Excessive fluid is not needed: So why is Dr. Durward so wasteful? Timothy E Bunchman MD Professor & Director Pediatric Nephrology [email protected].

Excessive fluid is not needed: So why is Dr. Durward so wasteful?

Timothy E Bunchman MDProfessor & DirectorPediatric Nephrology

[email protected]@gmail.com

www.pcrrt.com

Comparison of Urea Clearance: CVVH vs CVVHD

(Maxvold et al, Crit Care med. 2000 Apr;28(4):1161-5)

0

5

10

15

20

25

30

CVVH CVVHD

U

rea

Cle

aran

ce(m

ls/m

in/1

.73

m2)

BFR = 4 mls/kg/minFRF/Dx FR = 2 l/1.73 m2/hrSAM = 0.3 m2

p = NS

Dialysis Dose and OutcomeRonco et al. Lancet 2000; 351: 26-30

• Conclusions:– Minimum UF rates should be ~ 35

ml/kg/hr– Survivors had lower BUNs than non-

survivors prior to commencement of hemofiltration

425 patientsEndpoint = survival 15 days

after D/C HF

146 UF rate 20ml/kg/hrsurvival significantly lower

in this group compared to the others

139 UF rate 35ml/kg/hrp=0.0007

140 UF rate 45ml/kg/hrp=0.0013

Intensive vs non Intensive RRT

HD and CRRT at 6 days per week and 35 mls/kg/hr daily

Vs. HD and CRRT at 3 days per week and 20

mls/kg/hr daily Intensity of Renal Support in Critically Ill

Patients with Acute Kidney Injury The VA/NIH Acute Renal Failure Trial Network* NEJM july 3, 2008 vol. 359 no. 1

The VA/NIH Acute Renal Failure Trial Network. N Engl J Med 2008;359:7-20

Kaplan-Meier Plot of Cumulative Probabilities of Death (Panel A) and Odds Ratios for Death at 60 Days, According to Baseline Characteristics (Panel B)

Copyright restrictions may apply.

Lins, R. L. et al. Nephrol. Dial. Transplant. 2009 24:512-518; doi:10.1093/ndt/gfn560

Survival curves in patients randomized to intermittent (IRRT) or continuous (CRRT) renal replacement therapy investigating ICU mortality and hospital

mortality

Meta Analysis-8 Studies(Clin J Am Soc Nephrol 5:956-963, 2010)

Intensity of Dialysis result in the following No difference in death rate No difference in outcome based upon APACHE

score No difference in renal recovery No difference in outcome based upon weight

Look at data on nutritional loss! Look at data on drug loss!

Wasteful

Comparison of Total Amino Acid losses: CVVH vs CVVHD

(Maxvold et al, Crit Care Med 2000 Apr;28(4):1161-5 )

12.4 11.6

0

2

4

6

8

10

12

14

16

CVVH CVVHD

Am

ino

Aci

d L

oss

es

(g

/day

/1.7

3 m

2)

NS

Sieving Coefficients

Solute (MW) Convective Coefficient Diffusion Coefficient

Urea (60) 1.01 ± 0.05 1.01 ± 0.07

Creatinine (113) 1.00 ± 0.09 1.01 ± 0.06

Uric Acid (168) 1.01 ± 0.04 0.97 ± 0.04*

Vancomycin (1448) 0.84 ± 0.10 0.74 ± 0.04**

Calcium (protein bound) 0.67 + 0.1 0.61 + 0.07

Cytokines (large) adsorbed minimal clearance

*P<0.05 **P<0.01

Rebottled slide to follow

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