Renal Replacement Therapy (RRT)
Core Principles of RRT
RRT works using three main physical principles to clean the blood:
• Diffusion (Hemodialysis): Solutes (like urea and potassium) move from an area of high
concentration (blood) to an area of low concentration (dialysate fluid) across a semi-
permeable membrane. This is most effective for removing
small and middle-sized molecules.
• Convection (Hemofiltration): A pressure gradient is applied across the membrane,
forcing water and solutes out of the blood (this fluid is called ultrafiltrate). This process,
also known as "solvent drag," is effective at removing
small, middle, and large molecules, including inflammatory cytokines. Because
significant fluid is removed, a replacement solution is often required.
• Adsorption: The surface of the filter membrane physically binds and removes certain
molecules, such as endotoxins or cytokines. This requires specialized filters (e.g.,
Cytosorb), and clinical evidence for a survival benefit is limited.
Types of RRT Modalities
There are three main categories of RRT based on duration and flow rates:
Intermittent Hybrid Continuous
Feature
(IRRT/IHD) (PIRRT/SLED) (CRRT)
Duration 4-6 hours 6-16 hours 24 hours
High (200-400 Moderate (100- Low (100-200
Blood Flow
mL/min) 300 mL/min) mL/min)
Excellent
Hemodynamic Poor - high risk
Moderate - very
Stability of hypotension
gentle
Solute/Fluid Slow &
Rapid & Large Moderate
Shifts Gradual
Required
Often not
Anticoagulation Required (Heparin
required
or Citrate)
Intermittent Hybrid Continuous
Feature
(IRRT/IHD) (PIRRT/SLED) (CRRT)
Rapid A cost-effective Hemodynamically
Best For... toxin/potassium alternative to unstable patients,
removal CRRT cerebral edema
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Specific CRRT Modalities
Within CRRT, the choice of modality depends on the primary goal:
• SCUF (Slow Continuous Ultrafiltration): Uses convection only to gently remove fluid.
It's used for pure fluid overload without significant electrolyte or waste product issues.
• CVVHD (Continuous Veno-Venous Hemodialysis): Uses diffusion only. It requires
dialysate fluid and is best for removing small-to-medium-sized molecules (urea,
electrolytes).
• CVVH (Continuous Veno-Venous Hemofiltration): Uses convection only. It requires
a replacement solution and is better for clearing larger molecules like cytokines.
• CVVHDF (Continuous Veno-Venous Hemodiafiltration): Uses both diffusion and
convection. This is a "best of both worlds" approach, clearing solutes of all sizes. It
requires both dialysate and replacement fluids.
Which Modality is Best?
• For Hemodynamic Instability: CRRT is the preferred choice due to its gentle nature
and minimal impact on blood pressure. SLED/PIRRT is a reasonable second option,
while IRRT is generally avoided.
• For Sepsis: While convection (CVVH) can theoretically remove inflammatory cytokines,
multiple studies have shown no clear difference in patient survival or renal recovery
between the different CRRT modalities (CVVH vs. CVVHD) or even between CRRT
and SLED.
• The Bottom Line: The choice often comes down to patient stability and available
resources (cost, staffing). In a hemodynamically unstable patient, CRRT is ideal. If cost
is a major factor, SLED is a widely used and effective alternative. The
dose of therapy (targeting ~25 mL/kg/hr of effluent) is more important than the specific
modality chosen.