SICU Combine meeting
2012-4-26
蔡壁如
Case Presentation
• 56yr, Male: CAD s/p POBAS with ICMP s/p heterotopic
heart transplantation in 2004
• Hypertension
• Gout
• CRI
• Current Medication:
Burinex 1 mg/tab 1 tab BID
SR Diltelan SR 120 mg/cap 1 cap
Folic Acid 5 mg/tab 1 tab QD PO
Allopurinol 100 mg/tab 1 tab BID PO
Colchicine 0.5 mg/tab 1 tab BID PO
Sandimmun Neoral 25 mg/cap 2 cap BID PO
CellCept 250 mg/cap 2 cap BID PO
ER 2012-1-25
• At ER, afebrile but SpO2 93% with short of breath.
• EKG monitor showed intermittent VT.
• Cardiac echo showed poor recipient heart with
LVEF:23%
• LV systolic function is normal with LVEF:61.6%.
• BUN, Cre and potassium was 118, 6.06 and 7.9(H9).
•  Under the impression of acute kidney injury,
suspected rejection or infection-related
2012-1-26 start RRT
• AKI Cause
– Sepsis ?
– Rejection ?
– Both?  Acute on chronic ?
問題一：重症透析的人工膜選擇
5008HF
Stenotrophomonas maltophilia
1/30, 2/8, 2/10, 2/15
問題二：急性腎損傷透析液的選擇
Unveiling Current Controversies in
Acute Kidney Injury
Kellum JA, Ronco C, Vincent J- L (eds): Controversies in Acute Kidney Injury.
Contrib Nephrol. Basel, Karger, 2011, vol 174, pp 1–3
Dialyzer membranes for RRT in AKI
2012 KDIGO guideline for AKI
Dialyzer membranes for RRT in AKI
Hemodialysis-membrane biocompatibility and mortality of
patients with dialysis-dependent acute renal failure: a
Prospective randomized multicenter trial
人工膜:1.2m2
Low-Flux vs High Flux Synthetic Dialysis Membrane in
Acute Renal Failure : Prospective Randomized Study
• In conclusion,
no significant differences were found in the results of low-flux
versus high-flux synthetic membrane dialyzer treatment in
patient in terms of survival rate, recovery of renal
function, …….
• Low-flux synthetic polysulphone dialyzer (1.3 m2) vs High-flux
synthetic AN-69(1.3m2)
Artif Organs, Vol 25, No. 12, 2001
Membranes for Dialysis and
Hemofiltration --- 7.3
• Management of Acute Kidney Problems
– D. H. Krieter and C. Wanner. 2010
•  Materials : Synthetic membrane √
•  Low-flux vs High-flux
•  Size
High-flux vs Low-flux
• The Hemodialysis (HEMO) study
– not find a difference between low- and high-flux
membranes
Effects of high-flux hemodialysis on clinical outcomes: Results of the HEMO Study. J Am Soc Nephrol
2003 14:3251-3263.
• MPO study ( Membrane Permeability Outcome)
– High-flux benefits in DM and low serum albumin levels
( < 4 g/dl)
– No significant survival benefit
Membrane Permeability Outcome (MPO) Study Group Effect of membrane permeability
on survival of hemodialysis patients. J Am Soc Nephrol 2009 20:645-654
• No study was able to demonstrate differences
in survival between low- and high-flux
membranes.
•
•
•
•
Is the choice of membrane important for patients with acute renal failure requiring hemodialysis?
1995 Artif Organs 19:391-394.
Patient survival and renal recovery in acute renal failure: randomized comparison of cellulose acetate
and polysulfone membrane dialyzers. 2000 Mayo Clin Proc 75: 1141- 1147.
Comparison of cellulose diacetate and polysulfone membranes in the outcome of acute renal failure. A
prospective randomized study. 2000 Nephrol Dial Transplant 15:224- 230
Low-flux versus high-flux synthetic dialys is membrane in acute renal failure: prospective randomized
study. 2001 Artif Organs 25:946-950.
• Only with respect to the recovery of renal
function that a possible advantage of highover low-flux membranes.
•
(2000) Patient survival and renal recovery in acute renal failure: randomized comparison of cellulose acetate and
polysulfone membrane dialyzers. Mayo Clin Proc 75: 1141- 1147.
•
Biocompatible hemodialysis membranes for acute renal failure. 2008 Cochrane Database Syst Rev
23:CD005283
Modality of ARRT with Efficiency Defined
Marshall MR, Golper TA:Semin Dial 24:142-148,2011
Low-Efficiency Acute Renal Replacement Therapy :
Role in Acute Kidney Injury
• PIRRT effect of urea disequilibrium on time
concentration profiles  inbound and rebound
• 1.8 m2 low-flux(QB200, QD100, 12HR)  4% rebound
• 1.8 m2 low-flux (QB200, QD500, 8hr) 17% rebound
– High-efficiency PIRRT
– Unacceptable Disequilibrium
Mark R. Marshall*† and Thomas A. Golper
•
Seminars in Dialysis—Vol 24, No 2 (March–April) 2011 pp. 142–148
Low-Efficiency Acute Renal Replacement Therapy :
Role in Acute Kidney Injury
Low-Efficiency Acute Renal Replacement Therapy :
Role in Acute Kidney Injury
three major ways in which solute disequilibrium
affects the clinical care of patients:
ARRT dose
dialysis disequilibrium syndrome
hemodynamic instability
solute disequilibrium
• Symptoms of headache, disorientation and nausea at
its mildest, delirium, myoclonus ⁄ seizures and coma
at its most severe.
• The pathogenesis is incompletely understood
although it is clearly attributable to cerebral edema
from water influx as the final common pathway
Ronco C, Bellomo R, Kellum J. Critical Care Nephrology. 2009:1079–1083
Low-Efficiency Acute Renal Replacement Therapy :
Role in Acute Kidney Injury
• Prosaic Use of Lower-Efficiency ARRT
– Low-flux membrane
– Lower-efficiency
Case Presentation
• 52yrs, AMI with ventricular septal rupture status post
repairmen of ventricular septum on 2012/01/07,
• Tachypnea and agitation were noted around 8PM on
2/19, and desaturation to 90% was found. CXR showed
pulmonary edema, r/o pneumonia, and BW gain>7Kg ,
metabolic acidosis with dopamine infusion, he was
transferred to ICU. And start CRRT.
• 2/20 5008HF(standard setting), BUN/Cre:283/5.79 
2/23 BUN/Cre :33/1.83
• solute disequilibrium ???
• 停止透析:2012/3/4
Case Presentation
• 35yrs, DCMP with congestive heart failure and lung
edema s/p ECMO support(2012/3/22), s/p LVAD
support (2012/03/26)
• 3/28 septic shock  start RRT (SLED 2hr due to
BUN/Cre:174/4.91, prevent disequilibrium?)
• 3/28 night profound acidosis  5008HF
• 3/29 Expired
超過濾係數 Ultrafiltration Coefficient
 水份的移除
(Hydraulic Permeability)
 超過濾係數 Kuf
(ml/mmHg/hour)
• Low (Standard) Flux
UFcoefficient 2-9 ml/mmHg/hour
• Intermediate Flux
UFcoefficient 10-19 ml/mmHg/hour
• High Flux
UFcoefficient 20-80 ml/mmHg/hour
Categories for HD membranes
Vicken J. Membranes in Haemodialysis in；Peinemann KV, Pereira Nunes SP, (eds)
Membranes for Life Sciences. Wiley Co, 2007；1-48.
血液透析器設計理念
血液過濾器設計理念
血液透析過濾器 for SLEDD-f
血液透析器 for IHD
Wall thickness (µm)
Inner lumen (µm)
High-flux Dialyzer
40
200
Chronic Filter
200 µm
40 µm
血液透析器設計理念
血液過濾器設計理念
血液透析過濾器 for SLEDD-f
“理想的" 血液過濾（Hemofilter）
具高生物相容性
具良好的中大分子篩濾與清除效果
抗凝劑需要量越低越好
最少可連續使用24小時
“理想的" 血液過濾器
 Function
 Membrane permeability
– Diffusion
Low flux and High flux
– Convention High flux
 Filter and Fiber Geometry
 Adapted for low blood flow
– Large ID：short
 Biocompatibility
血液過濾器 – 中空纖維特性
Membrane geometry adapted to special needs in CRRT
• Decreased wall thickness
– increased diffusive clearance
Acute Filter
35 µm
• Increased inner lumen
– less shear-stress
– lower thrombogenicity
– lower heparin need
Wall thickness (µm)
Inner lumen (µm)
Hemofilter
35
220
220 µm
血液透析器設計理念
血液過濾器設計理念
血液透析過濾器 for SLEDD-f
high-flux dialyzer is required to SLEDD-f
• A high-flux dialyser is required to perform
SLEDD-f
– A dialysis membrane with high hydraulic
permeability, high solute permeability and large
The cut off of the membrane is ~ 30.000 Dalton.
surface exchange
1, 0
0 ,8
Siev ing C oef f icie n t
• Moderate transmembrane pressures (< 300mmHg)
• Simultaneously avoid or minimal albumin loss
• Highly biocompatible membrane is particular
importance
Sta n da rd m em bra ne
0 ,6
0 ,4
0,2
0
100
10
Urea
Creatinine
P o l y su lf o n e Ultra- F lu x
1000
10000
Inulin
Vit.B 12
M o le cu lar W e ig ht [ D alto n ]
ß2-M
K id n e y
100000
Albumin
Membranes for Dialysis and
Hemofiltration --- 7.3
Dialysis membranes should have：
• high diffusive and convective clearances for the
removal of a wide range of toxins.
• the best possible biocompatibility to avoid
undesirable interactions with blood components
• adequate hydraulic permeability for use in
intermittent or continuous renal replacement
therapy modes
• the highest pyrogen retention capability for the
use with non-ultrapure dialysate.
Membrane Size
• 早期: 1.2 m2
• 近期: 1.4 ~ 1.8 m2
SICU Dialysis indication
2009
(209)
2010
(242)
2011
(260)
Shock
63 (30.1%)
85 (35.1%)
108 (41.5%)
Sepsis
109 (52.1%)
101 (41.7%)
138 (53.0%)
ESRD
67
85
68
Others
2
2
3
SICU Dialysis method
2009
2010
2011
CAVH
CVVH
365
450
340
IHD
925
988
931
SLED
304
428
335
SLED-f
371
304
322
選一種人工腎臟：兼顧PIRRT and IHD ？
CRRT:1.4 m2 AV-600
台大AK
AN-69 :
Bradykinin release syndrome
J Am Soc Nephrol 20: 645–654, 2009
J Am Soc Nephrol 20: 645–654, 2009