HD Prescription

 The Kidney excrete waste products, control total body water

and aspects of acid base balance.
 Renal Failure occurs when the kidney is not capable of
fulfilling its obligation.
 In essence renal replacement therapy is required to either
prevent endogenous poisoning or fluid overload. It is
important to remember that urinary output does not represent
renal function : the kidney may be able to filter fluid but not
clear metabolic waste
 The most commonly cited clinical indication for renal
replacement therapy are :
 Fluid oveload
 Severe hypertension
 Hyperkalemia
 Metabolic Acidosis
 Uremia
Indication for starting Dialysis
 Oliguria ( urine output <200 mL/12h)
 Anuria/extreme oliguria ( urine output <50 mL/12h)
 Hyperkalemia ( K > 6.5 meq/L)
 Severe acidemia (ph <7.1)
 Azotemia (urea >30 mg/dl)
 Clinical significant organ (esp pulmonary) edema
 Uremic encephalopathy
 Uremic Pericarditis
 Uremic Neuropathy/myopathy
 Severe Dysnatremia ( Na <115 or >160)
 Hyperthermia
 Drug overdose with dialyzable toxin
Intermittent hemodialysis
 is the most efficient – Large amounts of flid can be removed
and electrolyte abnormalities can be rapidly corrected.
 However this is not suitable in unstable patients :20-30% of
patients with ARF who are being hemodialysed become
hypotensive, with huge associated osmotic shifts,
disequilbrium syndrome.
 Moreover it appears that the hemodynamic changes that
occur during hemodialyisis (hypotension) may worsen the
pre-existing renal injury by increasing the ischemic insult.
 Peritoneal dialysis has the advantage of being simple and
cost effective
 The major disadvantages of PD are:
 Poor solute clearance
 Poor uremic control
 Risk of peritoneal infection
 Mechanical obstruction of pulmonary and cardiovascular
performance
 Continuous hemodiafiltration techniques were developed to
overcome this deficiencies.
 In Critical illness the phenomenon of capillary leak increases
the interstitial volumes and makes patient edematous. This
makes the clearance of solute difficult to carry out.
 Continuous techniques lead to more effective urea clearance
and more controlled fluid removal
 This is the gold standard. Patients who are hemodynamically
stable are suitable for this mode.
 The set up is a :
 double lumen catheter
 pump which forces blood into a filter
 Dialysate (deionized water)
 Return line to the patient
 The blood flow rate is usually 200-400 ml/minute
 Dialysate flow is approximately 500 ml/min
 The filtratin rate is between 300-2000 ml/ hour, with urea
clearance of 150-250 ml/min.
 With this high flow and clearance rate, patients depending on
the extent of their catabolism, only require 3-4 hours of
dialysis, two or three times a week
 If we consider that the kidney works 24 hours a day, 7 days a
week, there must be a trade off.
 Patients swich from being metabolically clean immediately
post dialysis, to being uremic before the next session.
 There are huge swings in fluid between the intravscular and
extravacular compartment, causing transient hypotension
and disequilibrium
 Typically patients undergo dialysis for 3-4 hours daily or
alternate days depending on their catabolic state, although there
is some evidence that daily dialysis may improve outcomes.
 Vascular access for short term hemodialysis or hemofiltration is
usually achieved using a double-lumen catheter inserted into
the internal jugular.
 Anticoagulation with heparin is the standard method for
preventing thrombosis of the extracoporeal circuit durinc acute
intermittent dialysis
 The major complications of acute intermittent hemodialysis
relate to rapid shifts in plasma volume and solute compostition,
vascular access, the necessity for anticoagulation and dialysis
memprane incompability.
What is important about dialysis
membrane?
 The membrane is the surface through which dialysis or
ultrafiltration occurs : it is the core component of hemofilter.
 Different membranes are used in renal replacement therapy,
they may be cellulose based or synthetic.
 The cellulose membranes are “low-flux” – they are very thin,
ave low permeabilty co-efficient and are strongly hydrophilic:
they are known to activate the inflammatory cascades,
particularly complement and are thus unsuitable
(biocompatible) in critical illness.
 Synthetic membranes should be use in the setting for both
intermittent and continuous hemodialysis. These membranes
tend to be slightly thicker than cellulose ones, and have very
high sieving coefficients at a wide range of molecular weights
: these properties make synthetic membranes, particularly
effective at convective clearance.
 Thus regardless of the technique involved, renal replacement
therapy with synthetic filters will always include significant
ultrafiltration.
Dialysis Disequilibrium Syndrome
 The dialysis disequilibrium syndrome is a self-limited
condition characterized by nausea, vomiting, headache,
altered consciousness, and rarely seizures or coma. It
typically occurs after a first dialysis in very uremic patients.
The syndrome is triggered by rapid movement of water into
brain cells following the development of transient plasma
hypo- osmolality as solutes are rapidly cleared from the
bloodstream during dialysis. The incidence of this
complication has fallen in recent years with the more gradual
institution of dialysis, and the precise prescription of dialysis
to include such variables as membrane size, blood flow rate,
and sodium profile.
 The concept behind continuous renal replacement
techniques is to dialyse patients in a more physiologic way,
slowly, over 24 hours, just like the kidney. Intensive care
patients are particularly suited to these techniques as they
are, by definition, bed bound, and, when acutely sick,
intolerant of the fluid swings associated with IHD.
 CVVH – continuous venovenous hemofiltration , a form of
convective dialysis. The ultrafiltration rate is high, and
replacement electrolyte solution is required to maintain
hemodynamic stability. This mode is also very effective for
clearing mid sized molecules, such as inflammatory
cytokines. It is hypothesized that removal of such mediators
may play a role in improving outcome in sepsis. A very simple
version of this is SCUF (click here) - slow continuous
ultrafiltration , which is used for volume control in fluid
overloaded patients. SCUF does not require the use of
replacement fluid, and fluid removal is 300ml to 500ml per
hour.
 CVVHD (click here) -continuous venous venous
hemodialysis – which is continuous diffusive dialysis, the
dialysate is driven in a direction countercurrent to the blood.
This provides reasonably effective solute clearance, although
mostly small molecules are removed.
 CVVHDF (click here) continuous venous venous
hemodiafiltration , which is the most popular method of
dialysis in ICU, combines convective and diffusive dialysis.
Both small and middle molecules are cleared, and both
dialysate and replacement fluids are required
 CVVHDF is similar to IHD in slow motion: the blood flow is
100 – 200ml/min, the dialysate flow is 1000ml/hour, the
filtration rate is 10-20ml/hour (very efficient), the urea
clearance is 10-20ml/hour. As you can see, continuous
hemofiltration is as efficient as IHD at fluid removal by
ultrafiltration , but not as efficient at dialysis (diffusion), due to
the slow fluid flows. If you want to increase the urea/
creatinine clearance, you could increase the dialysate flow or
the blood flow, or both
 Anticoagulation is necessary to prevent clotting of the filter. This
may be a problem in patients who are at risk for bleeding or who
have had recent surgery. Classically heparin has been used.
This agent has a number of potential drawbacks: 1. The risk of
bleeding, as the patient requires systemic anticoagulation. 2.
Heparin requires the presence of antithrombin III, which is often
deficient in the ICU population. 3. Heparin may cause
thrombocytopenia (HIT syndrome). Agents that have been used
instead of heparin include: 1. PGE1 and PGI2, which have anti
platelet effects. 2. Citrate, which binds calcium and inhibits the
coagulation cascade – and is metabolized to bicarbonate in the
liver. 3. Low molecular weight heparins. 4. Hirudin . 5. Aprotinin
 By and large the dialysate and replacement solutions should
mirror what one wishes the blood chemistry to be – the
closest solution is Ringers Lactate (Hartmann’s Solution).
The reason for this is that as time passes, the blood and
dialysate levels of electrolytes will equilibrate: this is
dissimilar to IHD, whereby one rigorously cleans the blood
and ECF for a few hours and then awaits reaccumulation .
The continuous nature of CRRT means that any depletion of
electrolytes during the process will continue ad infinitum, until
the dialysate prescription is changed.

Are there any electrolyte issues
that I need to be concerned with?
 Be careful of potassium and phosphate loss: standard
dialysate solutions contain neither – and levels can drop very
low. KPO4 supplementation is often necessary. Note also
that there is no NaHCO3 in the dialysate , leading to loss of
bicarbonate: compensated for by the passage of lactate
(anionic, a base) into the bloodstream. Calcium may also be
required, although Ca and HCO3 cannot be given together,
because they precipitate. This is usually metabolized into
bicarbonate in the liver. In liver failure, it is wiser to use a
lactate free dialysate – such as normal saline, add give
bicarbonate supplementation.
 Conventional hemodialysis blood flow is 350-450 ml/min and
dialysate flow is 500-800 ml/min. In continuous hemodialysis
(CVVHD) blood flow is usually set at 100-200 ml/min, and
dialysate flows at 1000-2000 ml/hr