EPURAREA

EXTRACORPOREALA
RENALA

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 renala 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

 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 mmHg – mmHg = Transmembrane Pressure
negativa tragand Blood In (TMP)
ultrafiltratul prin filtru (from patient)

Fluid Volume
Reduction
Blood Out
to waste (to patient)

LOW PRESS HIGH PRESS

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

 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

 HEMOFILTRU- STRUCTURA

Racord efluent

Carcasa

Capilare cu sange

Compartiment
UF / Dializan
Racord sange

B.Filipoiu, Smart Medical Solutions

 SIEVING COEFFICIENT & CUT-OFF
Sieving Coefficient: Membrana Semipermeabila
Raportul dintre concentratia unei
Compartimentul
substante in filtrat si sange
dializantului

Cut-off:
Dimensiunea max. a masei moleculare
care trece prin porii membranei.
 In filtrele low-flux pana la 10 kDa
 In filtrele high-flux pana la 40-60
kDa

Uric Acid 170 Da

Creatinin 110 Da
Urea 60 Da Albumina
66 kDa Compartimentul sangelui
Albumina 66kDa

B.Filipoiu, Smart Medical Solutions

DIFUZIE vs. CONVECTIE

B.Filipoiu, Smart Medical Solutions

 OMNI®
• TOATE MODURILE CRRT ȘI ANTICOAGULARE SUNT DISPONIBILE IN ORICE
MOMENT

• SCUF: ULTRAFILTRARE CONTINUA LENTA

• CVVH: HEMOFILTRARE VENO-VENOASA CONTINUA

• CVVHD: HEMODIALIZA VENO-VENOASA CONTINUA

• CVVHDF: HEMODIAFILTRARE VENO-VENOASA

• HEPARINĂ

• CITRAT

• TPE: SCHIMB DE PLASMA TERAPEUTIC

• VOLUM MIC DE SANGE (OPTIUNE VIITOARE)

B.Filipoiu, Smart Medical Solutions

 OMNI®  Acelasi set pentru toate terapiile/modurile de
dilutie
Utilizare si  Interfata intuitiva (ecran touch screen 12 inch,
Design suport in remedierea alarmelor, grafice de
presiuni, etc )
 Gata de conectare in 15 min
 Protocol sigur si eficient pentru citrat- CVVHD1
Flexibilitate
 Reducerea automata a BFR in cazul problemelor de
terapeutica flux

 Mod Ingrijire Pacient

 98% din Doza Renala atinsa2-
Managementul compensarea automata in urma “timpilor morti”
fluidelor
 5.0% “timpi morti”2
 Cel mai bun din clasa, dupa ghidurile
ADQI3
1 Morgera S, Schneider M, Slowinski T, Vargas-Hein O, Zuckermann-Becker H, Peters H, Kindgen-Milles D, Neumayer HH: A safe ci-trate anticoagulation protocol with variable treatment efficacy and excellent control of the acid-base status. Crit
Care Med 2009; 37: 2018–2024
2 Schläpfer P, Durovray JD, Plouhinec V, Chiappa C, Bellomo R, Schneider A: A First Evaluation of OMNI ® , A New Device for Continuous Renal Replacement Therapy Blood Purif 2017;43:11–17 , value achieved with CVVHD RCA mode
3 Murugan R, Hoste E, Mehta RL, Samoni S, Ding X, Rosner MH, Kellum JA, Ronco C on behalf of the Acute Disease Quality Initiative (ADQI) Consensus Group ,Precision Fluid Management in Continuous Renal Replacement Therapy, Blood Purif
2016;42:266–278
 COMPONENTELE OMNI- SCANER KIT

• Scanarea setului cu oferirea

automata a informatiilor legate de
lotul de fabricatie si data de
expirare, inainte de a desigila setul

• Eliminarea erorilor umane

B.Filipoiu, Smart Medical Solutions

 COMPONENTELE OMNI-POMPE
POMPA DE SANGE- impinge sangele in
circuit

POMPA EFLUENT- arunca efluentul in

punga de efluent

POMPA DIALIZAT- asigura circulatia

dializatului din punga in filtru (in
contracurent cu fluxul de sange)

POMPA INLOCUITOR- asigura

circulatia inlocuitorului in circuit-pre- sau
post filtru

B.Filipoiu, Smart Medical Solutions

 OMNI®
ELIMINAREA AUTOMATA A AERULUI PRIN REGLAREA A 4 CAMERE DE
DEAERARE
• Datorita celor 4 camere cu reglare automata, plasate atat pe circuitul sangelui, cat și pe cel al fluidelor, care sunt proiectate sa
depisteze și sa elimine orice volum de aer intrat in circuit, timpul de lucru al personalului medical este redus semnificativ

INCALZITOR CERAMIC DE FLUIDE, INTEGRAT

• Este proiectat sa incalzeasca repede și cu acuratete fluidele în timpul tratamentului,

de la 30°c, pentru utilizare in cazul stopului cardiac, la 40°C pentru HVHF.

B.Filipoiu, Smart Medical Solutions

 OMNI® - SETURI TOTAL PRECONECTATE

• SETURILE INCLUD HEMOFILTRU

• GAMĂ LA DIMENSIUNE COMPLETĂ

0,8 – 1,2 - 1,6 MP

▪ INCARCAREA SETURILOR ESTE AUTOMATA, CU INDICATIII PAS CU

PAS

▪ SETUL ESTE TOTAL PRECONECTAT

▪ SE INCARCA IN ˜5 MIN

▪ VOLUMUL DE SANGE EXTRACORPOREAL: 152-192 ML

▪ CAMERE DE DEAERARE AUTOMATE- 4 LA NUMAR

B.Filipoiu, Smart Medical Solutions

 FLUIDELE OMNI®
INLOCUITOR, DIALIZAT SI SOLUTIA DE CITRAT

Solutire de electroliti pe baza de Solutie fara Calciu Solutie Citrat 4%

bicarbonat
Solutie de electroliti fara calciu, Trisodium citrate 4%- solutie
pe baza de bicarbonat, ce se pentru Anticoagularea
utilizeaza ca dializat in Regionala cu Citrat
CVVHD/HDF in Anticoagularea
Regionala cu Citrat
NOU: SOLUTIA DIALIZANT CU
1,25 MMOL FOSFAT

B.Filipoiu, Smart Medical Solutions

 IRA
Scaderea brusca şi potenţial reversibila a funcţiei renale

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

hidroelectrolitic şi acido-bazic 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 INJURIE 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
 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

 CAND E TIMPUL POTRIVIT PENTRU CRRT?
precoce: tardiv:
 sangerare  tratarea complicatiilor
 hipotensiune
 infectie
Hipervolemia asociaza rata crescuta a
mortalitatii, mornumar mare de zile de
spitalizare si, implicit, ingrijiri
complexe
S-a dovedit ca dupa primele 12 h de ATI
apare o incarcare hidrica cu 8-30l
(“Vasopressin and Septic Shock Trial”)

Nu exista un ghid care sa traseze indicatii clare in ceea ce priveste initierea

Decizia clinica are la baza havnu doar parametri ca urea, creat and diureza, ci si boala de baza, catabolismul, MSOF si
statusul complet al pacientului.

26
 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 laboratory 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

 ECHILIBRU HIDROELECTROLITIC SI ACIDO-BAZIC
Hipervolemia
Diuretice (diuretice de ansa, ca Furosemid) sunt in principal nefrotoxice

Daca este posibil se recomanda utilizarea in caz de urgenta penru restabilirea echilibrului hidric

In hipervolemia severa furosemid 250 mg in 1h, apoi 80 mg in 4h,doza max. total 500 mg  daca nuare efect  interupeti
 MEDICATIA IN AKI
Se recomanda intreruperea nefrotoxicelor si ajustarea (in functie de ghiduri) l apacientul cu CRRT

 Antimicrobial Agents: Penicillin, Amoxicillin, Ampicillin, Ciprofloxacim, Cephalosporin,

Sulfonamide, Rifampicin, Co-trimoxazole, Gentamicin, Aminoglycoside, Amphotericin B,
Vancomycin, Aciclovir
 Iodated Contrast Agents
 NSAID’s/Salicylates: Ibuprofen, Naproxen, Indomethacin, Piroxicam
 Antiulcer Agents: Cimetidine, Omeprazole
 Others: ACE-I, ARB, Cyclosporine, NSAR, Phenytoin, Thiacide Diuretics, Furosemide,
Allopurinol, Mesalazine

Pentru ajustarea dozelor- www.dosing.de

 Evidente clinice:
DOZE IN CRRT
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.

High-volume versus standard-volume haemofiltration for septic shock patients with acute kidney injury (IVOIRE
study): a multicentre randomized controlled trial. In the IVOIRE trial, there was no evidence that HVHF at
70 mL/kg/h, when compared with contemporary SVHF at 35 mL/kg/h, leads to a reduction of 28-day
mortality or contributes to early improvements in haemodynamic profile or organ function. HVHF, as applied in
this trial, cannot be recommended for treatment of septic shock complicated by AKI

B.Filipoiu, Smart Medical Solutions

 Effect of Early vs Delayed Initiation of Renal Replacement Therapy on Mortality in Critically Ill Patients With Acute Kidney Injury
The ELAIN Randomized Clinical Trial 2016
Zarbock A1, Kellum JA2, Schmidt C1, Van Aken H1, Wempe C1, Pavenstädt H3, Boanta A1, Gerß J4, Meersch M1

INTERVENTIONS:
Early (within 8 hours of diagnosis of KDIGO stage 2; n = 112) or delayed (within 12 hours of stage 3 AKI or no initiation; n = 119)
initiation of RRT

MAIN OUTCOMES AND MEASURES:

The primary end point was mortality at 90 days after randomization. Secondary end points included 28- and 60-day mortality, clinical
evidence of organ dysfunction, recovery of renal function, requirement of RRT after day 90, duration of renal support, and intensive
care unit (ICU) and hospital length of stay

RESULTS:

Early initiation of RRT significantly reduced 90-day mortality (44 of 112 patients [39.3%]) compared with delayed initiation of
RRT (65 of 119 patients [54.7%]

More patients in the early group recovered renal function by day 90 (60 of 112 patients [53.6%] in the early group vs 46 of 119
patients [38.7%] in the delayed group

Duration of RRT and length of hospital stay were significantly shorter in the early group than in the delayed group (RRT: 9
days in the early group vs 25 days in the delayed group;

Hospital stay: 51 days in the early group vs 82 days in the delayed group
B.Filipoiu, Smart Medical Solutions
Was no significant effect on requirement of RRT after day 90, organ dysfunction, and length of ICU stay.
B.Filipoiu, Smart Medical Solutions
 DOZE
B.Filipoiu, Smart Medical Solutions
 G=100 KG CRRT
20?
35?

B.Filipoiu, Smart Medical Solutions

 G=100 kg → CVVHDF
Doza efluent=25ml/kgc/h

2500ml/h

CVVHD → DIALIZANT CVVHF → SUBSTITUTIE

DIALIZANT = 1250ml/h SUBSTITUTIE=1250ml/h

B.Filipoiu, Smart Medical Solutions

 CATETERIZAREA
Jugulara
 Cel mai utilizat site
 Rata cea mai mica de complicatii
 Verificare Rx Vena jugulara interna
Vena subclavie
Subclaviculara
 Foarte putin utilizata
 Rata mare a complicatiilor
 Verificare Rx

Femurala
 RAR utilizata
 Asociaza complicatii Vena femurala

Verificarea fluxului cateterului:

Se aspira 20 cc c cateterul clampat. Pentru un flux de 200ml/min, seringa se
umple in 6s
 Heparinizarea in CRRT
Initial Continuu aPTT ACT
Risc sangerare
IU/kg IU/kg/h sec. sec.

Fara risc 50 10-20 60 <250

Risc scazut 15-25 5-10 45 160-180

Risc crescut 10 2.5-5 30 120

APTT 70-90 s
ACT 180-220s 37

B.Filipoiu, Smart Medical Solutions

 ANTICOAGULAREA CONTINUA

aPTT/sec ACT/sec
120 240

100 200

80 160

60 120

40 80

Timp/h
0 1 2 3 4 5 6
Doza continua

Bolus initial
 HIT – trombocitopenia indusa de heparina
2 tipuri:

• HIT 1 apare dupa 5 zile in 5%, Trombocitopenia >100,000/µl, asimptomatic

• HIT 2 apare dupa 5-10 zile in ca. 3%, Trombocitopenia <100,000/µl, “white clot syndrome”, reactie imuna, incazuri rare poate aparea in cateva ore,
heparina este contraindicata

Thrombocytopenia

Heparin
IgG-Heparin-PF4-Complex

Heparin-PF4-Complex
PF4

Thrombocyte antibody-antigene-reaction

IgG

PF4 = Platelet Factor 4, IgG = Immunoglobulin G Thrombus

*Innere Medizin 2012 Taschenbuch – 1. Oktober 2011 von Gerd Herold (Autor) , Taschenbuch: 966 Seiten, Verlag: Herold, Gerd (1. Oktober 2011), S. 808
 Anticoagularea cu Citrat

Defect Injury
Endothelium X Tissue
Endogenous System Exogenous System
XII XI IX
Tissue Factor (III) +
XIIa XIa IXa Ca2+ (IV) + VII
VIII
Ca2+ (IV) Citrate
TF3

Thrombocytes TF3 + Xa + V + Ca2+ (IV)

XIII Thrombin Prothrombin (II)

Fibrin Monomers Fibrinogen (I)

activation
XIIIa
inhibition
Fibrin
 METABOLIZAREA CITRATULUI

 Cam 1/3 din compexele Ca-Citrate sunt indepartate prin dializor

 Aproximativ 2/3 merg in pacient

 Prin metabolizarea compkexelorin ficat, rinichi si muschi scheletici,

cresc Na si Ca *

 In ciclul Krebs, ficatul este capabil sa metabolizeze o concentratie

de Citrat de 100 mmol/l fara probleme EFECTE ADVERSE:
• HipocalcemiEe(Tetania, Aritmie)
• Alcaloza metabolica
La pacientii cu IHA SI MSOF:
 1 molecula Citrat → 3 molecule Bicarbonat • Anion gab 
• Acidoza metabolica
• tCa2+/iCa2+ >2.5
 T ½ al citratului- cca. 5 min*

* Andrew Davenport and Ashita Tolwani Citrate anticoagulation for continuous renal replacement therapy (CRRT) in patients with acute kidney injury admitted to the intensive care unit; NDT Plus (2009) 2: 439–447
 IMPORTANT / INFORMATII GENERALE

Fluxul de Citrat se ajusteaza concomitent cu BFR

Rata Efuent = Start CVVHD;

4 mmol Citrat / l de sange
Rata filtrare + rata dializat 1.7 mmol Calciu / l Efuent

43
 PROTOCOL CITRAT*
Greutate pacient Flux dializant Flux sange FLUIDE NECESARE
ml/h ml/min
Doza renala > 20ml/kg/h

50 Kg 1300 70  Trisodium Citrate 4 %

60 Kg 1500 80  Calcium gluconat

70 Kg 1800 90  Dializant fara Calciu: 4/2mmol K+

80 Kg 2000 100
90 Kg 2200 110
100 kg 2400 120
110 kg 2800 140
120 kg 3000 150
130 kg 3300 170

Folositi doar solutie dializant fara calciu

Calciul i. al pacientului trebuie corectat inainte de RCA

*Morgera S, Schneider M, Slowinski T, Vargas-Hein O, Zuckermann-Becker H, Peters H, Kindgen-Milles D, Neumayer HH:

A safe citrate anticoagulation protocol with variable treatment efficacy and excellent control of the acid-base status. Crit Care Med 2009; 37: 2018–2024
 MONITORIZARE PARAMETRI LABORATOR (OMNI PROTOCOL)

Parametru Interval timp

Pacient iCa2+ Inainte de a incepe, dupa 1 h, la fiecare 3 h pt. 12 h si la 6 h ulterior

Pacient tCa2+ Inainte de a incepe, la fiecare 6 h

Postfiltru iCa2+ Dupa 5 min, la 5 min dupa fiecare modificare, la fiecare 6-8 h
tCa2+ = total Ca2+

45