Thread by @ssfarouk, 1/As kidney replacement therapies (KRT) have become a strained and limited resource [...]

1/

As kidney replacement therapies (KRT) have become a strained and limited resource during the #COVID19 pandemic, here is a quick #tweetorial on how these treatments work:

What is the main mechanism by which clearance is achieved during intermittent #hemodialysis?

2/

KRT has 2 powers:

Clearance (removal of solutes, like potassium

)

Volume removal

...and it comes in 2 flavors:

Intermittent

Continuous

3/ How does the potassium go from 7.2 meq/L to 4 after an intermittent #hemodialysis (iHD) session?

Chemistry 101: DIFFUSION!

Solutes are cleared via diffusion as they move

their concentration gradient across a SEMIPERMEABLE membrane

DOI: 10.1056/NEJMc1301071

3/ How does the potassium go from 7.2 meq/L to 4 after an intermittent #hemodialysis (iHD) session? Chemistry 101: DIFFUSION! Solutes are cleared via diffusion as they move their concentration gradient across a SEMIPERMEABLE membraneDOI: 10.1056/NEJMc1301071

4/ A closer look at that dialysis filter...

Blood runs through the filter "straws", while the dialysate runs in the opposite direction

around them & does not come in direct contact with the

Larger filters with bigger pores can be used to further optimize clearance.

4/ A closer look at that dialysis filter...Blood runs through the filter "straws", while the dialysate runs in the opposite direction around them & does not come in direct contact with the Larger filters with bigger pores can be used to further optimize clearance.

5/ Strategies to maximize clearance (particularly relevant now given the #COVID19-related strain on KRT):

Bigger filter size

Higher dialysis blood flow rates (usually, these are 300-400 cc/min)

Widen the concentration gradient and try a potassium-free dialysate

5/ Strategies to maximize clearance (particularly relevant now given the #COVID19-related strain on KRT):Bigger filter sizeHigher dialysis blood flow rates (usually, these are 300-400 cc/min)Widen the concentration gradient and try a potassium-free dialysate

6/ So that's how we remove solute. What about the fluid?

Ultrafiltration (UF), or ISOTONIC fluid removal, is achieved via pressure that is exerted across the membrane that drives fluid out.

DOI: 10.1056/NEJMct1206045 @luck_urine

7/ Here's what goes into the iHD order:

Access, blood flow, + dialysate flow rates (standard 800 cc/min)

Dialysate composition

Ultrafiltration volume

Filter size

Duration (standard 3.5hrs - though #COVID19 has forced shorter treatment times, affecting clearance)

7/ Here's what goes into the iHD order:Access, blood flow, + dialysate flow rates (standard 800 cc/min)Dialysate compositionUltrafiltration volumeFilter sizeDuration (standard 3.5hrs - though #COVID19 has forced shorter treatment times, affecting clearance)

8/ What about SLED? (sustained low efficiency dialysis)

It's just like iHD, but...not as efficient...and should be done for longer durations (e.g. 8 hours) to obtain similar clearance to iHD

9/ Let's move on to the CONTINUOUS KRTs

The Players: CVVH, CVVHD, & CVVHDF

CVVH = continuous venovenous hemofiltration

CVVH is the only continuous modality that does NOT use a dialysate. So how do we get clearance?

REPLACEMENT FLUID

9/ Let's move on to the CONTINUOUS KRTs The Players: CVVH, CVVHD, & CVVHDFCVVH = continuous venovenous hemofiltration CVVH is the only continuous modality that does NOT use a dialysate. So how do we get clearance?REPLACEMENT FLUID

10/ If you've seen a pt connected to a #CVVH machine, you remember the huge bags hanging in the room - these are bags of replacement fluid that achieve clearance & are infused into the patient via the filter.

Hospitals can purchase pre-made replacement fluid (example below)

11/ Remember that replacement fluid is essentially infused unchanged into the pt, so use caution in those with hypoNa to avoid overcorrection

Of note: Therapy fluid can be infused either before or after the CVVH filter. If you do it before, may lose some solute (via convection)

12/ The graphic below illustrates the differences between #CVVH, #CVVHD, and #CVVHDF

CVVH:

Convection + replacement fluid;

dialysate
CVVHD

Dialysate + convection;

replacement fluid
CVVHDF:

Dialysate + convection + replacement fluid

@RenalFellowNtwk #FOAMed

12/ The graphic below illustrates the differences between #CVVH, #CVVHD, and #CVVHDFCVVH: Convection + replacement fluid; dialysateCVVHDDialysate + convection; replacement fluid CVVHDF: Dialysate + convection + replacement fluid @RenalFellowNtwk #FOAMed

13/ Say you only need volume removal, but no clearance:

Use your resources wisely and opt for a pure- #convection therapy:

Slow continuous ultrafiltration ( #SCUF) AKA aquapheresis or "CHF Solutions"

Don't waste dialysate or replacement fluid if you don't need it!

#COVID19

14/ Compared to iHD, continuous KRT will achieve slower clearance & volume removal

(e.g. 100 cc/hr vs 1L/hr)

PIRRT = "middle ground" and uses higher RF rates to lower tx times & has been used during #COVID19 pandemic to maximize CKRT machine use

https://www.nxstage.com/hcp/therapies/pirrt/

14/ Compared to iHD, continuous KRT will achieve slower clearance & volume removal (e.g. 100 cc/hr vs 1L/hr)PIRRT = "middle ground" and uses higher RF rates to lower tx times & has been used during #COVID19 pandemic to maximize CKRT machine use https://www.nxstage.com/hcp/therapies/pirrt/

15/ In summary:

KRT = continuous/intermittent

Solute clearance: diffusion; UF: convection

Modality choice: Volume/solute removal needs + what's available

Optimize treatments that may be shorter by

blood/RF flow rates, using larger filters, & tailoring your dialysate

16/

And did not cover this above - but acute #PeritonealDialysis is another innovative and effective way to relieve some of the strain on resources like iHD & CVVH

Will let @osamaelshamy88 tackle that #tweetorial...

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