High Volume Haemofiltration

OVERVIEW

• High volume haemofiltration (HVH) is CRRT where the filtration rate is large
• aka “high-volume,” “high intensity,” or “high flow”
• definition of HVHF is controversial (e.g. >50 mL/kg/h)
• The role of HVH in ICU is unclear and is a controversial issue.

RATIONALE

• effective removal of middle molecules (e.g. cytokines) may be beneficial in conditions such as severe sepsis
• middle sized molecules that can be removed by convection (endotoxin, cytokines, oxygen free radicals, arachidonic acid metabolites)

PROPOSED BENEFITS

• HVHF reduce pressor requirements and improve survival in animal models of sepsis and HVH
• new haemofilters have been shown to remove all mediators involved in sepsis (Hoffmann JN, et al (1999) “Hemofiltrate from patients with severe sepsis and depressed left ventricular contractility contains cardiotoxic compounds.” Shock, 12:174-180.)
• HVH has been shown in paediatric cardiac surgery to decrease SIRS response, reduce post operative blood loss and improve oxygenation (Journois D, et al 1996)
• High-volume, zero-balanced hemofiltration to reduce delayed inflammatory response to cardiopulmonary bypass in children (Anesthesiology 1996, 85:965-976.)
• survival benefit in small studies of cardiac arrest and pancreatitis

DISADVANTAGES

• large centre dependent
• fluid management problems
• electrolyte balance problems (hypophosphataemia)
• requires high blood flow (>300mL/min) to avoid excess predilution or excessive haemoconcentration and maintain filtration fraction <25%
• most data from single centre and small groups of patients (low quality)
• in the 2009 RENAL study there was no benefit in effluent flow rates of 25 vs 40mL/kg/hr (doesn’t preclude a benefit at higher rates however)
• requires frequent filter changes
• no evidence for HVHF in sepsis (Cochrane SR 2013)
• IVOIRE study 2013 — no benefit in sepstic shock for HVHF at 70 mL/kg/h when compared with contemporary SVHF at 35 mL/kg/h (underpowered as stopped early)
• risk of hypothermia
• removal of micronutrients and drugs in blood

References and Links

• Borthwick EM, Hill CJ, Rabindranath KS, Maxwell AP, McAuley DF, Blackwood B. High-volume haemofiltration for sepsis. Cochrane Database Syst Rev. 2013 Jan 31;1:CD008075. doi: 10.1002/14651858.CD008075.pub2. Review. PubMed PMID: 23440825.
• Joannes-Boyau O, Honoré PM, Perez P, Bagshaw SM, Grand H, Canivet JL, Dewitte A, Flamens C, Pujol W, Grandoulier AS, Fleureau C, Jacobs R, Broux C, Floch H, Branchard O, Franck S, Rozé H, Collin V, Boer W, Calderon J, Gauche B, Spapen HD, Janvier G, Ouattara A. High-volume versus standard-volume haemofiltration for septic shock patients with acute kidney injury (IVOIRE study): a multicentre randomized controlled trial. Intensive Care Med. 2013 Jun 6. [Epub ahead of print] PubMed PMID: 23740278.
• Rimmelé T, Kellum JA. High-volume hemofiltration in the intensive care unit: a blood purification therapy. Anesthesiology. 2012 Jun;116(6):1377-87. doi: 10.1097/ALN.0b013e318256f0c0. Review. PubMed PMID: 22534247. [Free Full Text]