Outline Principles of clearance Factors Modalities Not Cover Measure Clinical outcomes K Solute Dialysis Adequacy Drug Dosing Poisoning Intermittent Hemodialysis Nocturnal Home Hemodialysis ID: 934008
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Slide1
Solute Clearance
Monika Aggarwal, MD,MS,FASN
Slide2OutlinePrinciples of clearance FactorsModalitiesNot CoverMeasure
Clinical outcomes
Slide3(K
Solute)
Slide4Dialysis Adequacy Drug DosingPoisoning
Slide5Intermittent HemodialysisNocturnalHome HemodialysisQuotidian/TIWSustained Low efficiency dialysis (SLED)Continuous Renal Replacement Therapies
CVVHCVVHDCVVHDFSCUFProlonged Intermittent Renal Replacement Therapies (PIRRT)Peritoneal DialysisCAPDAPD
Slide6Slide7B2microglobulin
11800
Slide8Slide9Surface Area
Flux (Pore Size)Efficiency (Number of Pores)
Slide10Slide11DiffusionSolute Molecular Weight
Volume of distributionProtein BoundCompartmentConcentrationDialysisTimeBFRDFRDialyzerPore numbers, Surface area, thickness KoA= Diffusive clearance of dialyzerHigh efficiency dialyzer KoA >800-1000 ml/min
Slide12Slide13Slide14Slide15Slide16Diffusive ClearanceMaintain concentration GradientCountercurrentHigher DFR
Dialyzer (KoA)Higher BFRTime Number of treatments
Slide17Slide1867-year-old male, ESRD, three times a week in-center HD. T=4 hoursBFR=400 ml/minDFR =500 ml/minKoA=800 ml/minWeight 70 kg Increase clearance of Urea(K
urea) per session :Increase DFR to 800 ml/minChange dialyzer to KoA = 1000 ml/minIncrease TimeIncrease Number of sessions to 4 days a week
Slide1965-year-old female, CKD 5BUN 200 mg/dlCreatinine 11 mg/dlRisk for dialysis disequilibrium syndrome Slow clearance of Urea(Kurea
) :Low BFRLow DFRShort sessionSmallest Dialyzer
Slide2055-year-old male, ESRD, three times a week HDPhosphorus =11 mg/dlTime =4 hoursKoA =1200 ml/minDFR=800 ml/minBFR=400 ml/min Increase Phosphorus Clearance:
Increase TimeShorter More Frequent DialysisIncrease DFR=1000 ml/minIncrease KoA =1400 ml/min
Slide2135-year-old male : Hydroxychloroquine overdose after hearing about it on the news. You are called to dialyzeMolecular weight =336 DaltonsProtein binding = 50%Vd= 200L/kgDialysis will be ineffective:
Large VdMolecular weightProtein Binding
Slide22ConvectionSoluteMolecular weight
Sieving Coefficient Ultrafiltration rateHigh flux membrane (larger pore size, thinner membrane)Kuf=Convective clearance of dialyzer=“leakiness”High flux dialyzer Kuf> 15-20 ml/hour/mm of hg
Slide23Sieving Coefficient
Solute (MW) Convective Coefficient Diffusion Coefficient Urea (60) 1.01 ± 0.05 1.01 ± 0.07Creatinine (113) 1.00 ± 0.09 1.01 ± 0.06Uric Acid (168) 1.01 ± 0.04 0.97 ± 0.04*Vancomycin (1448) 0.84 ± 0.10 0.74 ± 0.04**Cytokines (large) adsorbed minimal clearance *P<0.05 **P<0.01SC= D/P
Slide24Convective ClearanceDialyzer (KUF)
UF (Replacement Fluid)
Slide25Slide2660-year-old male with ESRD, three times a week HD. On Vancomycin 1 gram every other dialysis for MRSA bacteremia. Vancomycin MW 1485 Da .Time=4 hoursBFR=400 ml/minDFR=800 ml/minDialyzer =Optiflux F16 (1.5 m2, Kuf 10 ,K0A
977)Optiflux F160 (1.5 m2, Kuf 61,K0A1167)Vancomycin dosing :No change as surface area sameMore frequent dosing as K0A higherMore frequent dosing as Kuf increased
Slide27Modality
DiffusiveConvectiveHemodialysis (HD)MostSomeSLEDMostSomeNocturnal HDMostSomeHome HDMostSomeHemodiafiltration (HDF)YesYesCVVHDMostSome (depends on UF)CVVHNoneAllCVVHDFYesYesPIRRTDepends on Rx
Slide28Peritoneal DialysisDiffusion (Solute)Convective (Solute)Osmosis (Water)
Slide29Diffusive ClearanceSurface Area
Solute sizeConcentration gradientDwell Time(Modality & Membrane)Dwell volumeMembrane Permeability
Slide30Surface Area (pore numbers, type, vascularity)Hydrostatic pressure gradientOsmotic gradientPeritoneal PermeabilityHigh vs. Low transporterType of dianeal (Icodextrin ,dextrose)
Reflection coefficient UF & Convective Clearance
Slide3166-year-old female, APD at night, Slow Transporter, 10 hours5 exchanges90 minutes3000 ml Increase Urea Clearance :Add a daytime exchangeIncrease Number of exchanges but decrease dwell time
Increase Dwell time and decrease number of exchangesIncrease Dwell Volume