EPURAREA

EXTRACORPOREALA
RENALA
 IRA
Scaderea brusca şi potenţial reversibila a funcţiei renale

perturbarea metabolismului ↓ filtrarii ↑ rapida a nivelului seric al compuşilor azotaţi

hidroelectrolitic şi acido-basic glomerulare neproteici (azotemie/retenţie azotata acuta) ±
oligurie

AKI

↑ creatininei serice cu 0,3 mg/dl <48 de ore (valorile

absolute) ± oligurie (diminuarea diurezei sub 0,5 ml/kg/ora timp
↑ creatininei serice cu 50% (valorile relative) de mai mult de 6 ore)

LA CONFERITA ACUTE KIDNEY INJURY NETWORK (AMSTERDAM-2005) S-A RECOMANDAT UTILIZAREA TERMENULUI DE LEZIUNE RENALA ACUTA
(ACUTE KIDNEY INJURY – AKI), ÎN DETRIMENTU IRA, REZERVATA CAZURILOR CELE MAI GRAVE ALE AKI

B.Filipoiu, Smart Medical Solutions

B.Filipoiu, Smart Medical Solutions
 Foloseste fluxuri mici- previne
episoadele hipotensive

Favorizeaza recuperarea functiei Este bine tolerata de pacientii

renale instabili hemodinamic

DE CE CRRT?
Indeparteaza cantitati importante Mimeaza indeaproape functia
de apa si produsi de excretie, in renale fiziologica
timp

Restabileste si mentine
echilibrul electrolitic si acido-
bazic

B.Filipoiu, Smart Medical Solutions

 Tehnica de purificare extracorporeala care are intentia de
a substitui functia renala pentru o perioada de timp
CONTINUOUS
indelungata, fiind aplicata timp de 24h/zi
RENAL
REPLACEMENT
THERAPY

- mimeaza functia renala fiziologica

- previne degradarea renala
- incurajeaza recuperarea functiei renale
INCET & CONTINUU

REGLEAZA ECHILIBRUL ACIDO-BAZIC SI ELECTROLITIC

INDEPARTEAZA MARI CANTITATI DE FLUIDE SI PRODUSI DE EXCRETIE IN
PERIOADA DE TIMP IMPORTANTA
B.Filipoiu, Smart Medical Solutions
 TERAPII CRRT

• SCUF- ULTRAFILTRARE LENTA CONTINUA

• CVVH- HEMOFLTRARE VENO-VENOASA CONTINUA

• CVVDH- HEMODIALIZA VENO-VENOASA CONTINUA

• CVVHDF- HEMODIAFILTRARE VENO-VENOASA CONTINUA

B.Filipoiu, Smart Medical Solutions

 CRRT
Modalities

SCUF CVVH CVVHD CVVHDF

Difuzie
Convectie Difuzie +
Ultrafiltrare
Convectie

B.Filipoiu, Smart Medical Solutions

 ULTRAFILTRAREA

Trecerea unui lichid prinr-o membrana semipermeabila pe baza gradientului

de presiune (diferenta intre presiunea pozitiva si cea negativa din circuit)

Obiectivul principal este reducerea bilantului pozitiv

B.Filipoiu, Smart Medical Solutions

 ULTRAFILTRAREA

POMPA DE SANGE REALIZEAZA O

PRESIUNE POZITIVA IMPINGAND
SANGELE PRIN MEMBRANA
HEMOFILTRULUI

Pompa de efluent
creeaza o presiune
negativa tragand Blood In
ultrafiltratul prin filtru (from patient)

Fluid Volume
Reduction
Blood Out
to waste (to patient)

LOW PRESS HIGH PRESS

B.Filipoiu, Smart Medical Solutions
 Indicata in:
● bilant pozitiv

S ● edem pulmonar
● rezistenta la diuretice(fara uremie sau dezechilibre acido-bazice importante

C
U
F
B.Filipoiu, Smart Medical Solutions
 DIFUZIA

Presupune migrarea unei solutii de la concentratie mare la concentratie mai

mica pe baza diferentei de concentratie intre sange si dializat si va dura pana la
stabilirea echilibrului de concentratie dintre cele doua solutii
Dializatul si sangele circula in contracurent la nivelul filtrului

B.Filipoiu, Smart Medical Solutions

 DIFUZIA
ESTE DEPENDENTA DE:
- DIMENSIUNILE MOLECULELOR
-PERMEABILITATEA MEMBRANEI PENTRU PARTICULE SPECIFICE
-FLUXURILE DE SANGE SI DIALIZAT

to waste

Dialysate Out Blood In

(from patient)

Dialysate In Blood Out

(to patient)

LOW CONC HIGH CONC B.Filipoiu, Smart Medical Solutions

C
Indicata in:
● eliminarea toxinelor cu greutate moleculara(GM) mica (uree, creatinina, fosfati)

V
V
H
D B.Filipoiu, Smart Medical Solutions
 CONVECTIA

Mobilizarea unei solutii prin membrana dializorului, cu ajutorul unui solvent

Proces fizic dependent de:

-marimea porilor membranei filtrului
-greutatea moleculara a substantelor (GM medie si mare)

B.Filipoiu, Smart Medical Solutions

 CONVECTIA

to waste Blood In
(from patient)
Repl.
Solution

Blood Out

(to patient)

LOW PRESS HIGH PRESS B.Filipoiu, Smart Medical Solutions

 ADSORBTIA
Presupune aderarea moleculelor la suprafata interna a membranei semipermeabile

UNELE PARTICULE IMPLICATE IN RASPUNSUL INFLAMATOR ADERA LA MEMBRANA FILTRULUI: BETA

2-MICROGLOBULIN (GM 11.8 KD), TNF (GM 52 KD),ETC

B .Filipoiu, Smart Medical Solutions

 Indicata in :

C ●dezechilibrul acido-bazic
●dezechilibrul electrolitic (cu sau fara exces de lichid)

V
V
H
B.Filipoiu, Smart Medical Solutions
C Indicata in SIRS, MSOF, ARF, sepsis, rabdomioloza,etc

V
V
H
D
F B.Filipoiu, Smart Medical Solutions
DIFUZIE vs. CONVECTIE

B.Filipoiu, Smart Medical Solutions

 Oligurie ( <200 ml/12 h)/
Anurie(<180ml/24h INDICATII CRRT Supraincarcarea
volemica

Acidoza
Hipertermie (>39,5ºC)
metabolica

Azotemia ARDS

Hiperpotasemie Sepsis
(K >6.5 mmol/L)

Edemul cerebral
Disnatremia severa progresiva
(Na >180 or 115 mmol/L)
Rabdomioliza

Coagulopatii care necesita

Sindromul de liza tumorala
cantitati mari de solutii (risc
edem pulmonar)

• Litiu • Metanol • Etilen glicol • Salicilati • Barbiturice • Metformin

• Aminoglicozide • Metronidazol • Carbapeneme • Cefalosporine • Peniciline

Bellomo & Ronco. Critical Care. 2000

 INDICATIILE KDIGO¹
1. UTILIZAREA DIURETICELOR

3.4.1: We recommend not using diuretics to prevent AKI. (1B)

3.4.2: We suggest not using diuretics to treat AKI, except in the management of volume overload. (2C)
5.2.2: We suggest not using diuretics to enhance kidney function recovery, or to reduce the duration or frequency of RRT. (2B)

2. INITIEREA CRRT

5.1.1: Initiate RRT emergently when life-threatening changes in fluid, electrolyte, and acid-base balance exist. (Not Graded)
5.1.2: Consider the broader clinical context, the presence of conditions that can be modified with RRT, and trends of laborato ry tests—rather than
single BUN and creatinine thresholds alone—when making the decision to start RRT. (Not Graded)

3. SEVRAREA DE CRRT

5.2.1: Discontinue RRT when it is no longer required, either because intrinsic kidney function has recovered to the point that it is
adequate to meet patient needs, or because RRT is no longer consistent with the goals of care. (Not Graded)

B.Filipoiu, Smart Medical Solutions 1-KDIGO-Kidney Disease Improving Global Outcomes

 INDICATIILE KDIGO¹
4. ANTICOAGULAREA

5.3.2: For patients without an increased bleeding risk or impaired coagulation and not already receiving effective systemic anticoagulation, we
suggest the following:
5.3.2.2: For anticoagulation in CRRT, we suggest using regional citrate anticoagulation rather than heparin in patients who do not have
contraindications for citrate. (2B)

5. DOZE IN CRRT
5.8.4: We recommend delivering an effluent volume of 20–25ml/kg/h for CRRT in AKI (1A). This will usually require a higher prescription
of effluent volume. (Not Graded)
In conclusion, there are now consistent data from two large multicenter trials (Hannover Dialysis Outcome Stud, ARFTN study, etc)showing
no benefits of increasing CRRT doses in AKI patients above effluent flows of 20–25ml/kg/h. In clinical practice, in order to achieve a
delivered dose of 20–25ml/kg/h, it is generally necessary to prescribe in the range of 25–30ml/kg/h, and to minimize interruptions in
CRRT.

B.Filipoiu, Smart Medical Solutions 1-KDIGO-Kidney Disease Improving Global Outcomes

 DOZE IN CRRT

Evidente clinice:

Ronco et al, 2000 (using post-dilution hemofiltration) and Saudan et al, 2006 found that lower doses around 20 -
25ml/kg/h were inferior to higher effluent flows of around 35 to 45 mL/kg/h in terms of survival (15 to 20%
reduction in mortality)

Two other studies by Bouman et al, 2002 (48 vs 20 mL/kg/h) and Tolwani et al, 2008 (20 vs 35 ml/kg/hr) however
found no difference in survival with higher effluent rates

The VA/HIH Acute renal failure Trial Network or ATN study in NEJM 2008 In-hospital mortality through day 60 was
51.2% among patients undergoing intensive therapy and 48.0% among those undergoing less -intensive therapy In the
more intensive arm IHD and or SLED were used six times per week and CVVHDF at an effluent flow rate of 35
mL/kg/h

The RENAL study by the ANZICS CTG in NEJM 2009 compared 25 v 40 mL/kg/). No difference in mortality
between the two groups at 90 days, a higher incidence of hypophosphatemia in the higher dose group.

B.Filipoiu, Smart Medical Solutions

EFECTUL ST asupra membranei – ADSORBTIA HEPARINEI
• Heparina este molecula incarcata negativ (SO4 )
• Ionii (+) ai PEI leaga ionii (-) ai Heparinei
• Previne formarea trombinei si coagularea
• Garanteaza o durata de viata a filtrului de pana la 72 h
+
- - - - +
+
- -+ + Hep
-- --+ + - -+ ar
in

- - - -+ - -+ +
- - + - + Hep a
- -
+
- -+
+
Heparin - -+ rin

-- + - -+ + - -+ +
- - + - + +

in
+
-

ar
- Polyethyleneimine -

p
He
+ +
(PEI)
AN69 AN69 ST AN69 ST
membrana membrana membrana

B.Filipoiu, Smart Medical Solutions

 TERAPIA SEPSISULUI- OXIRIS®
• ESTE O MEMBRANA AN 69 – TRATATA CU POLYETILENIMINA (PEI), UN POLIMER CATIONIC CARE
GREFEAZA HEPARINA

Grefarea cu PEI este de 3 x mai mare decat in cazul ST

• ESTE PREHEPARINIZATA, CEEA CE REDUCE TROMBOGENITATEA SI OFERA UN REAL AJUTOR IN CAZUL

PACIENTILOR CU COAGULOPATII

• POATE FI FOLOSITA IN TOATE MODALITATILE DE TERAPIE CRRT

• PROPRIETATILE ADSORBANTE:
ADSORBTIA ENDOTOXINELOR: MEMBRANA PEI RETINE ENDOTOXINELE (INCARCATE
ELECTRIC NEGATIV)
ADSORBTIA CYTOKINELOR: MEMBRANA CU STRUCTURA “DE BURETE” ADSOARBE
CONCENTRATII MARI DE CITOKINE B. Filipoiu, Smart Medical Solutions
 sa nu induca
sangerari
sa aiba T ½
scurt usor de
monitorizat

sa previna
infundarea sa aiba
filtrului antidot

actiune limitata
fara efecte la nivelul
sistemice circuitului
extracorporeal
ANTICOAGULAREA CU HEPARINA
• FUNCTIONEAZA PRIN ACTIVAREA ANTITROMBINEI
III→INHIBAREA FACT. IX SI FACT. X

aPTT= 1,5-2× val de referinta

• COMPLICATII: SANGERARI, HIT

(TROMBOCITOPENIA INDUSA DE HEPARINA),
HIPERKALIEMIA

• DOZA RECOMADATA :
BOLUS: 20-40UI/KGC
RATA CONTINUA: 10-20UI/KGC/H

B.Filipoiu, Smart Medical Solutions

 ANTICOAGULAREA CU CITRAT

Infuzia solutiei cu citrat pe linia arteriala a circuitului extraorporeal determina formarea unui complex
care, prin saderea concentratiei de calciu ionizat (F IV) in sange, impiedica procesul de
coagulare

Citratul leaga toti cationii divalenti

In functie de terapie si fluxurile utilizate, un procent de Ca-Citrat este filtrat si pierdut in

efluent, prin urmare, doar o mica parte din citratul infuzat este livrata pacientului

Complexele Ca-citrat sunt metabolizate, in principal, la nivel hepatic, dar si la nivelul

rinichilor si muschilor scheletici

1 mmol Citrat F, R, Ms 3 mmoli Bicarbonat

 PBP DIALIZAT
SOLUTIE CITRAT-PRISMOCITRATE® 18/0 SOLUTIE FARA CALCIU-PRISM0CAL® B22

18 moli Citrat Nivel fiziologic de HCO3¯ (22+3), glucoza,

Se metabolizeaza Na,K
Nivel usor crescut de Mg –util pentru a
54 moli bicarbonat compensa pierderile
Pungi PVC free de 5 l, cu valabilitatate 12 luni
Posibilitate conectare spike si luer lock Punga Polyolefin de 5l cu valabilitate 12
luni
Conectare luer lock si spike

INLOCUITOR

PRISMASOL 2/ PHOXILIUM
DOZE IN CRRT
(ANTICOAGULANT:HEPARINA)
 CVVHDF-35ML/KG/H
EX.:PAC 70 KG

Flux sange = ≈2x G – in functie de FF

Pompa presange (PBP)= max 10 ml/kg/h → 700ml/h

Dializat= 875 ml/h

Inlocuitor=875 ml/h

B.Filipoiu, Smart Medical Solutions

CVVHDF-PROTOCOL CITRAT
 PRESIUNEA TRANSMEMBRANARA (TMP)

Filter P + Return P
TMP = ------------------------- - Effluent P POZ
POZ
2
SAU
NEG

B.Filipoiu, Smart Medical Solutions

 FRACTIA DE FILTRARE (FF)

Rata de ultrafiltrare

• FF%=
Fluxul de sange (1- Hct)
RATA DE ULTRAFILTRARE=FLUXUL DE INLOCUITOR+ ELIMINARE LICHID PACIENT

• 15-20% MAXIMUM PENTRU A REDUCE RISCUL DE COAGULARE

>25% DETERMINA HEMOCONCETRATIE IN F→ COAGULARE

• CRESTEREA FLUXULUI DE SANGE SCADE FF (CAND ESTE UTILIZATA POSTDILUTIA)

B.Filipoiu, Smart Medical Solutions
 DOZA DE EFLUENT

Q PBP+Q Dializat+Q Inlocuitor(pre+post)

DOZA EFL.=
Greutate

Q B(1-Htc) Q UF
Doza UFR= X
Q B(1-Htc)+Qpre BW

B.Filipoiu, Smart Medical Solutions

• PRISMAFLEX- O SINGURA PLATFORMA PENTRU TOATE TIPURILE DE TERAPII DE EPURARE
EXTRACORPOREALA (CRRT, MARS, CO2 REMOVAL/PRISMLUNG, TPE)

• VERSATILITATE CRESCUTA- PUTEM SCHIMBA CU USURINTA TIPUL DE TERAPIE (CVVHDF, CVVHD,

CVVHF, SCUF) IN TIMPUL TRATAMENTULUI, FARA A FI NECESARA OPRIREA APARATULUI SAU
SCHIMBAREA SETULUI
• TRATAMENTE SIGURE PENTRU PACIENT SI USOR DE CONDUS (ACCESUL VASCULAR SI
MONITORIZARAEA STRICTA A APTT-ULUI TERAPEUTIC-70-90S)
• MEMBRANE DEDICATE PENTRU FIECARE TIP DE TERAPIE- ST, OXIRIS-CE ASIGURA DURATA
TRATAMENTELOR DE PANA LA 72 DE H
• POSIBILITATI VARIATE DE ANTICOAGULARE- HEPARINA/ CITRAT, PREDILUTIE
• O ECHIPA CARE VA STA INTODEAUNA LA DISPOZITIE

B.Filipoiu, Smart Medical Solutions