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Dialysis and Replacement Solutions for Pediatric CRRT

This talk outlines the purpose and goals of solutions used in CRRT for pediatric patients, considerations when choosing a solution, characteristics of ideal solutions, and available options. It discusses commercial solutions, chemical content of various products, and factors to consider when selecting a solution. Anticoagulation strategies, concerns regarding preparation errors, and FDA approval status are also addressed. The presentation suggests approaches like CRRT with citrate anticoagulation, using commercial bicarbonate-based dialysate, and normal saline for replacement. An alternative method using on-line dialysate with SLED is mentioned.

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Dialysis and Replacement Solutions for Pediatric CRRT

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  1. Dialysis and Replacement Solutions for Pediatric CRRT Jordan M. Symons, MD University of Washington School of Medicine Children’s Hospital & Regional Medical Center Seattle, WA jordan.symons@seattlechildrens.org

  2. CRRT Solutions:Outline 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

  3. 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 55:1121-2, 1977.

  4. 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

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

  6. Neg Press H2O 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 H2O H2O H2O

  7. 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

  8. Characteristics of the Ideal CRRT Solution • Physiological • Reliable • Inexpensive • Easy to prepare • Simple to store • Quick to the bedside • Widely available • Fully compatible

  9. 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

  10. 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

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

  12. Chemical Content of Normocarb

  13. 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

  14. Chemical Content of Normocarb HF

  15. PrismaSate (Gambro) • Bicarbonate buffered • Small amount of lactate • 5 liter bag • 2 compartments to prevent precipitation • Six ionic formulations

  16. Chemical Content of PrismaSate

  17. PrismaSol (Gambro) • Bicarbonate buffered • Small amount of lactate • 5 liter bag • 2 compartments to prevent precipitation • Seven ionic formulations

  18. Chemical Content of PrismaSol

  19. Accusol (Baxter) • Bicarbonate buffered • No lactate • 2.5 liter bag • 2 compartments to prevent precipitation • Five ionic formulations

  20. Chemical Content of Accusol

  21. Duosol (B.Braun) • Bicarbonate buffered • No lactate • 5 liter bag • 2 compartments to prevent precipitation • Three ionic formulations

  22. Chemical Content of Duosol

  23. 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

  24. Chemical Content of NxStage PureFlow (1)

  25. Chemical Content of NxStage PureFlow (2)

  26. Choosing a Solution: Issues to Consider • Cost • Anticoagulation • Patient safety • CRRT modality • Diffusion (CVVHD) • Convection (CVVH) • Both (CVVHDF)

  27. Anticoagulation and Solutions May need to consider Ca++ content if using citrate for anticoagulation

  28. 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

  29. FDA Approval Status of CRRT Solutions

  30. R D 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

  31. 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

  32. Citrasate(Advanced Renal Technologies) • “A” concentrate for dialysis • Liquid or bulk powder • Citrate used as acidifying agent • Local anticoagulation greatly reduces need for heparin

  33. 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

  34. Thanks!

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