【持续性肾脏替代治疗crrt英文精品课件】treatment related factors

1 TreatmentRelatedFactors CatheterperformanceQBtendsberoughlycomparableforFEandR sidedSCandIJlinesMaximumachievableQBtendstobelowerby 100mL mininL sidedSCandIJlinesARtendstobehighestinshortFElines intermediateinlongFElines andlowestinSCandIJlinesDialyzerandfilterperformanceOliveretal SeminDial Vol14 pp432 435 2001Littleetal AJKD Vol36 pp1135 1139 2000Margettsetal JASN Vol10 pp211A 1999 2 Littleetal AJKD Vol36 pp1135 1139 2000 3 A IJcatheterwithnorecirculation B 20cmFEcatheterassumedtohaveARof0 at150mL min 8 5 at250mL minand17 at350mL min C 15cmFEcatheterassumedtohaveARof5 at150mL min 20 at250mL minand30 at350mL min iHDtreatmentsaremodelledunderthefollowingconditions duration240mins dialysateflow500mL min hemodialyzermasstransfercoefficient911mL min V40L nPCR0 8g kg day 4 TreatmentRelatedFactors Catheterperformance Dialyzer iHDandHybrid performanceHeparin freeiHDisassociatedwithsignificantfibrebundleclotting andalsowithreduceddeliverediHDdoseKdecreasesby10 20 duringinthehourbeforedialyzerclottingduringHybridTherapyLow fluxdialyzersareassociatedwithloweriHDdose KoA QD Sakiewiczetal JASN Vol10 pp196A 1999Evansonetal AJKD Vol32 pp731 738 1998Marshalletal UpToDate SustainedLow EfficiencyDialysis Paganinietal AmJKidneyDis Vol28 Suppl ppS81 S89 1996 5 MarshallandGolper UpToDate SustainedLow EfficiencyDialysis 6 TreatmentRelatedFactors Catheterperformance Filter CRRT performanceDowntimeduetofilterclottingisthemajorreasonforreducedCRRTdose 7 8 TreatmentRelatedFactors CatheterperformanceFilter CRRT performanceDowntimeduetofilterclottingisthemajorreasonforreducedCRRTdoseConcentrationpolarizationreducesfiltrationrateandthefiltrateconcentrationsofvariousmedium largesizedproteinsHighfiltrationfraction highUF lowQBorpostdilution isassociatedwithbothofabovePre dilutionversuspost dilution 9 TreatmentRelatedFactors 10 TreatmentRelatedFactors ForiHD longcathetersshouldbeusedforfemoralangioaccess andadjustdoseprescriptioninanticipationofincreasedARForiHD canadjustforsolutecompartmentalizationusingtheDaugirdas Garred orTattersallrateequationsForbothiHDandCRRT optimizeanticoagulationandadjustdoseprescriptionintheadventofdialyzerandfilterclotting 11 TreatmentRelatedFactors ForCRRT avoidhighfiltrationfractionbyhigherbloodflowratesandpre dilutiontominimizeconcentrationpolarizationandhemoconcentrationExceptusingRegionalCitrateAnticoagulationwithpost dilutionreplacementForCRRT adjustprescriptionforpredilutionwitheitheraFUN BUNratiooranempirical15 forlower doseprescriptions 2L hr and30 40 forhigher doseprescriptions 4L hr 12 Overview RevisitingofdoseandoutcomesPatientandtreatmentrelatedfactorsaffectingdoseprescriptionanddeliveryTherapy specificdose outcomedataApproachtoprescriptionandquantificationofacuteRRTdose 13 Dose OutcomeDataCRRT 14 15 TableI ClinicalDiagnosisofstudypatients 16 NotRandomized 17 18 19 20 21 22 23 24 Dose OutcomeData CRRT Doseisquantifiedaseffluent filtration rateindexedtobodysizeAdoseof35mL kg hrinpost dilutionmodeisreportedasgivingthebestresultsStartingacuteRRTearlierratherthanlaterissuggestedasgivingthebestresults 25 Dose OutcomeDataiHD 26 27 28 29 30 31 32 33 34 35 36 37 38 Dose OutcomeData iHD Doseisquantifiedasclearanceindexedtosolutepoolsize singlepoolKt V Adoseof 1 0isreportedasgivingthebestresultsDailyiHDisreportedasgivingbetterresultsthatalternatedayiHD 39 40 Phuetal 70patientswithsepsisrandomizedtoCVVHorCAPDAverageweight53kgMostcommondiagnosisfalciparummalariaCVVH25L daypre dilutionlactatebasedsubstitutionfluidrate Ku25L dayCAPD70L daydialysateexchanged Ku28L day 41 CAPDprovidedunsatisfactorycontrolofcidosis longerdurationofARF poorersurvival 42 Overview RevisitingofdoseandoutcomesPatientandtreatmentrelatedfactorsaffectingdoseprescriptionanddeliveryTherapy specificdose outcomedataApproachtoprescriptionandquantificationofacuteRRTdose 43 CRRTPrescription ForallCRRT aimfor 85 deliveryofprescribeddoseForallCRRT aimforeffluentrateof 35mL kg hr withappropriateadjustmentsfortheeffectofpre dilution andaccountingforpatientandtreatmentrelatedbarriers 44 CRRTPrescription ItisunlikelyCVVHcanachieveaneffluentrateof35mL kg hrwithouthighbloodflowrate pre dilutionExceptthepatientissmall pediatric ornotparticularlysickorUsingRegionalCitrateAnticoagulation post dilutionTheadequacyofaneffluentrateof35mL kg hrisunclearforCVVHD F sincethisdoseappliestodialysategeneratedbydiffusionratherthanfiltrategeneratedbyconvection 45 iHDPrescription ItisunlikelythatiHDcandeliveranadequatedoseoutsideofadailyornear dailyregimenunlessthepatientisunlessthepatientissmall pediatric ornotparticularlysickFordailyiHD aimforadeliveredsinglepoolKt Vofatleast 1 0 accountingforpatientandtreatmentrelatedbarriers prescribe1 3 46 iHDPrescription ThemostpracticalexpressionofiHDdoseissinglepoolKt V andismostaccuratelyachievedbyformalUKMThemostrealisticexpressioniHDdoseisequilibratedKt V andismostaccuratelyachievedbyadjustingsinglepoolKt VusingtheDaugirdas Garred orTattersallrateequations 47 PDPrescription ItisevenlesslikelythatPDcandeliveranadequatedoseoutsideofcontinuousflowPDunlessthepatientissmall pediatric ornotparticularlysick 48 DoseandTherapyChoice IfiHDisnotdeliveringadequatedosedespiteoptimizingallfactors tryHybridTherapyorCRRTIfCRRTisnotdeliveringadequatedosedespiteoptimizingallfactors tryHybridTherapyoriHDThereareincreasingdatasuggestingthatdelayingacuterenalreplacementtherapyincriticallyillpatientsisunwise 49 IsthereanexpressionofacuteRRTdosethatwillallowustoreconcilethesedifferentrecommendationsforiHDandCRRT 50 StandardKt V stdKt V Units week 1 51 52 53 stdKt V RequiresasolutesteadystateforcalculationExpressesacuteRRTdoseasanewlessintuitiveparameterBasedonpeak concentrationhypothesis whichcanreconcileKt VstandardsforCAPDandiHDdoseintheoutpatientsetting butisarbitraryanddifficulttodefineinthecriticallyill 54 CorrectedEquivalentRenalUreaClearance EKRc Units mL min 55 G TACorJ TAC 56 AcomparisonofBUNtime concentrationprofilesbetweentwointermittenthemodialysisregimensdeliveringacEKRof24ml min Thesolidlinereflectssoluteremovalover3treatmentsperweek thedottedsoluteremovalover7treatmentsperweek 57 EKRc 1stGeneration AnalogoustoGFR conceptuallysimplesinceitexpressesacuteRRTdoseasmL minIscorrectedforbodysize a70kgpersonwithaVof40LorBSAof1 73m2 I