The Acute Dialysis Quality Initiative—Part VII: Fluid composition and management in CRRT

  • Miet Schetz
    Department of Intensive Care, University of Leuven, Belgium; Nephrology and Critical Care. Maisonneuve-Rosemont Hospital, University of Montreal, Canada; and the Section of Nephrology, University of Chicago Hospitals, Chicago, IL.
    Search for articles by this author
  • Martine Leblanc
    Department of Intensive Care, University of Leuven, Belgium; Nephrology and Critical Care. Maisonneuve-Rosemont Hospital, University of Montreal, Canada; and the Section of Nephrology, University of Chicago Hospitals, Chicago, IL.
    Search for articles by this author
  • Patrick T. Murray
    Department of Intensive Care, University of Leuven, Belgium; Nephrology and Critical Care. Maisonneuve-Rosemont Hospital, University of Montreal, Canada; and the Section of Nephrology, University of Chicago Hospitals, Chicago, IL.
    Search for articles by this author
      This paper is only available as a PDF. To read, Please Download here.


      Fluid composition and management are important parts of continuous renal replacement therapy (CRRT). Most commercially available CRRT solutions are able to reestablish electrolyte homeostasis provided some phosphate supplementation is given. Supraphysiologic glucose concentrations should be avoided. Predilution fluid replacement allows higher ultrafiltration rates and can be considered as an adjunct to the anticoagulation regimen. Lactate is an effective buffer in most CRRT patients. Bicarbonate is preferred in patients with lactic acidosis and/or liver failure. When citrate is used as anticoagulant, frequent monitoring of pH is required. The clinical consequences of CRRT-induced decreases of body temperature are not clear. Substitution fluid should be sterile, but the bacteriologic requirements for CRRT dialysate are less clear. There is no consensus on the optimal parameters to monitor fluid management. Integrated balancing systems have theoretical advantages over adaptive use of intravenous fluid pumps. Although there is evidence that volume overload is associated with adverse outcome, there is no evidence that fluid removal per se improves outcome in critically ill patients with or without acute renal failure. © 2002 by the National Kidney Foundation, Inc.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Advances in Chronic Kidney Disease
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Kaplan AA
        • Longnecker RE
        • Folkert VW
        Continuous arteriovenous hemofiltration. A report of six months' experience.
        Ann Intern Med. 1984; 100: 358-367
        • Sigler MH
        • Teehan BP
        Solute transport in continuous hemodialysis: a new treatment for acute renal failure.
        Kidney Int. 1987; 32: 562-571
        • Bellomo R
        • Ernest D
        • Love J
        • et al.
        Continuous arteriovenous haemodiafiltration: Optimal therapy for acute renal failure in an intensive care setting?.
        Aust NZ L Med. 1990; 20: 237-242
        • Pataca MI
        • Ramesh BR
        • Parmer A
        • et al.
        Continuous arteriovenous haemodialysis in severe combined renal and respiratory failure.
        Blood Purif. 1992; 10: 262-268
        • Barton IK
        • Hilton PJ
        Veno-venous haemofiltration in the intensive care unit.
        Clin Intens Care. 1993; 4: 16-22
        • Bellomo R
        • Martin H
        • Parkin G
        • et al.
        Continuous arteriovenous haemodiafiltration in the critically ill: influence on major nutrient balances.
        Intensive Care Med. 1991; 17: 399-402
        • Bonnardeaux A
        • Pichette V
        • Ouimet D
        • et al.
        Solute clearances with high dialysate flow rates and glucose absorption from the dialysate in continuous arteriovenous hemodialysis.
        Am J Kidney Dis. 1992; 19: 31-38
        • Bellomo R
        • Colman PG
        • Caudwell J
        • et al.
        Acute continuous hemofiltration with dialysis: effect on insulin concentrations and glycemic control in critically ill patients.
        Crit Care Med. 1992; 20: 1672-1676
        • Monaghan R
        • Watters JM
        • Clancey SM
        • et al.
        Uptake of glucose during continuous arteriovenous hemofiltration.
        Crit Care Med. 1993; 21: 1159-1163
        • Frankenfield DC
        • Reynolds HN
        • Badellino MM
        • et al.
        Glucose dynamics during continuous hemodiafiltration and total parenteral nutrition.
        Intensive Care Med. 1995; 21: 1016-1022
        • Lopot F
        • Valek A
        Pre-vs. post-dilutional hemofiltration.
        Clin Nephrol. 1979; 12: 69-73
        • Ledebo I
        Predilution hemofiltration: a new technology applied to an old therapy.
        Int J Artif Organs. 1995; 18: 735-742
        • Ficheux A
        • Argiles A
        • Bosc JY
        • et al.
        Analysis of the influence of the infusion site on dialyser clearances measured in an in vitro system mimicking haemodialysis and haemodiafiltration.
        Blood Purif. 1999; 17: 10-18
        • 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: 486-492
        • 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: 910-917
        • Kierdorf H
        • Leue C
        • Heintz B
        • et al.
        Continuous venovenous hemofiltration in ARF: Is a bicarbonate or lactate-buffered solution better?.
        Contrib Nephrol. 1995; 116: 38-47
        • Morgera S
        • Heering P
        • Szentandrasi T
        • et al.
        Comparison of a lactate-versus acetate-based hemofiltration replacement fluid in patients with acute renal failure.
        Ren Fail. 1997; 19: 155-164
        • 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: 1212-1217
        • Heering P
        • Ivens K
        • Thumer O
        • et al.
        Acid-base balance and substitution fluid during continuous hemofiltration.
        Kidney Int. 1999; 56: S37-S40
        • Zimmerman D
        • Cotman P
        • Ting R
        • et al.
        Continuous veno-venous haemodialysis with a novel bicarbonate dialysis solution: Prospective cross-over comparison with a lactate buffered solution.
        Nephrol Dial Transplant. 1999; 14: 2387-2391
        • Veech RL
        The untoward effects of the anions of dialysis fluid.
        Kidney Int. 1988; 34: 587-597
        • Barton IK
        • Streather CP
        • Hilton PJ
        • et al.
        Successful treatment of severe lactic acidosis by haemofiltration using a bicarbonate-based replacement fluid.
        Nephrol Dial Transplant. 1991; 6: 368-370
        • Forni LG
        • Darling K
        • Evans M
        • et al.
        Lactate-intolerance with continuous haemofiltration: the role of bicarbonate-buffered haemofiltration.
        Clin Intens Care. 1998; 9: 40-42
        • Hilton PJ
        • Taylor J
        • Forni LG
        • et al.
        Bicarbonate-based haemofiltration in the management of acute renal failure with lactic acidosis.
        Quart J Med. 1998; 91: 279-283
        • Reynolds HN
        • Belzberg H
        • Connelly J
        Hyperlactatemia in patients undergoing continuous arteriovenous hemofiltration with dialysis.
        Crit Care Med. 1990; 18 (letter): 582
        • Davenport A
        • Will EJ
        • Davison AM
        Paradoxical increase in arterial hydrogen ion concentration in patients with hepatorenal failure given lactate-based fluids.
        Nephrol Dial Transplant. 1990; 5: 342-346
        • Davenport A
        • Aulton K
        • Payne RB
        • et al.
        Hyperlactatemia and increasing metabolic acidosis in hepatorenal failure treated by hemofiltration.
        Ren Fail. 1990; 12: 99-101
        • Davenport A
        • Will EJ
        • Davison AM
        Hyperlactataemia and metabolic acidosis during haemofiltration using lactate-buffered fluids.
        Nephron. 1991; 59: 461-465
        • Mehta RL
        • McDonald BR
        • Aguilar MM
        • et al.
        Regional citrate anticoagulation for continuous arteriovenous hemodialysis in critically ill patients.
        Kidney Int. 1990; 38: 976-981
        • Ward DM
        • Mehta RL
        Extracorporeal management of acute renal failure patients at high risk of bleeding.
        Kidney Int. 1993; 43: S237-S244
        • Palsson R
        • Niles JL
        Regional citrate anticoagulation in continuous venovenous hemofiltration in critically ill patients with a high risk of bleeding.
        Kidney Int. 1999; 55: 1991-1997
        • Kirschbaum B
        • Galishoff M
        • Reines HD
        Lactic acidosis treated with continuous hemodiafiltration and regional citrate anticoagulation.
        Crit Care Med. 1992; 20: 349-353
        • Matamis D
        • Tsagourias M
        • Koletsos K
        • et al.
        Influence of continuous haemofiltration-related hypothermia on haemodynamic variables and gas exchange in septic patients.
        Intensive Care Med. 1994; 20: 431-436
        • Manns M
        • Maurer E
        • Steinbach B
        • et al.
        Thermal energy balance during in vitro continuous veno-venous hemofiltration.
        ASAIO J. 1998; 44: M601-M605
        • Yagi N
        • Leblanc M
        • Sakai K
        • et al.
        Cooling effect of continuous renal replacement therapy in critically ill patients.
        Am J Kidney Dis. 1998; 32: 1023-1030
        • Golper TA
        • Leone M
        Backtransport of dialysate solutes during in vitro continuous arteriovenous hemodialysis.
        Blood Purif. 1989; 7: 223-229
        • Ronco C
        Backfiltration in clinical dialysis: nature of the phenomenon, mechanisms and possible solutions.
        Int J Artif Organs. 1990; 13: 11-21
        • Ronco C
        • Brendolan A
        • Feriani M
        • et al.
        A new scintigraphic method to characterize ultrafiltration in hollow fiber dialyzers.
        Kidney Int. 1992; 41: 1383-1393
        • Lonnemann G
        • Behme T
        • Lenzner B
        • et al.
        Permeability of dialyzer membranes to TNFa-inducing substances derived from water bacteria.
        Kidney Int. 1992; 42: 61-68
        • Pereira BJ
        • Snodgrass BR
        • Hogan PJ
        • et al.
        Diffusive and convective transfer of cytokine-inducing bacterial products across hemodialysis membranes.
        Kidney Int. 1995; 47: 603-610
        • Bommer J
        • Becker KP
        • Urbaschek R
        Potential transfer of endotoxin across high-flux polysulfone membranes.
        J Am Soc Nephrol. 1996; 7: 883-888
        • Krautzig S
        • Linnenweber S
        • Schindler R
        • et al.
        New indicators to evaluate bacteriological quality of the dialysis fluid and the associated inflammatory response in ESRD patients.
        Nephrol Dial Transplant. 1996; 11: 87-91
        • Panichi V
        • Tetta C
        • Rindi P
        • et al.
        Plasma C-reactive protein is linked to backfiltration associated interleukin-6 production.
        ASAIO J. 1998; 44: M415-M417
        • Lonnemann G
        Should ultra-pure dialysate be mandatory?.
        Nephrol Dial Transplant. 2000; 15: 55-59
        • Alamartine E
        • de Filippis JP
        • Toulon J
        • et al.
        On-line continuous venovenous hemodiafiltration: a technique for the control of ultrafiltration and convection during continuous renal replacement therapy.
        Ren Fail. 1994; 16: 707-714
        • Canaud B
        • Bosc JY
        • Leray-Moragues H
        • et al.
        On-line haemodiafiltration. Safety and efficacy in long-term clinical practice.
        Nephrol Dial Transplant. 2000; 15: 60-67
        • Vaslaki L
        • Karatson A
        • Voros P
        • et al.
        Can sterile and pyrogen-free on-line substitution fluid be routinely delivered? A multicentric study on the microbiological safety of on-line haemodiafiltration.
        Nephrol Dial Transplant. 2000; 15: 74-78
        • Mehta RL
        Fluid management in continuous renal replacement therapy.
        Semin Dial. 1996; 9: 140-144
        • Lauer A
        • Saccaggi A
        • Ronco C
        • et al.
        Continuous arteiovenous hemofiltration in the critically ill patient. Clinical use and operational characteristics.
        Ann Intern Med. 1983; 99: 455-460
        • Roberts M
        • Winney RJ
        Errors in fluid balance with pump control of continuous hemodialysis.
        Int J Artif Organs. 1992; 10: 292-308
        • Bosworth C
        • Swann S
        • Paganini E
        Evaluation of the IMED Gemini PC2 volumetric infusion pumps in extracorporeal continuous therapy circuits.
        Dial Transplant. 1990; 19: 26-28
        • Jenkins R
        • Harrison H
        • Chen B
        • et al.
        Accuracy of intravenous infusion pumps in continuous renal replacement therapies.
        ASAIO J. 1992; 38: 808-810
        • Ronco C
        • Brendolan A
        • Bellomo R
        Current technology for continuous renal replacement therapies.
        in: Critical Care Nephrology. Kluwer Academic Publishers, Dordrecht, The Netherlands1998: 1269-1308
        • Russell JA
        • Phang PT
        The oxygen delivery/consumption controversy. Approaches to management of the critically ill.
        Am J Respir Crit Care Med. 1994; 149: 533-537
        • Schumacker PT
        Oxygen supply dependency in critical illness: an evolving understanding.
        Intensive Care Med. 1998; 24: 97-99
        • Canaud B
        • Leray-Moragues H
        • Garred LJ
        • et al.
        Slow isolated ultrafiltration for the treatment of congestive heart failure.
        Am J Kid Dis. 1996; 28: S67-S73
        • Lowell JA
        • Schifferdecker C
        • Driscoll DF
        • et al.
        Postoperative fluid overload: Not a benign problem.
        Crit Care Med. 1990; 18: 728-733
        • Schuster DP
        The case for and against fluid restriction and occlusion pressure reduction in adult respiratory distress syndrome.
        New Horizons. 1993; 1: 478-488
        • Alsous F
        • Khamiees M
        • DeGirolamo A
        • et al.
        Negative fluid balance predicts survival in patients with septic shock. A retrospective pilot study.
        Chest. 2000; 117: 1749-1754
        • Mitchell JP
        • Schuller D
        • Calandrino FS
        • et al.
        Improved outcomes based on fluid management in critically ill patients requiring pulmonary artery catheterization.
        Am Rev Respir Dis. 1992; 145: 990-998
        • Inoue T
        • Sakai Y
        • Morooka S
        • et al.
        Hemofiltration as treatment for patients with refractory congestive heart failure.
        Clin Cardiol. 1992; 15: 514-518
        • Laggner AN
        • Druml W
        • Lenz K
        • et al.
        Influence of ultrafiltration/hemofiltration on extravascular lung water.
        Contrib Nephrol. 1991; 93: 65-70
        • Bellomo R
        • Farmer M
        • Boyce N
        Combined acute respiratory and renal failure: management by continuous hemodiafiltration.
        Resuscitation. 1994; 28: 123-131
        • Bagshaw ON
        • Anaes FR
        • Hutchinson A
        Continuous arteriovenous haemofiltration and respiratory function in multiple organ systems failure.
        Intensive Care Med. 1992; 18: 334-338
        • Lowrie LH
        Renal replacement therapies in pediatric multiple organ dysfunction syndrome.
        Pediatr Nephrol. 2000; 14: 6-12
        • DiCarlo JV
        • Dudley TE
        • Sherboitie JR
        • et al.
        Continuous arteriovenous hemofiltration/dialysis improves pulmonary gas exchange in children with multiple organ system failure.
        Crit Care Med. 1990; 18: 822-826
        • Kruger I
        • Jacobi C
        • Landwehr P
        Effects of continuous venovenous hemofiltration on pulmonary function and hemodynamics in postoperative septic multiorgan failure.
        Contrib Nephrol. 1995; 116: 108-111
        • Ronco C
        • Brendolan A
        • Bellomo R
        Online monitoring in continuous renal replacement therapies.
        Kidney Int. 1999; 56: S8-S14
        • 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: 1751-1757
        • McLean AG
        • Davenport A
        • Cox D
        • et al.
        Effects of lactate-buffered and lactate-free dialysate in CAVHD patients with and without liver dysfunction.
        Kidney Int. 2000; 58: 1765-1772
        • Van den Berghe G
        • Wouters P
        • Weekers F
        • et al.
        Intensive insulin therapy in critically ill patients.
        New Engl J Med. 2001; 345: 1359-1367