Dialysis and Replacement Solutions for Pediatric CRRT

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Dialysis and Replacement Solutions for Pediatric
CRRT

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

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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

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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.
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CAVH Good for Fluid Balance,Not So Good for
Metabolic Balance

• CAVH removes all molecules slowly
• Good for BP stability (slow UF)
• Not so good for metabolic control
• Need method to increase molecular clearance
  without increasing UF rate

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• Diffusion
• Small molecules diffuse easily
• Larger molecules diffuse slowly
• Dialysate required
• Concentration gradient
• Faster dialysate flow increases mass transfer

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• Convection
• Small/large molecules move equally
• Limit is cut-off size of membrane
• Higher UF rate yields higher convection but risk
  of hypotension
• May need to Replace excess UF volume

Neg Press
H2O
H2O
H2O
H2O
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Solutions in CRRT Address Molecular Control Issues

• Improved mass transfer using diffusion,
  high-grade convection, or combination
• CVVH a pure convection modality
• CVVHD a diffusion modality
• CVVHDF combined convection/diffusion
• Permits correction of metabolic abnormalities
• Provides complete renal replacement

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Characteristics of the Ideal CRRT Solution

• Physiological
• Reliable
• Inexpensive
• Easy to prepare
• Simple to store
• Quick to the bedside
• Widely available
• Fully compatible

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Options for CRRT Solutions

• Peritoneal dialysate
• Pre-made IV solutions
• Saline, Lactated Ringers
• Multi-bag systems
• Custom-made solutions
• Local pharmacy outsource
• Commercially available CRRT solutions

NO
MAYBE
UNNECESSARY
RARELY
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Commercial Solutions for CRRT Several Companies,
Multiple Options

• Previously limited options
• No bicarbonate-based solutions
• US regulations re drug vs. device
• Currently multiple manufacturers each offering a
  variety of formulations
• Bicarbonate as primary or only base
• The Choice may depend on local policy, vendors,
  economic pressures

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Normocarb (DSI)

• Bicarbonate buffered
• Concentrate must be compounded
• Final volume 3.24 liters (240ml concentrate added
  to 3 L bag)

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Chemical Content of Normocarb
Ion Concentration After Mixing (mEq/L)
Sodium 140
Potassium 0
Chloride 107
Bicarbonate 35
Calcium 0
Magnesium 1.5
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Normocarb HF (DSI)

• Bicarbonate buffered
• Concentrate must be compounded
• Final volume 3.24 liters (240ml concentrate added
  to 3 L bag)
• 2 ionic formulations
• Normocarb HF 25
• Normocarb HF 35

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Chemical Content of Normocarb HF
Ion (mEq/L) HF 25 HF 35
Sodium 140 140
Potassium 0 0
Chloride 116.5 106.5
Bicarbonate 25 35
Calcium 0 0
Magnesium 1.5 1.5
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PrismaSate (Gambro)

• Bicarbonate buffered
• Small amount of lactate
• 5 liter bag
• 2 compartments to prevent precipitation
• Six ionic formulations

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Chemical Content of PrismaSate
Ion (mEq/L) BK0/3.5 BGK2/0 BGK4/0/1.2 BGK4/2.5 B22GK4/0 BK2/0
Sodium 140 140 140 140 140 140
Potassium 0 2 4 4 4 2
Chloride 109.5 108 110.2 113 120.5 108
Bicarb 32 32 32 32 22 32
Lactate 3 3 3 3 3 3
Calcium 3.5 0 0 2.5 0 0
Magnesium 1 1 1.2 1.5 1.5 1
Gluc(mg/dL) 0 110 110 110 110 0
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PrismaSol (Gambro)

• Bicarbonate buffered
• Small amount of lactate
• 5 liter bag
• 2 compartments to prevent precipitation
• Seven ionic formulations

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Chemical Content of PrismaSol
Ion (mEq/L) BK 0/3.5 BGK 2/0 BGK 2/3.5 BGK 4/2.5 BGK 4/0 BGK 0/2.5 BK 0/0
Sodium 140 140 140 140 140 140 140
Potassium 0 2 2 4 4 0 0
Chloride 109.5 108 111.5 113 110.5 109 106.5
Bicarb 32 32 32 32 32 32 32
Lactate 3 3 3 3 3 3 3
Calcium 3.5 0 3.5 2.5 0 2.5 0
Magnesium 1 1 1 1.5 1.5 1.5 1.5
Gluc(mg/dL) 0 100 100 100 100 100 0
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Accusol (Baxter)

• Bicarbonate buffered
• No lactate
• 2.5 liter bag
• 2 compartments to prevent precipitation
• Five ionic formulations

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Chemical Content of Accusol
Ion (mEq/L) 5B9248 5B9249 5B9250 5B9251 5B9252
Sodium 140 140 140 140 140
Potassium 4 2 0 2 2
Chloride 113.5 111.5 109.5 116.3 113.5
Bicarb 35 35 35 30 30
Lactate 0 0 0 0 0
Calcium 3.5 3.5 3.5 2.8 0
Magnesium 1 1 1 1.5 1.5
Gluc (mg/dL) 100 100 0 100 100
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Duosol (B.Braun)

• Bicarbonate buffered
• No lactate
• 5 liter bag
• 2 compartments to prevent precipitation
• Three ionic formulations

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Chemical Content of Duosol
Ion (mEq/L) 4450 4451 4452
Sodium 136 140 140
Potassium 2 0 2
Chloride 107 109 111
Bicarb 25 35 35
Lactate 0 0 0
Calcium 0 3 3
Magnesium 1.5 1 1
Gluc (mg/dL) 0 100 100
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NxStage PureFlow (NxStage)

• Part of NxStage System One for acute care
• 5 liter bags
• Choice of buffers
• Lactate 3 formulations single-chamber bag
• Bicarbonate 5 formulations dual-chamber bag

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Chemical Content of NxStage PureFlow (1)
Ion (mEq/L) Lactate Buffer Lactate Buffer Lactate Buffer
Ion (mEq/L) RFP-204 RFP-205 RFP-207
Sodium 140 140 140
Potassium 1 3 1
Chloride 105 112 100
Bicarbonate 0 0 0
Lactate 40 35 45
Calcium 3 3 3
Magnesium 1 1 1
Glucose (mg/dL) 100 100 100
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Chemical Content of NxStage PureFlow (2)
Ion (mEq/L) Bicarbonate Buffer Bicarbonate Buffer Bicarbonate Buffer Bicarbonate Buffer Bicarbonate Buffer
Ion (mEq/L) RFP-400 RFP-401 RFP-402 RFP-453 RFP-454
Sodium 140 140 140 130 130
Potassium 2 4 0 2 4
Chloride 111 113 109 108.5 110.5
Bicarbonate 35 35 35 25 25
Lactate 0 0 0 0 0
Calcium 3 3 3 0 0
Magnesium 1 1 1 1.5 1.5
Gluc (mg/dL) 100 100 100 100 100
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Choosing a Solution Issues to Consider

• Cost
• Anticoagulation
• Patient safety
• CRRT modality
• Diffusion (CVVHD)
• Convection (CVVH)
• Both (CVVHDF)

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Anticoagulation and Solutions
May need to consider Ca content if using
citrate for anticoagulation
Solution Calcium?
Normocarb HF No
Accusol 4 Yes 1 No
PrismaSate 2 Yes 4 No
PrismaSol 4 Yes 3 No
Duosol 2 Yes 1 No
NxStage PureFlow 6 Yes 2 No
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Evaluation of Errors in Preparation of CRRT
Solutions

• Survey of 3 Pediatric Listserves
• Pediatric Critical Care, Nephrology, CRRT
• 16/31 programs reported solution compounding
  errors
• Consequences of improper solutions
• 2 deaths
• 1 non lethal cardiac arrest
• 6 seizures (hypo/hypernatremia)
• 7 without complications

Barletta et al, Pediatr Nephrol. 21(6)842-5,
2006 Jun
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FDA Approval Status of CRRT Solutions
Solution FDA Label
Normocarb HF Replacement
PrismaSate Dialysate
PrismaSol Replacement
Accusol Dialysate
Duosol Dialysate
NxStage PureFlow Dialysate
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Putting it All Together One Approach

• CRRT with citrate regional anticoag

• DIALYSATE commercial bicarb-based solution

• REPLACEMENT normal saline

• Adjust blend, change saline if indicated

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On-Line Dialysate with SLED An Alternative to
Solutions in CRRT

• Extended sessions using standard dialysis
  equipment
• Dialysate made on-line from concentrates
• Simple, convenient, MUCH cheaper
• Dialysate is not sterile

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Citrasate(Advanced Renal Technologies)

• A concentrate for dialysis
• Liquid or bulk powder
• Citrate used as acidifying agent
• Local anticoagulation greatly reduces need for
  heparin

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CRRT Solutions Summary

• Solutions needed to maximize clearance
• Bicarbonate has superseded lactate
• Industry-made solutions are available including
  some approved for replacement
• Pre-mixed, sterile solutions for CRRT are simple,
  safe, may be costly
• On-line dialysate for SLED is clean (not
  sterile), simple, cheap
• The best solution may still be pending

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Thanks!