Continuous Renal Replacement
Therapy (CRRT)
Prof. Dr. Abdul Muqueet
Prof. & Head of Nephrology Department
IBN SINA Medical College & Hospital
Background
• Various renal replacement therapies (RRTs) are available for managing
severe acute kidney injury (AKI), including intermittent haemodialysis
(IHD), continuous renal replacement therapy (CRRT), and prolonged
intermittent RRT.
• Decisions about technique are dictated by the dialysis
indication, clinician preference, outcome data, and, most importantly,
hemodynamic status.
• A 2015 multinational cross-sectional epidemiological study of patients
with AKI in intensive care units (ICUs) revealed that CRRT was the
preferred treatment modality in 75.2% of sessions, compared to
intermittent dialysis in 24.1% of sessions and peritoneal dialysis in 0.7%
of sessions.
Ref: Saunders, Hollie, et al. "Continuous Renal Replacement Therapy." StatPearls [Internet]. StatPearls Publishing, 2024.
Introduction
• CRRT comprises techniques that manage solute removal and fluid balance over 24
hours. CRRT filters blood through a semipermeable membrane using various solute
transport mechanisms.
• The specific mechanism defines each CRRT type.
• The 3 CRRT techniques are continuous Veno venous hemofiltration (CVVH), continuous
Veno venous hemodialysis (CVVHD), and continuous Veno venous hemodiafiltration
(CVVHDF).
• CRRT is a form of dialysis used in critically ill patients with acute kidney injury (AKI).
• It provides continuous 24-hour support, mimicking natural kidney function.
• Preferred in hemodynamically unstable patients.
Ref: Saunders, Hollie, et al. "Continuous Renal Replacement Therapy." StatPearls [Internet]. StatPearls Publishing, 2024.
Indications for CRRT
Acute Kidney Injury (AKI)
Fluid overload unresponsive to diuretics
Electrolyte imbalances (e.g., hyperkalemia)
Severe acidosis
Uremic complications
Ref: Saunders, Hollie, et al. "Continuous Renal Replacement Therapy." StatPearls [Internet]. StatPearls Publishing, 2024.
Types of CRRT Modalities
CVVH – Continuous Venovenous Hemofiltration: In this
technique, a large ultrafiltrate volume is passed across a
convention or high-permeability membrane.
CVVHD – Continuous Venovenous Hemodialysis: In this
technique, blood is passed through a filter, and waste
products are removed through diffusion. Replacement fluid is
then infused to replace the removed fluid.
Ref: Saunders, Hollie, et al. "Continuous Renal Replacement Therapy." StatPearls [Internet]. StatPearls Publishing, 2024.
Types of CRRT Modalities
CVVHDF – Continuous Venovenous Hemodiafiltration: In
this technique, diffusive clearance removes solutes and
toxins from the patient’s circulation. It combines
convection and diffusion to remove fluid and solids
through an efficient hemodiafilter.
• SCUF – Slow Continuous Ultrafiltration: This technique
involves the removal of excess fluid from the body
through ultrafiltration without the addition of
replacement fluid
Access: Large-bore central venous
catheter
Blood Flow Rate: 100–200 mL/min
How CRRT Fluid Removal: Ultrafiltration
Works
Solute Clearance: Diffusion and/or
convection
Replacement/Dialysate Fluid: Used
to maintain fluid/electrolyte balance
Ref: Saunders, Hollie, et al. "Continuous Renal Replacement Therapy." StatPearls [Internet]. StatPearls Publishing, 2024.
Ref: Saunders, Hollie, et al. "Continuous Renal Replacement Therapy." StatPearls [Internet]. StatPearls Publishing, 2024.
Components:
CRRT • Blood pump
Machine •
•
Ultrafiltration pump
Replacement/dialysate fluid bags
Overview • Filters (hemofilter)
Monitored by ICU or nephrology
staff
Ref: Saunders, Hollie, et al. "Continuous Renal Replacement Therapy." StatPearls [Internet]. StatPearls Publishing, 2024.
Preparation
Effluent Dose
The recommended average delivered effluent dose is 20 to 25 mL/kg/hr for patients
with AKI needing CRRT based on the Veterans Affairs/National Institutes of Health
Acute Renal Failure Trial Network Study and Randomized Evaluation of Normal versus
Augmented Level Replacement Therapy Study.
No benefit is seen above 25 mL/kg/hr. However, the prescribed dose does not equal
the delivered dose due to various factors, such as circuit downtime during
procedures, imaging tests, filter clotting, or fluid bag replacement.
Ref: Saunders, Hollie, et al. "Continuous Renal Replacement Therapy." StatPearls [Internet]. StatPearls Publishing, 2024.
Net Ultrafiltrate
• Significant heterogeneity exists in practice regarding the net
fluid removal goal and rate.
• Fluid removal must be individualized and is subject to
change. The general recommendation is to stay below 1.5 to
2.0ml/kg/hr.
Ref: Saunders, Hollie, et al. "Continuous Renal Replacement Therapy." StatPearls [Internet]. StatPearls Publishing, 2024.
Blood Flow Rate
• A minimum blood flow of 150 mL/min can be used to maximize clearance.
• This value maximizes clearance efficiency while maintaining hemodynamic
stability during CRRT.
Ref: Saunders, Hollie, et al. "Continuous Renal Replacement Therapy." StatPearls [Internet]. StatPearls Publishing, 2024.
Clinical Significance: When to Initiate CRRT
• Many factors should be considered when deciding to initiate
CRRT. The most important are the illness's severity and the
procedure's necessity.
• AKI's gravity and its trajectory may be used to assess disease
severity. Other factors include the presence of electrolyte and
acid-base disorders, evidence of fluid overload, and other
significant organ dysfunction requiring renal support for
recovery.
Ref: Saunders, Hollie, et al. "Continuous Renal Replacement Therapy." StatPearls [Internet]. StatPearls Publishing, 2024.
Advantages of CRRT
Better tolerated in unstable patients
Precise fluid management
Continuous acid-base and electrolyte
correction
Less hemodynamic fluctuation
Disadvantages of CRRT
REQUIRES ICU- RISK OF HIGH COST ANTICOAGULATION
LEVEL CARE BLEEDING/INFECTI OFTEN NEEDED
ON
Ref: Saunders, Hollie, et al. "Continuous Renal Replacement Therapy." StatPearls [Internet]. StatPearls Publishing, 2024.
Heparin – systemic or regional
Citrate anticoagulation –
Anticoagulati regional, preferred due to
on in CRRT lower bleeding risk
Monitoring calcium and acid-
base balance is essential
Ref: Saunders, Hollie, et al. "Continuous Renal Replacement Therapy." StatPearls [Internet]. StatPearls Publishing, 2024.
Ref: Saunders, Hollie, et al. "Continuous Renal Replacement Therapy." StatPearls [Internet]. StatPearls Publishing, 2024.
Nursing Considerations
Regular monitoring of:
Filter pressures
Electrolytes
Fluid balance
Anticoagulation status
Preventing clotting and infections
Complications
Hypotension
Electrolyte imbalances (hypokalaemia, hypophosphatemia)
Filter clotting
Infection
Bleeding due to anticoagulation
Ref: Saunders, Hollie, et al. "Continuous Renal Replacement Therapy." StatPearls [Internet]. StatPearls Publishing, 2024.
Summary
CRRT is vital in managing critically ill
patients with AKI.
Multiple modalities tailored to patient
needs.
Requires close monitoring by trained staff.
Improves patient outcomes when used
appropriately.
