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Pediatric CRRT: Dialysis and Replacement Solutions

Learn about the base composition, types, advantages, and disadvantages of CRRT fluid solutions in pediatric nephrology, comparing Bicarbonate-based and Lactate-based options for dialysate and replacement fluid. Understand the preparation, timing, and available options for CRRT fluids to optimize pediatric care.

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Pediatric CRRT: Dialysis and Replacement Solutions

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  1. Pediatric CRRT:Dialysis and Replacement Solutions William E. Smoyer, M.D. Pediatric Nephrology University of Michigan

  2. Introduction • Variety of CRRT solutions in use • Few commercial options for CRRT fluid in some countries (i.e. USA) • Major determinants • Base composition • Location of preparation • Timing of preparation

  3. Base Composition of CRRT Fluid • Replacement Fluid / Dialysate • Should be nearly physiologic (two exceptions) • 1) Cannot combine physiologic Ca++ and PO4-3 • 2) Need supraphysiologic HCO3- • Types of Solutions • Bicarbonate-based solutions (custom made) • Lactate-based solutions (pre-made)

  4. Bicarbonate-Based CRRT Fluid • Generally preferred over lactate-based solutions • Can be used for replacement fluid or dialysate • Avoids need for conversion of lactate into bicarbonate • Not stable for long periods due to CO2 diffusion • More expensive than lactate-based solutions • Not widely commercially available • No marketed solutions in USA • Marketed as “Hemosol” in Canada and Europe

  5. Bicarbonate-Based CRRT Fluid • Phosphorus-based Solution • Requires continuous calcium infusion • CaCl2 titrated to keep Ca++ at 1-1.3 mEq/L • Calcium-based Solution • Requires continuous phosphorus infusion • Na3PO4 at 1-2 mmol/kg/d

  6. Bicarbonate-Based CRRT Fluid • Options for Therapy • Custom made in hospital pharmacy (most common) • Generated by hemodialysis machine 1 • Alternating Ca- and HCO3-based solutions (hourly) • 0.45% saline + 70 mEq/L NaHCO3 + 0-4 mEq/L KCl • 0.9% saline + 300 mg/L CaCl2+200 mg/L MgSO4 + 0-4 mEq/L KCl • “Four Bag” Method 2 • COMPASS Program 1 LeBlanc et al. Am J Kid Dis. 26:910, 1995 2 Mault et al. ASAIO J 30:203, 1984

  7. Replacement Fluid or Dialysate Bicarbonate-Based Solutions

  8. Lactate-Based CRRT Fluid • Stable for long periods • Commercially available • 1.5% peritoneal dialysate • Lactated Ringer’s solution • Baxter Premix Dialysate (only FDA-approved) • Less expensive than bicarbonate-based fluid • Generally used only for dialysate

  9. Lactate-Based CRRT Fluid • 1.5% Peritoneal Dialysate (Not approved) • Advantages • Pre-made  Can be obtained more quickly • Inexpensive • Disadvantages • Lactate may  acidosis (liver failure, poor perfusion) • Dextrose is 1500 mg/dL and may  hyperglycemia • Na is 132 mEq/L and may  hyponatremia • K is 0 mEq/L and may  hypokalemia • PO4 is 0 mEq/L and may  hypophosphatemia

  10. Lactate-Based CRRT Fluid • Lactated Ringer’s Solution (Not approved) • Advantages • Pre-made  Can be obtained more quickly • Inexpensive • Disadvantages • Lactate may  acidosis (liver failure, poor perfusion) • Dextrose is 0 mg/dL and may  hypoglycemia • Na is 130 mEq/L and may  hyponatremia • K is 4 mEq/L (? not desirable if treating hyperkalemia) • PO4 is 0 mEq/L and may  hypophosphatemia

  11. Lactate-Based CRRT Fluid • Baxter Premix Dialysate (Not for infusion) • Advantages • Pre-made  Can be obtained more quickly • Inexpensive • Disadvantages • Lactate may  acidosis (liver failure, poor perfusion) • K is 2 mEq/L and may  hypokalemia • PO4 is 0 mEq/L and may  hypophosphatemia

  12. Dialysate 1.5% PD LR Baxter Glucose (mg/dL) 1500 0 100 Na (mEq/L) 132 130 140 K (mEq/L) 0 4 2 Cl (mEq/L) 96 109 117 Ca (mEq/L) 3.5 3 3.5 Phos (mg/dL) 0 0 0 Mg (mg/dL) 0.5 0 1.5 Lactate (mEq/L) 40 28 30 Osmolality (mOsm/L) 346 273 297

  13. Location of CRRT Fluid Preparation • Prepared in hospital (custom made) • NaHCO3-based fluid • Prepared in dialysis unit • NaHCO3-based fluid (Hemodialysis machine) 1 • Prepared in ICU • NaHCO3-based fluid (“Four Bag” Method) 2 • Prepared commercially • Lactate-based fluid • NaHCO3-based (COMPASS) 1 LeBlanc et al. Am J Kid Dis. 26:910, 1995 2 Mault et al. ASAIO J 30:203, 1984

  14. Timing of CRRT Fluid Preparation • Stock Solutions • Generally lactate-based • Less expensive • Hospal “Hemosol”(In Canada and Europe) • Immediate Use Solutions • All NaHCO3-based • More expensive

  15. CRRT Fluids in Pediatric Programs • Both HCO3- and lactate-based solutions being used in USA • Most programs using HCO3-based solutions • Most programs using solutions made in hospital pharmacy • Few programs using Baxter Premix Dialysate • No programs using dialysate generated with hemodialysis machine

  16. Summary • Variety of CRRT dialysate and replacement solutions available • NaHCO3-based solutions generally preferable • Lactate-based solutions less expensive and more readily available (usually dialysate only) • Custom-made solutions have risk of preparation errors • Need increased availability of standardized, pre-made NaHCO3-based solutions (esp. in USA)

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