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Evaluation of Continuous Renal Replacement Therapy Effluent to Assess Filtration Efficiency of Dialyzers in Renal Failure dogs.

Introduction

Acute Kidney Injury (AKI) and acute on chronic kidney diseases (AOCKD) occurs as a result of acute damage to hemodynamic filtration or excretory functions of kidney resulting in drastic reduction in GFR leads to accumulation of BUN and creatinine, dysregulation of fluid, acid-base and electrolyte balance (Lamiere et al., 2005; Bloom and Lobato, 2011). Despite advances in management of AKI, mortality rates among human and animal patients remains unacceptably high i.e. upto 50-70 percent (Waiker et al., 2008). Continuous Renal Replacement Therapy (CRRT) as a recently developed blood purification modality, therapy continues until return of renal functions or patient is transitioned to intermittent dialysis, functions similar to IHD where patient blood is divided into thousands of straw like semi permeable membranes in a dialyzer and uses principles of diffusion, convection and adhesion (Acierno, 2011). Indications for CRRT are refractory azotemia (BUN level [greater than or equal to]90mg/dl, creatinine level [greater than or equal to]5 mg/dl), interactable uremia, hyperkalemia, fluid overload, severe metabolic acidosis, pre-operative conditioning for renal transplantation, delayed graft function, graft rejection and acute on CRF (Elliott, 2000). The goal of CRRT is the removal of fluid and metabolic waste products and regulation of electrolytes and acid-base balance. Effluent is the filtered waste collected in a effluent bag during the CRRT procedure. Evaluation of effluent may aid in retrospective analysis of therapeutic adequacy of filter/hemodialyzer/artificial kidney. Present study was conducted at Nephrology Referral unit to assess the filtration efficiency of CRRT dialyzers by evaluating dialysis effluent.

Materials and Methods

Eighteen dogs presented with AKI or acute on Chronic kidney injury during the period of June' 2017 to May' 2018 were considered to study the filtration efficiency of hemodialyzers (AN 69 vs. PAES) by evaluating the hemodialysis effluent. All the dogs were subjected to complete clinical examination, hematobiochemical, imaging studies, coagulation parameters and blood gas analysis. Continuous renal replacement therapy (CVVHDF) was performed with Gambro Prismaflex (a) hemodialysis machine as per the standard protocols. Commercially available dialysis solution (Prismasol BO (b)) was used as a dialysate and replacement fluid to promote the process of diffusion and convection, effluent dose rate was set at 30-40ml/kg/hr. M-60 and M-100 filters contain AN 69 HF hollow fiber (Acrylonitrile and sodium methallyl sulfonate copolymer), with a surface area of 0.6[m.sub.2] (M-60) and 0.9[m.sub.2] (M-100) and HF-20 made up of PAES hollow fiber: Polyarylethersulfone membrane with a 0.2[m.sub.2] was used as a artificial kidney during the procedure in renal failure dogs (Kurtzaman, 1997). Effluent collected form a effluent bag attached to Gambro Prismaflex machine was used to assess the filtration efficiency of AN 69 vs. PAES filters by evaluating the chemical composition of filtrate (effluent urea nitrogen and creatinine).

Results and Discussion

AN 69 dialyzers (M-60 and M-100, AN-69 membrane) were used in 83.33 percent (15/18) and PAES dialyzer (HF-20, PAES membrane) was used in 16.66 percent (3/18) of dogs during Continuous renal replacement therapy (CVVHDF). Chemical composition of filtrate (effluent) and dialysate (Prismasol B0) used in CRRT is summarized in Table 1 and 2 respectively. Urea nitrogen (mg/dl) and creatinine (mg/dl) values observed in AN 69 vs. PAES filters were 125.7 and 8.65 vs. 61.71 and 4.02 respectively. Mineral (Ca and P) and electrolyte (Na, K and Cl) composition showed no significant changes in filtrates obtained from both types of dialyzers, as a dialysate and replacement fluid (Prismasol B0), contains buffers and electrolytes which mimics the normal physiological plasma and extracellular fluid (ECF). Electrolytes, acid-base components in dialysate and replacement solution gets exchanged with solutes in blood and maintains equilibrium, whereas accumulated nitrogenous waste substances in patient blood will be exchanged and filtered through dialyzer further collected in effluent waste. Present study shows filtration capacity (urea nitrogen and creatinine) of AN 69 dialyzers are double than the PAES filters, which could be due to larger surface area proportionate with filtration fraction (Prismaflex).

Conclusion

Effective removal of metabolic nitrogenous waste substances like blood urea nitrogen and creatinine were observed in M-60 and M-100 dialyzer than HF-20 dialyzer, which could be due to surface areas and filtration properties of dialyzers.

References

Acierno, M.J. (2011). Continuous renal replacement therapy in dogs and cats. Vet Clin Small Anim. 41: 135-46.

Bloom, C.A. and Labato, M.A. (2011). Intermittent Hemodialysis for small animals. Vet. Clin. Small. Anim. 41: 115-33.

Davenport, A. (2001). Dialysate and substitution fluids for patients treated by continuous forms of renal replacement therapy. Contrib Nephrol 132: 313-22.

Elliott, D.A. (2000). Hemodialysis. Clin.Tech. Small Anim. Pract. 15: 136-48.

Kurtzman Na. NKF-DOQI (1997). Clinical practice guidelines for vascular access and for the treatment of anemia of chronic renal failure. Am J Kidney Dis. 30: 3.

Lameire, N., Van Biesen, W. and Vanholder, R. (2005). Acute Renal Failure. Lancet 365: 417-30.

Prismaflex--Operator's Manual. Software version 4.00 Gambro Lundia Ab - Sweden.

Waikar, S.S., Liu, K.D. and Chertow, G.M. (2008). Diagnosis, epidemiology and outcomes of acute kidney injury. Clin. J. Amer. Soc. Nephrol. 3: 844-61.

P. Ramesh (1), D. Sumathi, M. Chandrasekar, K.G. Tirumurugaan and Ganne Venkata Sudhakar Rao

Department of Veterinary Clinical Medicine

Madras Veterinary College

Tamil Nadu Veterinary and Animal Science University (TANUVAS)

Chennai-600007 (Tamil Nadu)

(1.) Ph.D. Scholar and Corresponding author. E-mail: rameshvety777@gmail.com

a-Brand of Baxier India Pvt Ltd., Gurugram

b-Brand of Prismaflex International, France
Table.1: Chemical composition of hemodialysis filtrate (effluent)
obtained during CRRT.

Dialyzer  Capacity/  Urea       Creatinine   TP     Alb    Ca      P
used      Flow       Nitrogen   mg/dl        g/dl   g/dl   mg/dl   mg/dl
          rate       mg/dl

M-60 &    High flow  125.17     8.65         0.38   0.14   7.38    7.58
M-100     N=15
HF-20     Low flow    61.71     4.02         0.53   0.17   7.10    3.96
          N=03

Dialyzer   Glucose   Na mmol   K mmol   Cl mmol
used       mg/dl     /L        /L       /L

M-60 &     72.35     138.70    2.89     103.38
M-100
HF-20      65.00     138.70    2.43     105.63

Table 2: Chemical composition of body fluids and CRRT (Prismasol-B0)
solution (Davenport, 2001)

              Plasma     ECF   Prismasol B0

Sodium       136-145    145     137-144
Potassium      3.5-5.5    5.0         0
Calcium        1.1-1.3    2.0    1.25-2.0
Magnesium      0.8-1.2    2.0    0.25-1.0
Chloride      98-106    110.0    98-112
Bicarbonate    21-28     27.0     27-38
Lactate          < 0.1    1.5    2.5-10
Glucose        4.2-6.4    4.0      0-11
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Title Annotation:Clinical Article
Author:Ramesh, P.; Sumathi, D.; Chandrasekar, M.; Tirumurugaan, K.G.; Rao, Ganne Venkata Sudhakar
Publication:Intas Polivet
Date:Jul 1, 2018
Words:1084
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