CRRT TERMINOLOGY Stefano Picca, MD 6th International Conference on Pediatric Continuous Renal Replacement Therapy Rome,Italy. 2010, April 8-10 CRRT TERMINOLOGY Stefano Picca, MD Dept. of Nephrology and Urology, Dialysis Unit “Bambino Gesù” Pediatric Research Hospital ROMA, Italy

CRRT modalities… …everchanging array of names and abbreviations… …lack of standardization… creates unnecessary confusion…prevents accurate comparisons and multicenter research, and is scientifically undesirable… Bellomo, Ronco, Mehta, AJKD,1996

Gibney N, Kimmel PL, Lazarus M, 2000

CRRT NOMENCLATURE P PHYSICAL PRINCIPLE TREATMENT DURATION CONVECTION (ultrafiltration) DIFFUSION (dialysis) CONVECTION + DIFFUSION from Ricci et al, 2009 P A B A B

DEFINITIONS (1) SCUF Slow Continuous UltraFiltration Venovenous Circuit Slow ultrafiltration No substitution fluid This method is used very rarely. The interest is only to remove an excess of fluid and salt in the extracellular sector like in chronic congestive hart failure patients (Dr Paganini, Cleveland Clinic, USA / Dr Canaud, Montpellier, France). Note that the TMP reached in this method does not exceed 30 mmHg (over 50 mmHg in CAVH and CVVH). Filtrate collecting device

DEFINITIONS (2) CVVH (postdilution) Continuous VenoVenous Hemofiltration Venovenous Circuit High ultrafiltration Substitution fluid Replace- ment fluid This method is used very rarely. The interest is only to remove an excess of fluid and salt in the extracellular sector like in chronic congestive hart failure patients (Dr Paganini, Cleveland Clinic, USA / Dr Canaud, Montpellier, France). Note that the TMP reached in this method does not exceed 30 mmHg (over 50 mmHg in CAVH and CVVH). Filtrate collecting device

DEFINITIONS (3) CVVH (predilution) Continuous VenoVenous Hemofiltration Venovenous Circuit High ultrafiltration Substitution fluid Replace- ment fluid This method is used very rarely. The interest is only to remove an excess of fluid and salt in the extracellular sector like in chronic congestive hart failure patients (Dr Paganini, Cleveland Clinic, USA / Dr Canaud, Montpellier, France). Note that the TMP reached in this method does not exceed 30 mmHg (over 50 mmHg in CAVH and CVVH). Filtrate Replace- ment fluid

DEFINITIONS (4) CVVHD Continuous VenoVenous HemoDialysis Venovenous Circuit Dialysate (diffusion) Low ultrafiltration (convection) , usually BW loss No substitution fluid This method is used very rarely. The interest is only to remove an excess of fluid and salt in the extracellular sector like in chronic congestive hart failure patients (Dr Paganini, Cleveland Clinic, USA / Dr Canaud, Montpellier, France). Note that the TMP reached in this method does not exceed 30 mmHg (over 50 mmHg in CAVH and CVVH). Filtrate- Diaysate Dialysate

DEFINITIONS (5) CVVHDF Continuous VenoVenous HemoDiaFiltration Venovenous Circuit Dialysate (diffusion) High ultrafiltration (convection) Substitution fluid Replace- ment fluid This method is used very rarely. The interest is only to remove an excess of fluid and salt in the extracellular sector like in chronic congestive hart failure patients (Dr Paganini, Cleveland Clinic, USA / Dr Canaud, Montpellier, France). Note that the TMP reached in this method does not exceed 30 mmHg (over 50 mmHg in CAVH and CVVH). Filtrate- Diaysate Dialysate

DEFINITIONS: flows in children (6) Qb: blood flow (from 10 ml/kg/min in infants to 150-200 ml/min in adolescents) Replace- ment fluid This method is used very rarely. The interest is only to remove an excess of fluid and salt in the extracellular sector like in chronic congestive hart failure patients (Dr Paganini, Cleveland Clinic, USA / Dr Canaud, Montpellier, France). Note that the TMP reached in this method does not exceed 30 mmHg (over 50 mmHg in CAVH and CVVH). Filtrate- Qd: dialysate flow (from 200 to 5000 ml/h) Diaysate Quf: ultrafiltration rate (2000 ml/1.73 m2/h or?) Dialysate

MISCELLANEOUS TECHNIQUES: HYBRID (1) Sustained Low Efficiency Dialysis (SLED) Sustained Low Efficiency Daily Dialysis (SLEDD) Prolonged Intermittent Daily RRT (PDIRRT) Extended Dialysis (ED) Extended Daily Dialysis (EDD) Extended Daily Dialysis with filtration (EDDf) In adults: Reduced blood flow (100-200 ml/min) Reduced dialysate flow (100-200 ml/min) 10-12 hours a day

MISCELLANEOUS TECHNIQUES: HYBRID (2) from Baldwin, 2009

MISCELLANEOUS TECHNIQUES (3) high-volume hemofiltration: In adults, claimed to be more efficient in: mediators removal hemodynamics improvement of immune dysfunction Adapted from Ronco, 2006

“MAXIMAL”(?) EFFICIENCY IN CVVH ADULT-CHILD-NEONATE BW (kg) TBW (l) Qb (ml/min) UF/h (=K urea) (l/h) K urea per liter of TBW NEONATE 3 2.4 30 0.25 0.10 CHILD 25 15 80 1.2 0.08 ADULT 70 42 150 2.5 0.05

PUBMED, March 2010: CVVHD-hemodiafiltration: 58 post-2000 papers 40/58 use the acronym CVVHD incorrectly 15/40 incorrect definition in nephrology journals 15/40 incorrect definition in IC journals

CRITICAL NEPHROLOGIST IN CRITICAL SITUATION Word: a speech sound or series of speech sounds that symbolizes and communicates a meaning usually without being divisible into smaller units capable of independent use. Merrian-Webster on line, 2010 (www.merriam-webster.com) CVVHD CHP CPFA CAVHDF HVHF CVVHDF CAVH CRRT PE SLEDD CVVH CAVHD SLED CRITICAL NEPHROLOGIST IN CRITICAL SITUATION …and dialysis??