Dialysis and Replacement Solutions for CRRT

1
Dialysis and Replacement Solutions for CRRT

• Jordan M. Symons, MD
• University of Washington School of Medicine
• Childrens Hospital Regional Medical Center
• Seattle, WA
• jordan.symons_at_seattlechildrens.org

2
CRRT SolutionsOutline 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 551121-2, 1977.
4
CRRT Machines Current Generation
5
Convective Clearance To increase clearance by
convection, increase ultrafiltration rate (will
require more replacement fluids)
6
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 CRRTBlood Lactate
Levels
Zimmerman et al, Neph, Dial Transpl 1999
142387-2391
11
Bicarbonate vs. Lactate in CRRTBlood Lactate
Levels in Children
Maxvold et al, Blood Purif 1727, 1999 abstract
12
Bicarbonate vs. Lactate in CRRT Cardiovascular
Events
Bicarbonate
Lactate
Barenbrock M et al, Kid Int 581751-1757, 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
Modality May Have an Impact on Choice of Solutions

• Diffusion requires the use of a dialysate
• Convection requires the use of replacement fluids

26
Whats 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!