NO WATER, NO PROBLEM: USING CRRT FOR HEMODIALYSIS PATIENTS

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Each dialysis session uses approximately 150 to 200 L of water [1]. While this was an issue discussed by policymakers and environmentalists, the winter storm that swept across the southwest United States in February 2021 made the bedside physician keenly aware of the problem. The region saw an unprecedented disruption of water and power supplies which put end-stage renal disease (ESRD) patients in jeopardy. Intermittent hemodialysis (IHD) could not be performed due to lack of running water, low water pressures, and unsanitary water conditions. We present 4 cases when continuous renal replacement therapy (CRRT) was utilized to provide urgent hemodialysis in hemodynamically stable, non-critically ill ESRD patients during this time of water supply crisis. CASE PRESENTATION: Our patients were between the ages 47-62 years old, mostly male. All patients were ESRD patients on IHD three days per week. Shortness of breath was the presenting complaint in 3 of 4 patients, each of whom had missed their last scheduled HD session due to inclement weather. 1 of 4 patients presented with altered mental status. Indications for hemodialysis included volume overload with pulmonary edema and respiratory distress, hypertensive crisis, refractory hyperkalemia, and uremic encephalopathy. The CRRT equipment used included the PRISMAX system for CRRT with M150 filters. Renal replacement solution containing 32 mEq/L bicarbonate, 4 mEq/L potassium, and 2.5 mEq/L calcium was used as dialysate fluid. Continuous veno-venous hemodialysis (CVVHD) more was used with a dialysate flow rate of 6L /hour and a blood flow rate of 200/per hour with calculated urea clearance of 100 ml/min. The duration of treatment was 8 hours to achieve the target Kt/V of 1.15, comparable to the recommended 1.2 provided by IHD. 9-10 bags of dialysate were used per each session. Fluid removal ranged from 150-500 ml/hr. 1 patient required a repeat session on a subsequent day due to incomplete treatment due to filter clotting. All patients tolerated the procedure well with the resolution of their acute conditions and normalization of blood pressure and electrolytes. 1 patient developed brief hypotension which resolved with fluid administration. No other adverse events were seen. DISCUSSION: CRRT has typically been used for renal replacement therapy in critically ill patients. It requires specialized equipment and a higher nurse: patient ratio as compared to IHD but can be used to manage volume overload and electrolyte derangements in ESRD patients without the substantial water requirements of IHD. CONCLUSIONS: We demonstrate limited CRRT as an alternative to safely manage ESRD patients needing urgent hemodialysis in the scenario of a natural disaster resulting in a water outage. REFERENCE #1: Hoenich NA, Levin R, Ronco C: Water for haemodialysis and related therapies: recent standards and emerging issues. Blood Purif 2010;29:81–8 DISCLOSURES: No relevant relationships by Sukhmani Boparai, source=Web Response Scientific Medical Advisor relationship with ALung Technologies, Inc. Please note: $5001 - $20000 by Steven Conrad, source=Web Response, value=Consulting fee No relevant relationships by Rajkamal Hansra, source=Web Response No relevant relationships by Prathik Krishnan, source=Web Response No relevant relationships by Audrey Netzel, source=Web Response