CRRT

2015.4.14

CRRT

CRRTCRRTCRRT

Iwagami M et al,Nephrol Dial Transplant. 2015.Mar.19

CRRTCRRT

INTENSIVIST 2010,2,2 :329-345

CRRT(continuous replacement therapy)

hemodialysis(HD) CHD,CVVHD hemofiltration(HF) + continuous(C)=CHF,CVVH hemodiafiltration(HDF) CHDF,CVVHD

(C)HF

(C)HD

AB

INTENSIVIST 2010,2,2 :287-296

Federico P et al,Clinical Pharmacokinetics; 2007; 46, 12

CL=(QECE-QDCO)/CB

CL=QB(CB-CB0)/CB Qoutflow=QD+QF

INTENSIVIST 2010,2,2 :241-255

CRRT dose

23 2.0(1.2~2.1)L/hr 8035mL/kg/hr

1825(1200~2400)ml/hr CVVH:32(29~36)mL/kg/hr

CVVHDF:44(29~57)mL/kg/hr

2.28L/hr(24.3mL/kg/hr) 622L/hr

8 27(22~34)mL/kg/hr

12mL/kg/hr(720mL/hr)

CRRT

10mg/L 1520mg/L 1015mg/L MRSAMRSAVCMMIC 1520mg/L Sakoulas GGold HSCohen RAet alEffects of prolonged vancomycin administration on methicillin-resistant Staphylococcus aureusMRSA in a patient with recurrent bacteraemiaJ Antimicrob Chemother2006 Apr574699-704 Hidayat LKHsu DIQuist Ret alHigh-dose vancomycin therapy for methicillin-resistant Staphylococcus aureus infectionsefficacy and toxicityArch Intern Med2006 Oct 23166192138-44

PK/PD

AUC/MIC or Cmax/MIC

Time above MIC

AUC/MIC

PK

Gordon C et al,Crit Care Med 2009,37, 7

CHD 500mg24st250mg 500mg24st 20

TDM c. CHDF 1) 15-20 mg/kg1C1- 2) 17.5-10 mg/kg24TDM C1- 3) TDM C1- CRRT

CAVH/CVVH: 24~48500mg VCM CAVH/CVVHCHF CRRT

Antibiotic Dosing in Critically Ill Adult Patients Receiving Continuous Renal Replacement Therapy CLINICAL PRACTICE CID 2005:41 (15 October) 15~20mg/kg CVVH500mg q24h~1500mg q48h CVVHD,CVVHDF1~1.5g q24h CRRT CRRT

The Impact of Variation in Renal Replacement Therapy Settings on Piperacillin, Meropenem,and Vancomycin Drug Clearance in the Critically Ill: An Analysis of Published Literature and Dosing Regimens* Crit Care Med. 2014 Jul;42(7):1640-50.

RRT MEPMPIPCVCM MEPM55.3PIPC60.3VCM 56.9 MEPM89%PIPC83%VCM60%

MEPM151.3ml/min33.8ml/minPIPC131.8ml/min27.3mi/minVCM189.3ml/min35.6ml/minMEPMrs=0.43, p=0.12PIPCrs=0.77,p=0.10VCMrs=0.90, p=0.08

(ml/min) (ml/min)

RR

T

RR

T

Vancomycin pharmacokinetics in critically ill patients receiving continuous venovenous haemodiafiltration Br J Clin Pharmacol. 2004 Sep;58(3):259-68.ICU750mg q12st CVVHDF10 CRRT/hr CVVHDF1.8 0.4 L/hr30 6.7mL /min) CRRT1.37.2 2.5 0.7 L/hr41.7 11.7mL /min CVVHDF76 16.5 CVVHDF12 413 mg

CRRTVCM750mg12st 15450mg12st

CHDF 15mg/kg240.5g3~4TDM 1g/24or 0.5g123~4TDM CRRT

CRRT 12st CRRTCRRT

CRRT CRRT CRRT

CRRT

PK/PD CRRTCLcrrt),CLtot ke

PK

Gordon C et al,Crit Care Med 2009,37, 7

ClearanceCL

CLCL[L/h]Q[L/h]

CRRT CLr=CurineRurine/Cp,in,r (L/hr) =Coutflow(Qd+Qf) =CoutflowQoutflow

Coutflow/Cp,in,r=Sd(Sc) CLcrrt=SdQoutflowfuQoutflow

fu Qoutflow(Qb)

crrt(CLcrrt) (CLtot)

CLtot=fuQoutflow+fuCLcr fu Vd(ke) Ke=CLtot/Vd

Vd:(L/kg)

Ex)24 AUC0-24hr,vcm/MICvcm400 AUC0-24hr,vcm MIC AUC0-24hr,vcm(D)CLtot AUC0-24hr=D(mg/24hr)/CLtotD(mg/24hr) Ctrough=(Dvcm/Vd)(exp(-ke24)/((1-exp(-ke24)) D(mg) Ctrough

5060kg CRRTQb,in=80mL/minQoutflow=1.2L/hr VCM:MIC=1 VCMAUC0-24hr/MIC=400hr Ctrough=10~20mg/L

crrt(CLcrrt,vcm) (CLtot,vcm)

CLcrrt,vcm=fuQoutflow

VCMfu0.7 0.71.2L/mL)=0.84(L/hr) CLcrrt,vcmfuCLcr 0

VCMVd(Vd,vcm) (ke,vcm)

Ke,vcm=CLtot/Vdvcm

Vd=0.7L/kg Vd=0.7(L/kg)60(kg)=42(L) Ke,vcm=CLtot/Vdvcm=0.84(L/hr)/42(L) =0.02(hr-1)

PK/PD

AUC0-24hr,vcm/MICvcm400

AUC0-24,vcm(mg/hr/L)/1(mg/L)=400(hr) AUC0-24,vcm=400(mg/hr/L)

AUC0-24hr=D(mg/24hr)/CLtot,vcm(L/hr) Dvcm(mg/24hr)

Dvcm(mg/24hr)/0.84(L/hr) =400(mg/hr/L/24hr) Dvcm(mg/24hr)=4000.84 =336(mg/24hr)

Ctrough=(Dvcm/Vd)(exp(-ke24)/((1-exp(-ke24))Ctrough=13.1(mg/L)

CRRT CRRT CRRT