomedataApproachtoprescriptionandquantificationofacuteRRTdose115OverviewRevisitingofdoseandCRRTPrescriptionForallCRRT,aimfor>85%delivery

ofprescribeddoseForallCRRT,aimforeffluentrateof>35mL/kg/hr,withappropriateadjustmentsfortheeffectofpre-dilution,andaccountingforpatientandtreatmentrelatedbarriers116CRRTPrescription43CRRTPrescriptionItisunlikelyCVVHcanachieveaneffluentrateof35mL/kg/hrwithouthighbloodflowrate+/-pre-dilutionExceptthepatientissmall/pediatric,ornotparticularlysickorUsingRegionalCitrateAnticoagulation+post-dilutionTheadequacyofaneffluentrateof35mL/kg/hrisunclearforCVVHD(F)

sincethisdoseappliestodialysategeneratedbydiffusionratherthanfiltrategeneratedbyconvection117CRRTPrescriptionItisunlikeliHDPrescriptionItisunlikelythatiHDcandeliveranadequatedoseoutsideofadailyornear–dailyregimen

unlessthepatientisunlessthepatientissmall/pediatric,ornotparticularlysickFordailyiHD,aimforadeliveredsinglepoolKt/Vofatleast>1.0,accountingforpatientandtreatmentrelatedbarriers(?prescribe1.3)118iHDPrescriptionItisunlikelyiHDPrescriptionThemostpracticalexpressionofiHDdoseissinglepoolKt/V,andismostaccuratelyachievedbyformalUKMThemostrealisticexpressioniHDdoseisequilibratedKt/V,andismostaccuratelyachievedbyadjustingsinglepoolKt/VusingtheDaugirdas,Garred,orTattersallrateequations119iHDPrescriptionThemostpractPDPrescriptionItisevenlesslikelythatPDcandeliveranadequatedoseoutsideofcontinuousflow

PD

unlessthepatientissmall/pediatric,ornotparticularlysick120PDPrescriptionItisevenlessDoseandTherapyChoiceIfiHDisnotdeliveringadequatedosedespiteoptimizingallfactors,tryHybridTherapyorCRRTIfCRRTisnotdeliveringadequatedosedespiteoptimizingallfactors,tryHybridTherapyoriHDThereareincreasingdatasuggestingthatdelaying

acuterenalreplacementtherapyincriticallyillpatientsisunwise121DoseandTherapyChoiceIfiHDIsthereanexpressionofacute

RRTdosethatwillallowusto

reconcilethesedifferent

recommendationsforiHDand

CRRT?122IsthereanexpressionofacutStandardKt/V(stdKt/V)

Units:week-1123StandardKt/V(stdKt/V)

Units1245112552stdKt/VRequiresasolutesteadystateforcalculationExpressesacuteRRTdoseas