1. No category

Munuaiskorvaushoito
lapsilla
Heikki Valkonen
SULAT 2015
Helsinki
Sisältö
•
•
Sisältö
•
Lasten akuutti munuaisvaurio
•
Eri munuaiskorvaus modaliteetit
Ei sisälly
•
Biomarkkerit
•
Krooninen munuaisten vajaatoiminta
•
Antikoagulaatio
Yleistä
•
Tutkittua tietoa vähän, lähinnä retrospektiivisiä tai
rekisteritutkumksia
•
Hemodialyysi käytännöt ekstrapoloitu aikuispuolelta
•
Lapsilla käytetyt dialyysimuodot
•
Peritoneaalidialyysi
•
Intermittoiva hemodialyysi
•
Jatkuva hemodialyysi
Akuutti munuaisvaurio (AKI)
•
Merkittävä vaikutus
•
Kuolleisuuteen
•
Tehojakson pituuteen
•
Ventilaattori hoidon pituuteen
AKI - luokittelu
•
RIFLE
•
pRIFLE
•
AKIN
•
KDIGO
pRIFLE
Estimated CCL
Risk
eCCL decrease by 25%
Injury
eCCL decrease by 50%
Failure
eCCL decrease by 75% or
eCCL < 35 ml/min/1.73m2
Loss
Persistent failure >4 weeks
End stage
End-stage renal disease
(persistent failure >3 months)
eCCL = (k * height (cm)) /
Crserum (mg/dl)
Urine output
<0.5 ml/kg/h for 8 h
<0.5 ml/kg/h for 16 h
<0.3 ml/kg/h for 24 h or
anuric for 12 h
infant (LBW < 1y) 0.33; Infant (term < 1y) 0,45
Child or Adolescent Girl 0.55
Adolescent Boy 0.7
tors unique to neonatal renal physiology, as described earlier. At this time, there is
general acceptance that an SCr increase of 0.3 mg/dL or more (KDIGO AKI stage 1)
is sufficient to trigger concern for AKI in neonatal patients in the appropriate clinical
context.42 Thus, modifications to the KDIGO definition have been made in a proposed
neonatal AKI definition as follows.8 Because SCr normally declines over the first week
of life,43 each SCr is compared with the lowest previous value. In addition, because
Vastasyntyneiden AKI:n
luokittelu
Box 1
Proposed neonatal AKI classification
Stage
SCr
Urine Output
0
1
No change in SCr or increase <0.3 mg/dL
SCr increase !0.3 mg/dL within 48 h or
SCr increase !1.5–1.9 " reference SCra within 7 d
SCr increase !2 to 2.9 " reference SCra
SCr increase !3 " reference SCra or
SCr !2.5 mg/dL or
Receipt of dialysis
!0.5 mL/kg/h
<0.5 mL/kg/h for 6–12 h
2
3
<0.5 mL/kg/h for !12 h
<0.3 mL/kg/h for !24 h or
anuria for !12 h
a
Baseline SCr is defined as the lowest previous SCr value.
Modified from Jetton JG, Askenazi DJ. Update on acute kidney injury in the neonate. Curr Opin
Pediatr 2012;24(2):191–6.
0,3 mg/dl = 26,52 µmol/l
1,0 mg/dl = 88,4 µmol/l
2,5 mg/dl = 221 µmol/l
Lasten AKI
•
2106 lasta (Ei sydänkirurgisia potilaita)
•
AKI 17.9% (377 / 2106) (AKIN classification)
•
Kuolleisuus
•
10.3% AKi ryhmässä vs. 1.7%
•
OR 3.7
•
Pidempi teho-hoito aika
•
Pidempi ventilaattorihoidon tarve
Alkandari et al. Critical Care 2011, 15:R146
Lasten AKI
Alkandari et al. Critical Care 2011, 15:R146
http://ccforum.com/content/15/3/R146
Page 6 of 12
Table 1 Patient characteristics by AKI status and variable associations with AKIa,b
Mean (± SD), median or n (%)e
AKI (n = 377)
Non-AKI (n = 1,729)
P valuec
AKI risk factors adjusted ORs (95% CI)d
5.0 (5.5), 2.2
6.0 (5.7), 4.0
0.002
0.99 (0.97 to 1.01)
PRISM scoref
7.9 (6.3), 7
4.8 (4.6), 4
< 0.001
1.10 (1.08 to 1.13)g
Centre Hospitalier
Universitaire Ste-Justine
116 (30.8%)
620 (35.9%)
0.06
0.79 (0.61 to 1.02)
Female gender
161(42.7%)
757 (43.8%)
0.7
1.00 (0.79 to 1.27)
Mechanically ventilated
226 (60.0%)
747 (43.2%)
< 0.001
1.52 (1.18 to 1.94)g
Measured bSCr
218 (57.8%)
757 (43.8%)
< 0.001
2.22 (1.72 to 2.86)g
Postoperative (noncardiac)
102 (27.1%)
624 (36.1%)
0.001
0.68 (0.51 to 0.90)g
Admission for trauma
Documented infection
15 (4.0%)
39 (10.3%)
132 (7.6%)
67 (3.9%)
0.01
< 0.001
0.59 (0.33 to 1.07)
1.92 (1.23 to 2.99)g
5.4 (9.7), 1
2.2 (8.6), 0
< 0.001
Not applicable
9.7 (21.7), 3.1
4.6 (16.2), 2
< 0.001
Not applicable
39 (10.3%)
30 (1.7%)
< 0.001
Not applicable
Characteristics (N = 2,106)
AKI risk factors
Age, years
Outcomes
Length of mechanical
ventilation, days
PICU length of stay, days
PICU mortality
a
AKI = acute kidney injury; bSCr = baseline serum creatinine; I = confidence interval; OR = odds ratio; PICU = pediatric intensive care unit; PRISM = Pediatric Risk
of Mortality; SD = standard deviation;
b
AKI was defined according to the traditional Acute Kidney Injury Network staging system by using the lowest SCr level in the previous three months or ageand gender-based normative values as bSCr. Patients with no SCr data available were assumed not to have developed AKI; cP values are based on the univariate
comparison test performed between AKI and non-AKI groups; dadjusted ORs were calculated based on multiple logistic regression analysis to evaluate
independent risk factors for AKI; en (%) data represent the column percentage (for example, proportion of AKI patients who were female and proportion of AKI
patients who were treated at Centre Hospitalier Universitaire Ste-Justine); fonly 2,085 patients had PRISM scores available; gstatistically significant (P < 0.05) ORs
represent independent AKI risk factors.
Alkandari et al. Critical Care 2011, 15:R146
bSCr measured and not being a postoperative patient
(odds ratios shown in Table 1).
shows that, overall, almost all AKIs occurred within the
first two or three days after PICU admission.
Vastasyntyneen AKI
•
Perinataali hypoksia
•
VLBW ( < 1500g )
•
Synnynnäiset sydänviat
•
Sydänkirurgia joka vaatii sydänkeuhkokenetta (23 - 52%)
•
ECMO (71%)
•
Sepsis
•
Synnynnäiset munuaisten ja virtsateiden anomaliat
Jetton JG, Askenazi DJ. Clin Perinatol 41 (2014)
487–502.
Nestelasti ja AKI
•
•
CRRT hoidettuja lapsia N=297
•
Sepsis(31.2%)
•
Kantasolu siirto (15.2%)
•
Sydämen vajaatoiminta
(11.5%)
•
Hemato/Onkologia (8.8%)
Lineaarinen suhde mortaliteetilla
ja nestelastilla
320
Figure 1. Mortality rates of pediatric intensive care unit
patients receiving continuous renal replacement therapy
subdivided by degree of fluid overload. Error bars represent
• 1% nestelasti lisä -> 3% lisäys
95% confidence intervals for the mortality rate in each fluid
mortaliteettiin
overload group. There was a statistically significant difference in mortality among the 3 groups. Patients with ! 20%
fluidVol
overload
had2significantly
higher
mortality
than patients
SM Sutherland, et al. American Journal of Kidney Diseases,
55, No
(February),
2010:
pp 316-325
with ! 10% fluid overload and those with 10%-20% fluid
a
o
r
0
p
h
(
c
w
(
C
f
s
s
o
Dialyysi indikaatiota
•
Hoitoresistentti asidoosi ( pH < 7.1) tai hoidosta
huolimatta nopeasti syvenevä asidoos
•
Anuria tai oliguria
•
Hoitoresistentti hyperkalemia (> 6 - 6.5)
•
Kliinisesti merkittävä nesteretentio (keuhkopöhö,
nouseva IAP), joka ei hallittavissa diureetein
•
Uremia (enkefalopatia, pahoinvointi, kouristukset,
perikardiitti, vuoto)
Koska aloittaa
munuaiskorvaushoidot?
•
Edellisten indikaatioiden täyttyessä?
•
Nestelasti ?
•
•
10%— 20% ———— > 20%
•
Kunnes furosemidilla ei vastetta ?
Kuinka kauan voidaan odottaa spontaania
munuaisten toipumista?
Coarctation repair
Truncus arteriosus repair
Anomalous origin of coronary artery from pulmonary artery repair
Complete atrioventricular canal repair
Ventricular septal defect and coarctation repair
Ventricular septal defect
Valvuloplasty, mitral
Konno procedure
Absent pulmonary valve repair
Other
Varhainen PD
sydänkirurgian jälkeen
6
5
5
5
5
5
4
3
2
11
Early vs late PD
•
1.0
Early = Leikkauspäivänä
0.8
•
Retrospektiivinen tutkimus
•
3550 sydänleikkausta
•
Early PD
Late = 1.POP tai myöhempi
Survival probability
•
Delayed PD
0.6
0.4
Log-rank P = 0.02
146 PD hoidettua lasta
0.2
•
•
109 Early PD
43.5% pienempi kuolleisuus
varhaisessa PD:ssä
Bojan M, et al. Kidney International (2012)
No. at risk:
109
86
0.0
37
0
69
62
52
50
48 Early PD
24
21
19
19
16
15 Delayed PD
15
30
45
60
75
The prop
dialysis o
a
Relative
at the ‘
more t
Propen
Abbreviation: AKI, acute kidney injury.
•
peritone
90
Days of follow-up
Figure 2 | Ninety-day survival among patients with early
and delayed peritoneal dialysis. Survival is shown using
Kaplan–Meier
curves. Patients with peritoneal dialysis (PD)
82,
474–481;10.1038/ki.2012.172;
The pr
betwee
Early P
proced
and de
extraco
associa
was co
relative
had go
of the v
overlap
s.d. ¼ 0
s.d. ¼ 0
tive, a
betwee
weight
rendere
no furt
Sho
betwee
signific
and a s
rate in
PD gro
largest
group
Peritoneaali dialyysi
•
Ensisijainen ja yleisin vaihtoehto pienillä lapsilla
•
Yksinkertainen aloittaa
•
Halpa
•
Soveltuu myös hemodynaamisesti epävakaalle
potilaalle
•
Ei vaadi antikoagulaatiota
Peritoneaali dialyysi
•
PD-katetrin laitto suhteellisen yksinkertainen
toimenpide
•
Ei vastaa teholtaan hemodialyysiä
•
Usein saavutetaan riittävä puhdistuma ja nesteen
poisto
•
Nesteenpoistoa ei voi kontrolloida yhtä tarkasti kuin
hemodialyysillä
Peritoneaali dialyysi
•
Glukoosi osmoottisena molekyylinä
•
•
•
Muodostaa voimakkaan osmoottisen paine gradientin vatsakalvolla ->
Ultrafiltraatio
Puskurit
•
laktaatti
•
bikarbonaatti
Elektrolyytit
•
Natrium
•
Kalium
•
Kalsium
Edellytykset peritoneaali
dialyysin onnistumiseen
•
Ehjä vatsakalvo joka toimii filtterinä dialyysille
•
Intraperitoneaaliset absessit
•
Kiinnikkeet
•
Tuore laparotomia
•
Pallearuptuura
•
Toimiva PD-katetri (väliaikainen tai pysyvä)
•
Välineet
•
Nesteet, letkut, filtraatti pussi
Peritoneaali dialyysi komplikaatiot
•
Peritoniitti
•
Katetri infektiot
•
Vuoto
•
Suoliperforaatio
•
Katetri ongelmat: Tukokset, kipu, virtaus ongelmat,
…
Peritoneaalidialyysi
annostus
•
Dialyysi volyymi 10 - 20 ml/kg tai 600 - 800 ml / m2
BSA
•
Esim: Tunnin kierto: Sisään 5min - vatsaontelossa
40min - ulos valutus 15min
CRRT
•
Soveltuu kaiken ikäisille
•
Tosin mitä pienempi lapsi sitä enemmän
ongelmia dialyysireitin kanssa
•
Vaatii kätännössä aina antikoagulaation (sitraatti,
hepariini, epoprostenoli/PGI-2, LMWH)
•
Monimutkaisempi laitteisto
•
Helposti yhdistettävissä ECMO kiertoon
- 2012
Munuaiskorvaus hoitojen
syyt
ORIGINAL ARTICLES
Table II. Differences in survival depending on primary diagnosis
Primary diagnosis
Number/total (% of cohort)
Survive
Non-survivors
Survival versus non-survival P value
Sepsis
Cardiac disease
Inborn error of metabolism
Hepatic
Oncology*
Primary pulmonary
Renal†
Otherz
25/84 (30%)
16/84 (19%)
13/84 (15%)
9/84 (11%)
6/84 (7%)
5/84 (6%)
5/84 (6%)
5/84 (6%)
9/25 (36%)
6/16 (38%)
8/13 (62%)
0/9 (0%)
3/6 (50%)
3/5 (60%)
4/5 (80%)
3/5 (75%)
16/25 (64%)
10/16 (62%)
5/13 (38%)
9/9 (100%)
3/6 (50%)
2/5 (40%)
1/5 (20%)
2/5 (40%)
.37
.59
.15
<.01
.73
.44
.09
.19
*3 neuroblastoma, 2 acute lymphocytic leukemia, 1 hemophagocytic syndrome.
†Autosomal recessive polycystic kidney disease, cortical necrosis, unknown cause of chronic kidney disease, renal agenesis, congenital nephrotic syndrome.
z2 nephrotoxin, 1 congenital diaphrmatic hernia, 1 Omenn’s syndrome, status post bone marrow transplant, 1 censored.
Askenazi)DJ)et)al.)Con1nuous)Renal)Replacement)Therapy)for)Children)#10)kg:)A)Report)from)the)Prospec1ve)Pediatric)
Con1nuous)Renal)Replacement)Therapy)Registry.)J"Pediatr"2012.")
)
CRRT aloitus
1.
Dialyysikanyyli
2.
Filtteri
3.
Antikoagulaatio
4.
Dialyysikoneen säädöt / dialyysi annos
5.
Ravitsemus
6.
Priming (veri / kirkas / albumiini)
Hemodialyysikanyyli
Paino
2 – 6 kg
6 – 15 kg
15 – 30 kg
> 30 kg
Väliaikainen katetri
6.5 – 7 Fr
8 Fr
9 – 10 Fr
11.5 – 12.5 Fr
Paino
2.5 – 8 kg
8 – 15 kg
Tunneloitu katetri
Väliaikainen katetri
Medicomp 8 Fr
15 – 20 kg
Medicomp 8 tai 12.5 Fr
20 – 40 kg
> 40 kg
Medicomp 12.5 Fr
Palindrome 14.5 Fr
Hemodialyysikanyyli
Katetrin koko ja sijainti vaikuttaa kelan ikään
Hackbarth R et al. The effect of vascular access location and size on circuit survival in
pediatric continuous renal replacement therapy: A report from the PPCRRT registry.
Int J Artif Organs 2007; 30(12): 1116 – 1121.
Dialyysiannos / modaliteetti
•
CVVH, CVVHD, CVVHDF, SCUF
•
Kaikki modaliteetit mahdollisia lapsilla
•
Dialyysi annos 2000 - 3000 ml/h/1.73 m2
•
Koneeseen säädettävä n. 10% suurempi annos
kuin tavoitellaan, dialyysikoneen downtimen takia
Septinen AKI ja CRRT
•
CRRT:llä mahdollisesti immunomoduloiva vaikutus
•
Puhdistaa inflammaatio mediaattoreita korkeilla
annoksilla
•
“Munuais annos” = 20 - 30ml/kg/h
•
“Sytokiini annos” = 50 - 70 (-100) ml/kg/h
•
Toisaalta puhdistaa myös antibiootteja,
hivenaineita, aminohappoja, yms…
High-volume
hemofiltration
septic
acute
kidney
33.9 hours)
[26].
specifically described;
it was noted that three 1.5 tofor
R E S E A Rhowever,
CH
Open Access
patients in the HVHF group and one in the SVHF had
injury:
a systematic
and
meta-analysis
hypothermia, defined
as a core temperature review
<34°C while Discussion
High-volume
hemofiltration
for septic
acute kidney
receiving CRRT [28]. Associated with this, core temperature A systematic search of the literature for randomized
1,2
3
4
5
Edward
Clark1,2, Amber
Molnar
Olivier Joannes-Boyau
, Patrick M trials
Honoré
, Lindsey
Sikoraaccording
was significantly
lower inOthe
HVHF ,compared
with SVHF controlled
evaluating
HVHF,
to the Par6*
group
(37.2°C
versus 37.9°C;
P < 0.001). The authors also de- dubice definition [29], compared with SVHF as adjuvant
and
Sean
M Bagshaw
1,2
4
5
Edward Clark , Amberoccurred
O Molnar1,2more
, Oliviercommonly
Joannes-Boyau3, therapy
Patrick M Honoré
, Lindsey
Sikora
scribed that hypophosphatemia
for
sepsis
and
septic
AKI, found only four eli6*
and Sean M Bagshaw
among HVHF-treated
patients (65%) compared with SVHF gible studies for analysis. The quality of each study in(54%);
however, hypophosphatemia was not specifically cluded in our review was reasonable, considering the
Abstract
• [28].
4 tutkimusta
joissa verrattu matala vs korkea
annoksista
( >for
50ml/kg/h)
defined
inherent
challenges
blinding an extracorporeal therAbstract
hemodialyysia
Introduction:
High-volume
hemofiltration
(HVHF)
is isan
attractive
therapy
for the
treatment
of
septic
acute kidney
The study
byIntroduction:
Joannes-Boyau
et al.hemofiltration
[26] reported
apy.therapy
Our
found
thatacute
HVHF,
High-volume
(HVHF)three
an attractive
forreview
the treatment
of septic
kidney compared with
injury (AKI).
Small
experimental
and stroke,
uncontrolled
studies
suggested
and
survival
benefits mortalat
adverse
events
(one
acute
one myocarSVHF,
hadhemodynamic
nohemodynamic
significant
impact
on atshort-term
injury
(AKI).
Smallembolic
experimental
and uncontrolled
studies have
have
suggested
and survival
benefits
higher
doses
of
HVHF
than
those
used
for the
high-intensity ity,
arms
of the
RENAL
and
ATNand
studies.
aim was
to aim was to
higher
of
HVHF
those
for
the
high-intensity
arms
of the
RENAL
ATNOurstudies.
Our
• doses
dial
infarction,
and
onethan
episode
ofused
major
postoperative
kidney
recovery,
improvement
in hemodynamic
proN = 470,
Kaikilla
septinen
sokki,
ainoastaan
aikuisia,
ei
sydänkirurgiaa
evaluate the effects of high-volume hemofiltration (HVHF) compared with standard-volume hemofiltration (SVHF)
evaluate the
effects
of high-volume
hemofiltration
with standard-volume
hemofiltration
(SVHF)In a
bleeding).
One
major
adverse event
occurred in(HVHF)
the compared
file, or reduction
in ICU or hospital
length-of-stay.
for septic AKI.
for septic
AKI. Methods:28-päivän
• Outcome:
mortaliteetti
A systematic review
and meta-analysis of publications between 1966 and 2013 was performed. The review
injury: a systematic review and meta-analysis
was limited toreview
randomized-controlled
trials thatof
compared
HVHF (effluent
rate greater
ml/kgwas
per hour)
versus
Methods: A systematic
and meta-analysis
publications
between
1966than
and502013
performed.
The review
SVHF in the treatment of sepsis and septic shock. The primary outcome assessed was 28-day mortality. Other outcomes
was limited to assessed
randomized-controlled
trials that compared HVHF (effluent rate greater than 50 ml/kg per hour) versus
were recovery of kidney function, lengths of ICU and hospital stays, vasopressor dose reduction, and adverse
SVHF in the treatment
of sepsis and septic shock. The primary outcome assessed was 28-day mortality. Other outcomes
events.
assessed were Results:
recovery
kidney
function,
of were
ICU included.
and hospital
stays, vasopressor
dose
and adverse
Fouroftrials,
including
470 totallengths
participants,
Pooled analysis
for 28-day mortality
didreduction,
not show
any meaningful difference between HVHF compared with SVHF (OR, 0.76; 95% CI, 0.45 to 1.29). No included
events.
studies reported statistically significant differences between groups for any of the secondary outcomes. Adverse
Results: Four trials,
470 total participants,
were included.
analysis
forin 28-day
mortality
events,including
including hypophosphatemia
and hypokalemia,
were morePooled
commonly
observed
HVHF-treated
patients,did not show
although
reportingbetween
was inconsistent
across
studies.
any meaningful
difference
HVHF
compared
with SVHF (OR, 0.76; 95% CI, 0.45 to 1.29). No included
Conclusions:
Insufficient
evidence exists
of a therapeutic
benefit groups
for routine for
use of
HVHF
septic
AKI, other than
on
studies reported
statistically
significant
differences
between
any
offorthe
secondary
outcomes.
Adverse
an experimental basis. Given the logistic challenges related to patient recruitment along with an incomplete
Figure 2including
Forest plot hypophosphatemia
for odds of 28-day mortality.
events,
and hypokalemia,
more
commonly
in HVHF-treated
patients,
understanding of the biologic mechanisms
by which HVHF were
may modify
outcomes,
further observed
trials should focus
on
although reporting
wasextracorporeal
inconsistent
across
studies.
alternative
therapies
as an
adjuvant therapy for septic AKI rather than HVHF.
Conclusions: Insufficient evidence exists of a therapeutic benefit for routine use of HVHF for septic AKI, other than on
The definition
of what along
constitutes
volume in
Introduction
an experimental
basis. Given the logistic challenges related to patient
recruitment
withhigh
an incomplete
Sepsis is a common cause of critical illness and the leading HVHF remains unclear [6,7]. Based on the results of two
understanding
of the
biologic
mechanisms
outcomes, further
trials[8,9]
should
focus on
large modify
randomized-controlled
trials (RCTs)
and subcause
of death
for patients
admitted toby
the which
intensiveHVHF
care may
sequent
reviews
unit (ICU) [1]. Ittherapies
has been theorized
that the removal
of for
alternative extracorporeal
as an adjuvant
therapy
septicsystematic
AKI rather
than[10,11],
HVHF.the adequate dose of
inflammatory mediators and/or bacterial toxins from the
bloodstream could result in a beneficial downregulation of
hemofiltration treatment for acute kidney injury (AKI)
(that is, the renal dose) has been defined as an effluent
Dialyysiannos /
antikoagulaatio
- 2012
Table VII. CRRT circuit data in children #10 kg
•
•
•
84 lasta vuosilta 2001 – 2005
Yhdysvalloista
Kaikki alle 10kg painoisia
Sitraatti 55%, hepariini 45%
£5 kg
(N = 170)
>5 kg
(N = 251)
Anticoagulation protocol
Citrate
76 (45%)
155 (62%)
Heparin
94 (55%)
96 (38%)
Prime
Blood
164 (96.5%)
202 (80%)
Saline
5 (3%)
29 (12%)
Albumin
1 (0.5%)
20 (8%)
Parameter
Blood flow* (mL/kg/min)
12 (7.9-15.6)
6.6 (4.8-8.8)
Daily effluent volume* 3328 (2325-4745) 2321 (1614-2895)
(mL/h/1.73 m2)
Circuit life
28 (11-67)
37 (16-67)
P value
<0.001
<0.001
<0.001
<0.001
Sy
5t
sim
ica
wi
am
tio
ate
of
an
tho
str
co
*Median (IQR).
ho
im
who were unable to achieve dry weight after CRRT initiation
suc
had higher mortality.
an
FO has been shown to be associated with mortality in crit3,12-18
Askenazi DJ et al. Continuous Renal Replacement Therapyically
for Children
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kg:adults.
A Report
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ill children
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Mikä modaliteetti on paras?
•
Kaikilla modaliteeteilla edut ja haitat
•
Punnittava potilaskohtaisesti
•
Huomioitava
•
Nesteen poisto
•
Clearance / Dysequilibrium
•
Elektrolyytti tasapaino
•
Lapsen hemodynamiikka
•
Infektio status
The GOOD: CRRT
•
Good
•
Tehokas
•
Helposti kontrolloitavissa
•
“Fysiologinen”
•
Hemodynaamisesti
epävakaalle paras
vaihtoehto
•
•
Ei kontraindikaatioita
•
Bad
•
Kallis
•
Vaatii henkilökunnan
koulutuksen
•
Katetri infektiot
Ugly
•
Dysequilibrium riski
•
Antikoagulaatio
The Bad: iHD
•
•
Bad
•
Työläs ja kallis
•
Hemodynaamisesti
vaativa
•
Vuorokauden
nesteenpoisto 2-4h
aikana!
Good
•
Erittäin tehokas
•
Ugly
•
Dysequilibrium riski
The Ugly: PD
•
Good
•
•
•
Bad
Halpa
•
Huono puhdistuma
Melko nopeasti
toteutettava
•
Kontraindikaatiot
•
Ugly
•
Yksinkertainen
•
Nesteenpoisto huonosti
kontrolloitavissa
•
Sopii myös epävakaalle
hemodynamiikalle
•
Peritoniitti riski