DO WE NEED STILL DIALYSIS ON TOP OF CVVH REVIEW OF CURRENT POSITIVE & NEGATIVE St

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1 DO WE NEED STILL DIALYSIS ON TOP OF CVVH REVIEW OF CURRENT POSITIVE & NEGATIVE St 1.-Background of Convection-VS- Diffusion 2.- Convection Vs Diffusion:Simple Additional Effect? 3.- Positive Studies on the Effect of Dialysis on Top of CVVH.. 4.Negative 4.- Studies on the Effect of Dialysis on Top of CVVH What is the Situation in Case of Citrate 6.- Conclusions- Perspectives P.M. Honoré,Intensivist-Internist-Nephrologist Head of Clinics ICU,UZ-VUB University,Jette (Bxl,Bel) 8 th Annual Manchester Critical Care Meeting Ramada Picadilly Hotel-Manchester th April 2011

2 Solute Classes by Molecular Weight Daltons Inflammatory Mediators (1,200-50,000) large middle small

3 CVVH Continuous Veno-Venous Hemofiltration to waste Blood In (from patient) Repl. Solution Blood Out (to patient) LOW PRESS HIGH PRESS (Convection)

4 CVVHDF Continuous Veno-Venous Hemodiafiltration to waste Blood In (from patient) Dialysate Solution Repl. Solution Blood Out (to patient) LOW PRESS LOW CONC HIGH PRESS HIGH CONC (Convection) (Diffusion)

5 Anatomy of a Hemofilter blood in dialysate out Cross Section hollow fiber membrane dialysate in blood out Outside the Fiber (effluent) Inside the Fiber (blood) Journois D.Dialysis on top of CVVH?MAPAR 2008;

6 Positive Studies Regarding CVVDF The Geneva Study 206 patients Between 2000 et 2003 CVVH at 25 ml/kg/h CVVH at 25 ml/kg/h 102 CVVH 104 CVVHDF Survival at day % 59 % Excluding 26 moribound patients Survival at day % 64 % Sepsis 56 % 64 % Predilution 100 % 100 % + CVVD at 18 ml/kg/h In total = 42 ml/kg/h Saudan P et al. Kidney Int 2006;70:

7 Negative Studies Regarding CVVDF The Melbourne I Study 100 patients Between 2000 et 2002 CVVH at 25 ml/kg/h CVVHDF at 25 ml/kg/h 50 CVVH 50 CVVHDF Retrospective Controlled Diff in Ca++,Mg++,Po4-- + CVVD at 12.5 ml/kg/h In total = 25 ml/kg/h Morimatsu H, Uchino S, Bellomo R et al Int J artif Organs 2002 ;25 :

8 Negative Studies Regarding CVVHDF:Calcium Morimatsu H, Uchino S, Bellomo R et al Int J artif Organs 2002 ;25 :

9 Negative Studies Regarding CVVHDF:Phospore Morimatsu H, Uchino S, Bellomo R et al Int J artif Organs 2002 ;25 :

10 Negative Studies Regarding CVVHDF:Mg++ Morimatsu H, Uchino S, Bellomo R et al Int J artif Organs 2002 ;25 :

11 Negative Studies Regarding CVVDF The Melbourne II Study 100 patients Between 2000 et 2002 CVVH at 25 ml/kg/h CVVHDF at 25 ml/kg/h 50 CVVH 50 CVVHDF + CVVD at 12.5 ml/kg/h In total = 25 ml/kg/h Diff in Na+,K+,HCO3-- Morimatsu H, Uchino S, Bellomo R et al Int J artif Organs 2003 ;26:

12 Negative Studies Regarding CVVDHF:Potassium Morimatsu H, Uchino S, Bellomo R et al Int J artif Organs 2003 ;26:

13 Negative Studies Regarding CVVHDF:HCO3-- Morimatsu H, Uchino S, Bellomo R et al Int J artif Organs 2003 ;26:

14 Negative Studies Regarding CVVDF However, CVVH was associated with a lower incidence of metabolic acidosis (13.8% for CVVH vs. 34.5% for CVVHDF; p<0.0001) And so CVVH was a better Tool to correc Metabolic Acidosis Morimatsu H, Uchino S, Bellomo R et al Int J artif Organs 2003 ;26:

15 Negative Studies Regarding CVVDF The Melbourne III Study 100 patients Between 2000 et 2002 CVVH at 25 ml/kg/h CVVHDF at 25 ml/kg/h 50 CVVH 50 CVVHDF + CVVD at 12.5 ml/kg/h In total = 25 ml/kg/h Diff in Azotemic Control Morimatsu H, Uchino S, Bellomo R et al Renal Fail 2002;24:

16 Negative Studies Regarding CVVDF Morimatsu H, Uchino S, Bellomo R et al Renal Fail 2002 ;24:

17 Negative Studies Regarding CVVDF Morimatsu H, Uchino S, Bellomo R et al Renal Fail 2002 ;24:

18 Negative Studies Regarding CVVDF Throughout the duration of therapy, mean urea levels ( mmol/l for CVVHDF vs mmol/l for CVVH,p<0.0001) And mean creatinine levels ( vs mmol/l, p<0.0001) were better controlled in the CVVH group. Conclusions: Conclusions:CRRT strategies based on different techniques might have a significantly different impact on azotemic control. Morimatsu H, Uchino S, Bellomo R et al Renal Fail 2002 ;24:

19 CVVH or CVVHDF with CITRATE? Tolwani A.CJASN 2006;1:79-87

20 Conclusions & Perspectives CVVH is NOT Inferior to CVVHD in Controlling Ca++,Po4 and Mg++ CVVH is Better than CVVHDF in Correcting Acidosis.. CVVH is Superior to CVVHDF in Azotemic Control.. So Far, no study is supporting the use of Dialysis on Top of CVVH.. Regarding New concentrations of Citrate, CVVH is surely feasible but we are waiting studies..