Continuous venovenous hemodialysis: Technical considerations
- Paul M Palevsky, MD
Paul M Palevsky, MD
- Section Editor — Renal Failure
- Professor of Medicine
- University of Pittsburgh
- VA Pittsburgh Healthcare System
The continuous renal replacement therapies (CRRTs) comprise a spectrum of treatments that include both hemofiltration (convection-based solute and water removal) and hemodialysis (diffusion-based solute removal) techniques [1,2]. (See "Continuous renal replacement therapies: Overview".)
These techniques have gained favor in the treatment of critically ill patients with renal failure primarily because of improved hemodynamic stability compared with intermittent hemodialysis. Although some investigators have suggested that the use of CRRT is associated with improved outcomes in acute renal failure (ARF), this has not yet been demonstrated by prospective, randomized trials.
CRRT techniques initially utilized arteriovenous extracorporeal circuits, in which blood flow was driven by the gradient between the mean arterial pressure (MAP) and venous pressure. Continuous venovenous hemodialysis (CVVHD) was developed in the mid-1980s as an alternative to continuous arteriovenous hemofiltration (CAVH) and continuous arteriovenous hemodialysis (CAVHD) . The use of a pump-driven venovenous circuit in CVVHD permits blood flows that are both higher and more constant than provided by an arteriovenous circuit. In addition, the elimination of the need for a large-bore arterial catheter eliminates the associated risks of arterial thrombosis and arterial bleeding [4,5].
The technical aspects of performing CVVHD are reviewed here. General discussions of CRRT and the technical aspects of other modalities are presented separately. (See "Continuous arteriovenous hemodialysis: Technical considerations" and "Continuous renal replacement therapy in acute kidney injury (acute renal failure)".)
Angioaccess in continuous venovenous hemodialysis (CVVHD) is generally achieved using a standard double-lumen hemodialysis catheter (figure 1). Blood flow through the extracorporeal circuit is driven by a blood pump, with rates usually maintained between 100 and 300 mL/min. Lower blood flow rates are used in children. Dialysate is perfused through the hemofilter/hemodialyzer, countercurrent to the direction of blood flow.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Manns M, Sigler MH, Teehan BP. Continuous renal replacement therapies: an update. Am J Kidney Dis 1998; 32:185.
- Mehta RL. Continuous renal replacement therapy in the critically ill patient. Kidney Int 2005; 67:781.
- Tam PY, Huraib S, Mahan B, et al. Slow continuous hemodialysis for the management of complicated acute renal failure in an intensive care unit. Clin Nephrol 1988; 30:79.
- Tominaga GT, Ingegno M, Ceraldi C, Waxman K. Vascular complications of continuous arteriovenous hemofiltration in trauma patients. J Trauma 1993; 35:285.
- Bellomo R, Parkin G, Love J, Boyce N. A prospective comparative study of continuous arteriovenous hemodiafiltration and continuous venovenous hemodiafiltration in critically ill patients. Am J Kidney Dis 1993; 21:400.
- Parienti JJ, Thirion M, Mégarbane B, et al. Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial. JAMA 2008; 299:2413.
- Ifediora OC, Teehan BP, Sigler MH. Solute clearance in continuous venovenous hemodialysis. A comparison of cuprophane, polyacrylonitrile, and polysulfone membranes. ASAIO J 1992; 38:M697.
- Relton S, Greenberg A, Palevsky PM. Dialysate and blood flow dependence of diffusive solute clearance during CVVHD. ASAIO J 1992; 38:M691.
- Himmelfarb J, Tolkoff Rubin N, Chandran P, et al. A multicenter comparison of dialysis membranes in the treatment of acute renal failure requiring dialysis. J Am Soc Nephrol 1998; 9:257.
- Palevsky P, Piraino B, Perlmutter J, Greenberg A. Slow continuous ultrafiltration and dialysis for the treatment of acute renal failure (Abstract). J Am Soc Nephrol 1991; 2:343.
- Thomas AN, Guy JM, Kishen R, et al. Comparison of lactate and bicarbonate buffered haemofiltration fluids: use in critically ill patients. Nephrol Dial Transplant 1997; 12:1212.
- McLean AG, Davenport A, Cox D, Sweny P. Effects of lactate-buffered and lactate-free dialysate in CAVHD patients with and without liver dysfunction. Kidney Int 2000; 58:1765.
- Barenbrock M, Hausberg M, Matzkies F, et al. Effects of bicarbonate- and lactate-buffered replacement fluids on cardiovascular outcome in CVVH patients. Kidney Int 2000; 58:1751.
- Hilton PJ, Taylor J, Forni LG, Treacher DF. Bicarbonate-based haemofiltration in the management of acute renal failure with lactic acidosis. QJM 1998; 91:279.
- Johnston RV, Boiteau P, Charlebois K, et al. Responding to tragic error: lessons from Foothills Medical Centre. CMAJ 2004; 170:1659.
- Culley CM, Bernardo JF, Gross PR, et al. Implementing a standardized safety procedure for continuous renal replacement therapy solutions. Am J Health Syst Pharm 2006; 63:756.
- Leblanc M, Moreno L, Robinson OP, et al. Bicarbonate dialysate for continuous renal replacement therapy in intensive care unit patients with acute renal failure. Am J Kidney Dis 1995; 26:910.
- Mehta RL, McDonald BR, Aguilar MM, Ward DM. Regional citrate anticoagulation for continuous arteriovenous hemodialysis in critically ill patients. Kidney Int 1990; 38:976.
- Kutsogiannis DJ, Mayers I, Chin WD, Gibney RT. Regional citrate anticoagulation in continuous venovenous hemodiafiltration. Am J Kidney Dis 2000; 35:802.
- Cointault O, Kamar N, Bories P, et al. Regional citrate anticoagulation in continuous venovenous haemodiafiltration using commercial solutions. Nephrol Dial Transplant 2004; 19:171.
- Tolwani AJ, Campbell RC, Schenk MB, et al. Simplified citrate anticoagulation for continuous renal replacement therapy. Kidney Int 2001; 60:370.
- Tobe SW, Aujla P, Walele AA, et al. A novel regional citrate anticoagulation protocol for CRRT using only commercially available solutions. J Crit Care 2003; 18:121.
- Swartz R, Pasko D, O'Toole J, Starmann B. Improving the delivery of continuous renal replacement therapy using regional citrate anticoagulation. Clin Nephrol 2004; 61:134.
- Roberts M, Winney RJ. Errors in fluid balance with pump control of continuous hemodialysis. Int J Artif Organs 1992; 15:99.
- Pichette V, Leblanc M, Bonnardeaux A, et al. High dialysate flow rate continuous arteriovenous hemodialysis: a new approach for the treatment of acute renal failure and tumor lysis syndrome. Am J Kidney Dis 1994; 23:591.
- Brunet S, Leblanc M, Geadah D, et al. Diffusive and convective solute clearances during continuous renal replacement therapy at various dialysate and ultrafiltration flow rates. Am J Kidney Dis 1999; 34:486.
- Ronco C, Bellomo R, Homel P, et al. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet 2000; 356:26.
- Saudan P, Niederberger M, De Seigneux S, et al. Adding a dialysis dose to continuous hemofiltration increases survival in patients with acute renal failure. Kidney Int 2006; 70:1312.
- Tolwani AJ, Campbell RC, Stofan BS, et al. Standard versus high-dose CVVHDF for ICU-related acute renal failure. J Am Soc Nephrol 2008; 19:1233.
- VA/NIH Acute Renal Failure Trial Network, Palevsky PM, Zhang JH, et al. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med 2008; 359:7.
- RENAL Replacement Therapy Study Investigators, Bellomo R, Cass A, et al. Intensity of continuous renal-replacement therapy in critically ill patients. N Engl J Med 2009; 361:1627.