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Does it Matter?
Patrick D. Brophy MD
University of Michigan
Pediatric Nephrology
OBJECTIVES
Definitions
– CVVH vs CVVHD
Mechanisms of action
– Convective vs Diffusive clearance
Other Issues & Selective data review
– Drug Clearance, membranes & patients, anticoag
Implementation of one modality over another-
Rationale
– Sepsis vs ARF vs Toxic ingestions
– Advantages and Disadvantages, expertise
Definitions
Continuous Venous Venous Hemofiltration
Mimics the process which occurs in the
mammalian kidney
Describes an almost exclusive convective
treatment with highly permeable membranes
Ultrafiltrate produced is replaced by a sterile
solution (High UF rates)
Patient weight loss results from the difference
between ultrafiltration and reinfusion rates
Definitions
Continuous Venous Venous Hemodialysis
Describes a predominantly diffuse treatment
in which blood and dialysate are circulated
either side of the dialysis membrane in
countercurrent directions.
Dialysate may be custom or commercially
produced
The ultrafiltration rate is approximately equal
to the scheduled weight loss (lower UF rate).
Definitions
Qb Qb
Qef
f
Qef Qd
f
Qr Qr
Qb Qb
Qef Qef Qd
f Pre-Dilution CVVH f CVVHDF
Mechanisms of Action
CVVH
Convection
Solute is removed by “Solvent Drag”. The solvent
carries the solute (plasma water) through a semi-
permeable membrane.
The Roller Pump creates Hydrostatic Pressure,
which drives the solvent through the membrane.
The membrane pore size limits molecular transfer
More efficient removal of larger molecules than
diffusion
Mechanisms of Action
CVVH
Convection
Since it mimics the mammallian kidney its thought
to be more “physiologic” and provides better
removal of middle molecules (500-5000 Daltons)
thought to be responsible for uremia.
With the advent of highly porous membranes need
to use larger markers (500-50000 Daltons) to
determine “uremic clearance”.
Enhanced clearance of autologous cytokines-
thought to be involved in Septic Inflammatory
Response Syndrome (SIRS).
Mechanisms of Action
CVVH
Convection
Sieving Coefficient- clearance coefficient for
hemofiltration defined by UV/P
U= Filtrate Concentration
V= Volume
P= Mean plasma concentration over the clearance period
SC is 1 for molecules that pass through the
membrane easily & 0 for those that do not
Mechanisms of Action
CVVHD
Diffusion (predominantly)
Solute diffuses down an electrochemical gradient
through a semi-permeable membrane in response
to an electrolyte solution running counter current to
the blood flow through the filter.
Diffusive movement occurs via Brownian motion of
the solute- smaller molecules (ie urea) have
greater kinetic energy and are preferentially
removed based on the size of the concentration
gradient
Mechanisms of Action
CVVHD
Diffusion (predominantly)
Some convection occurs due to prescribed UF and
if High flux filters are utilized
Solute removal is proportional to the concentration
gradient and size of each molecule
Dialysate flow rate is slower than BFR and is the
limiting factor to solute removal
Solute removal is directly proportional to dialysate
flow rate
Mechanisms of Action
CVVHD
Diffusion (predominantly)
Diffusion Coefficient- clearance coefficient for
hemodialysis defined by UV/P
U= Dialysate (+Filtrate) Concentration
V= Volume
P= Mean plasma concentration over the clearance period
Principle same as for SC with 1= to optimal
clearance and 0= to no (minimal clearance)
Other Issues
The greatest difference between
modalities is likely the impact of the
membrane utilized and their specific
characteristics.
There are no data available assessing
patient outcomes using diffusive (CVVHD)
and convective (CVVH) therapies
Other Issues
Low molecular weight solutes
Middle/High molecular weight solutes
Drug/Toxin Clearance
Impact on Adsorptive membrane
characteristics
Anticoagulation
Patient Characteristics
Low Molecular Weight Solutes