..

2557
Hemodialysis Clinical Practice
Recommendation 2014

 .. 2557
ISBN 978-616-91290-7-3
:
:

4 2

10320

02-716-6091, 02-716-7450

02-718-1900

E-mail: kidney@loxinfo.co.th
1 : 2557 (154 )
: 2,000
:

:
facebook.com/BanTaiSoiDesign
:

39/205-206 84

10210

02-996-7392-4

02-996-7395


(hemodialysis)

(Thailand Renal Replacement
Therapy Registry, TRT) .. 2553
(prevalence case) 30,835
482.6
(incidence case) 6,244 97.73





..
2557

1 2557


.. 2555

31 2555



.. 2555




.. 2556


(Quality of Evidence)
(Strength of Recommendation)
(Guide to Develop
Clinical Practice Guidelines)
9 .. 2554

.. 2557

1 2557

 .. 2555

.. 2555

31 2555

2

1.

2.

3.
4.
5.
6.

7.
8.

9.
10.
11.

19
26
34
38
44
49
53
62
68
81
90

12.
13.

14.
15.
16.
17.

99
104
114
122
125
130

3
.. 2557
1.
2.
3.

4.

133
134
135
137

24

2 . 42
. endotoxin

43
3 4Ts Scoring System
Heparin (HIT) 2

48

52

5 59
6

73

7
(Intradialytic Hypertension)

97

8
(Intradialytic Hypotension)

103

9 112

10

128

11

129

33

37

3 B C

61

80

98

113

1.

1.1
1. 4
2. 3
(estimated Glomerular Filtration
Rate, eGFR) 7 .//1.73

3. 1
1

(++/I)
1.2
4 (++/I)
1.3
1. eGFR 6 .//1.73

2. 5 eGFR 6 ./
/1.73


2.1

2.2

2.3
2.4

2.5

(++/I)

2.

2.1

3 arteriovenous fistula (AVF)

4-6 arteriovenous graft (AVG) graft

(++/III)

.. 2557

 2.2


4

(+/IV)
2.3
AVF
AVG
(permanent catheter)
(++/II)
2.4



(++/IV)
2.5 AVF

(+/II)
2.6 AVF
6 (+/IV)
2.7
internal jugular vein

(+/IV)

 2.8 AVF
AVG
(+/III)

3.
3.1

(++/IV)
3.2
(biocompatibility)

(++/I)
3.3 (reuse dialyzer)


(+/I)
3.4 (bloodline)

(-/IV)

4.
4.1
AAMI
regular pure European Pharmacopoeia
online hemofiltration hemodiafiltration
ultrapure
(++/II)
4

.. 2557

 4.2 reverse
osmosis (recirculation
loop)
(++/IV)
4.3




(++/IV)

5.
5.1
unfractionated heparin
low molecular weight heparin
(++/II)
5.2


(++/II)
5.3 heparin (heparin-induced thrombocytopenia, HIT) 2


(++/II)

 5.4

(++/IV)

6.
6.1
(first few sessions)
(++/IV)
6.2

(dialysis disequilibrium syndrome)
40 (++/III)

7.
7.1

(++/I)
7.2


(+/IV)

.. 2557

 7.3

(standard precaution)
(++/I)
7.4


(++/I-2)
7.5 external pressure
transducer
internal pressure transducer


(+/IV)
7.6
clamp

(disinfection)

(+/IV)
7.7
HIV 6-12


(+/I)

8.

8.1

3

(++/IV)
8.2
(Hb) 1

(++/IV)
8.3 (iPTH)
6

(++/IV)
8.4
18 24 /
(++/III)
8.5
4 5.5 /
(++/III)
8.6
Kt/V
/ urea reduction ratio 3 (++/II)

.. 2557

9.
9.1
6


(++/III)
9.2
30-35 / 1 /
1.2 / 1 /
(++/I)
9.3


(++/III)

10.
10.1



(++/I)
10.2

(acute coronary
syndrome)

 aspirin nitroglycerin

(++/IV)
10.3
(cardiac arrhythmia)



(++/IV)
10.4
(air embolism) clamp
blood pump 100%


(++/IV)
10.5
(anaphylaxis) A clamp blood line

B

(++/IV)

11.
11.1
30

(++/IV)
10

.. 2557

 11.2
140/90 . 130/80 .

(++/III)
11.3 (non
pharmacological therapy)
/
1. 2-3

2. 18.5-23 .
3.

4.
(probing dry-weight)
5.
sodium profile
(++/IV)
11.4 angiotensin
coverting enzyme inhibitor (ACEI) angiotensin II
receptor blocker (ARB)
b-blocker calcium
channel blocker
(++/III)

11

 11.5 (intradialytic hypertension)

(++/II)
11.5



(++/III)

12.
12.1 (intradialytic hypotension)

(++/I)
12.2

(++/II)
12.3

(++/II)

12

.. 2557

13.

13.1

3


(++/IV-1)
13.2
2.7-4.9 ./. 9.0-10.2
./.
(++/IV-2)
13.3 (intact parathyroid hormone, PTHi) 2 9
130-600 /.
(++/IV-2)
13.4

(phosphate binder)

(++, III-2)
13.5 2

active
(+, IV-1)

13

 13.6


(+, IV-2)

14.
14.1
(hemoglobin, Hb)
13.0 /. 12.0 /.
15
(++/IV-1)
14.2
(erythropoiesis stimulating agent, ESA)
Hb 10 /.

(+/IV-1)
14.3 ESA
Hb 10-11.5 /. 13 /. (+/I-1)
14.4 ESA
ferritin 500 % TSAT
30
1-3

(++, III)
14.5 epoetin 300
( 450
14

.. 2557

 ) Hb
ESA

(+, IV-1)

15.
15.1
(residual renal function)

(+, IV-1)
15.2

(++, IV-2)

16.
16.1

(++, IV-1)
16.2
(narrow therapeutic index)


(++, III)
16.3

(++, III)

15

17.
17.1

(++, IV-1)
17.2 (withhold) (withdraw)

1.

2.

3.


4.

5. ( )

16

.. 2557

6. 75
2 4
1

1)

2) comorbidity score ( Charleson

comorbidity score > 8 French Renal Epidemiology and
Information Network (FREIN) 6-Month Prognosis Clinical
Score > 9)
3)
(Functional Status) ( Karnofsky Performance Status score 40)
4)

(++, IV-1)

17

1.

1.1
1. 4
2. 3
(estimated Glomerular Filtration Rate,
eGFR) 7 .//1.73

3. 1
1

(++/I)

.. 2552

19


(1)

1)

3 (eGFR 30-59 .//1.73 )

2) 4 (eGFR 15-29 .//1.73 )

(renal replacement therapy)

(2)
( 1
)
1.2
4 (++/I)
4

20

.. 2557




(vascular access)
(3)
1.3
1, eGFR 6 .//1.73

2. 5 eGFR 6 ./
/1.73


2.1

2.2

2.3
2.4

2.5

(++/I)

21

 4
eGFR 5-7 .//1.73
eGFR 10-14 .//1.73

6 (4)
(5)


4


(6)

1. Smart NA, Titus TT. Outcomes of early versus late

nephrology referral in chronic kidney disease: a
systematic review. Am J Med 2011; 124:1073-80.
2. Chan MR, Dall AT, Fletcher KE, et al. Outcomes in
patients with chronic kidney disease referred late to
nephrologists: a meta-analysis. Am J Med 2007;
120:1063-70.
3. Luxton G; CARI. The CARI guidelines. Timing of referral
of chronic kidney disease patients to nephrology services
(adult). Nephrology (Carlton) 2010;15 Suppl 1:S2-11.

22

.. 2557

4. Cooper BA, Branley P, Bulfone L, et al. A randomized,

controlled trial of early versus late initiation of dialysis.
N Engl J Med 2010; 363:609-19.
5. Harris A, Cooper BA, Li JJ, et al. Cost-effectiveness
of initiating dialysis early: a randomized controlled
trial. Am J Kidney Dis 2011; 57:707-15.
6. Pollock CA, Cooper BA, Harris DC. When should we
commence dialysis? The story of a lingering problem
and todays scene after the IDEAL study. Nephrol Dial
Transplant 2012; 27:2162-6.

23

Estimated
GFR*
(.//
1.73
)
G1
>90

G2 60-89

G3a 45-59
G3b 30-44
G4 15-29

G5
<15
(

---

24

(./)
<30 30-300 >300
A1 A2 A3

.. 2557

* Estimated glomerular filtration rate (eGFR)

CKD-EPI (Chronic Kidney Disease
Epidemiology Collaboration)
enzymatic method ( modified kinetic Jaffe
reaction )

Serum Creatinine
eGFR
(./.)
<0.7
144x(SCr/0.7)-0.329x(0.993)Age
>0.7
144x(SCr/0.7)-1.209x(0.993)Age

<0.9
>0.9

141x(SCr/0.7)-0.411x(0.993)Age
141x(SCr/0.7)-1.209x(0.993)Age

25

2.

2.1

3 arteriovenous fistula (AVF)

4-6 arteriovenous graft (AVG) graft

(++/III)


(temporary double lumen catheter)


(permanent)

6-8 AVF AVG

graft
2-4 (1)
2.2

26

.. 2557

 4

(+/IV)








(patency)
4(2)
2.3
AVF
AVG
(permanent catheter)
(++/II)

AVF (thrombosis)

AVG
1 6 1 10

27

(3,4)

2.4



(++/IV)






(informed consent)
2.5 AVF
(+/II)

(isometric exercise)
AVF


AVF (2,5)

28

.. 2557

 2.6 AVF 6

(+/IV)
AVF

(continuous thrill)
(arterial anastomosis) (outflow
vein) stethoscope (bruit)
diastole systole
6 Rule of Six
6 AVF,
600 ./, 6 ..
6 .. AVF
6 AVF
accessory vein

pulse
systole
(6)
2.7 internal
jugular vein

(+/IV)

29

 internal jugular
vein (stenosis)
subclavian vein femoral
vein internal jugular vein




(exit site)
(tunnel)

2.8 AVF
AVG
(+/III)

AVF AVG


pulse

dynamic venous pressure, static intra-
access pressure access flow
recirculation ( urea-based method) pre-pump

30

.. 2557

negative pressure
(7)

1) blood flow

2)

3) static intra-access pressure

/ access flow
4)
5)

( 1
)

31

1. Ortega T, Ortega F, Diaz-Corte C, Rebollo P, Ma

Baltar J, Alvarez-Grande J. The timely construction of
arteriovenous fistulae: a key to reducing morbidity and
mortality and to improving cost management. Nephrol
Dial Transplant 2005; 20:598-603.
2. Hakim RM, Himmelfarb J. Hemodialysis access failure:
A call to action. Kidney Int 1998; 54:1029-40.
3. Rayner HC, Pisoni RL, Gillespie BM, et al. Creation,
cannulation and survival of arterio-venous fistulae-data
from the Dialysis Outcomes and Practice Patterns Study
(DOPPS). Kidney Int 2003; 63:323-30.
4. Thomson P, Stirling C, Traynor J, Morris S, Mactier R. A
prospective observational study of catheter-related
bacteraemia and thrombosis in a haemodialysis cohort:
univariate and multivariate analyses of risk associations.
Nephrol Dial Transplant 2010; 25:1596-60.
5. Salimi F, Majd Nassiri G, Moradi M, et al. Assessment
of effects of upper extremity exercise with arm tourniquet
on maturity of arteriovenous fistula in hemodialysis
patients. J Vasc Access 2013; 14:239-44.
6. Sands J. Vascular access: the past present and future.
Blood Purif 2009; 27:22-7.
7. McCauley P, Wingard RL, Shyr Y, Pettus W, Hakim RM,
Ikizler TA. Vascular access blood flow monitoring
reduces access morbidity and costs. Kidney Int 2001;
60:1164-72.
32

.. 2557

Vascular Access:
AV fistula graft

Doppler U/S

Fistulogram

Arm swelling
Difficult cannulation
Loss of continuous bruit
Prolonged bleeding
Decreased URR/Kt/V >10% x 2
without other causes
Recurrent clotting >2/mo
Dialyzer clotting or poor reuse
Hemodynamic
Dynamic venous pressure
>120 mmHg @ BFR 200 ml/min x 3
Static venous pressure
>0.5 ratio @ BFR 0 ml/min x 2
Recirculation >10% (by BUN)
Inability to achieve BFR
Decreased Intra-access flow

Intervention : Stent,
Thrombolysis, Revision, Graft replacement w/AVF

Intervention

Surgical Correction

33

3.
3.1


(++/IV)

3.2
(biocompatibility)

(++/I)


neutrophil monocyte
(1)



urea kinetic model
( 8.6)

34

.. 2557

 3.3 (reuse dialyzer)

(+/I)


(2)

--
American Association for the Advancement
of Medical Instrumentation (AAMI)

total cell volume (TCV) ultrafiltration
(UF) coefficient TCV
80% UF coeff 75%
(3) ( 2
)

(CDC)
(4)

35

 3.4 (bloodline)

(-/IV)


5

1. Takemoto Y, Naganuma T, Yoshimura R. Biocompatibility of the dialysis membrane. Contrib Nephrol 2011;
168:139-45.
2. Galvao TF, Silva MT, Araujo ME, Bulbol WS, Cardoso
AL. Dialyzer reuse and mortality risk in patients with
end-stage renal disease: a systematic review. Am J
Nephrol 2012; 35:249-58.
3. Association for the Advancement of Medical Instrumentation. Reuse of Hemodialyzers. AAMI Recommended
Practice ANSI/AAMI RD47:2002 and RD 47:2002/A1:2003.
Arlington, VA: Association for the Advancement of
Medical Instrumentation, 2003.
4. Fabrizi F, Messa P, Martin P. Transmission of hepatitis
C virus infection in hemodialysis: current concepts. Int
J Artif Organs 2008; 31:1004-16.

36

.. 2557

 2 (3)
Dialyzer Reprocessing
1. Rinse / Pre-clean
2. Clean
3. Inspect / Test
4. Disinfect
5. Document / Store
5. Document / Store
Record summary
Storage conditions:
clean; minimize
deterioration,
contamination, and
breakage

1. Rinse / Pre-clean
Remove some of
the blood from the
blood component
RO water preferably
used, within 10 min

Dialyzer

Reprocessing

4. Disinfect
Peracetic acid
Formaldehyde
Glutaraldehyde
Heat disinfection
with acetic acid

Safe and effective

way to keep the
cost of dialysis
within reasons

Reuse: To use own

dialyzer, after being
reprocessed, for
multiple treatments 2. Clean

Peracetic acid
Bleach
(sodium hypochlorite)
Hydrogen peroxide

3. Inspect / Test
Inspect: crack, defect
Performance Test
TCV > 80% baseline
UF coefficient > 75%
Pressure Leak Test

37

4.
4.1
AAMI
regular pure European Pharmacopoeia
online hemofiltration hemodiafiltration
ultrapure
(++/II)

AAMI (1) European
Best Practice Guideline(2)
endotoxin online hemofiltration hemodiafiltration

endotoxin
ultrapure(3) ( 2

endotoxin )
4.2 reverse
osmosis (recirculation
loop)
(++/IV)
38

.. 2557


reverse osmosis (RO)
RO membrane

endotoxin
(recirculation)


6
endotoxin

4.3




(++/IV)





.. 2550 (4)

39

1) AAMI 1
2) 1 spread
plate membrane filtration Tryptone
glucose extract agar Reasoners agar No. 2 (20o-22o
7 )
3) endotoxin 3 1
hemofiltration hemodiafiltration
limulus amoebocyte lysate (LAL)
6

endotoxin (
100 CFU/mL endotoxin 0.25 EU/mL)(5)
AAMI action level ( 50 CFU/mL
endotoxin 0.125 EU/mL)



biofilm

40

.. 2557

1. Association for the Advancement of Medical

Instrumentation. Guidance for the preparation and
quality management of fluids for hemodialysis and
related therapies, ANSI/AAMI/ISO 23500:2011, Arlington,
VA: Association for the Advancement of Medical
Instrumentation, 2011.
2. European Directorate for the Quality of Medicines.
Purified water. In: European Pharmacopoeia 6.3.
Strasbourg, 2009, pp 4344-6.
3. Damasiewicz MJ, Polkinghorne KR, Kerr PG. Water
quality in conventional and home haemodialysis. Nat
Rev Nephrol 2012; 8:725-34.
4. .
.. 2550. [ 1
.. 2557]. : www.nephrothai.org/news/news.
asp?type=KNOWLEDGE &news_id=133
5. International Organization for Standardization. Quality
of dialysis fluid for hemodialysis and related therapies
(ANSI/AAMI/ISO 11663:2009). Arlington, VA, Associaltion
for the Advancement of Medical Instrumentation, 2010.

41

42

.. 2557

(./)
AAMI
European Pharmacopoeia

Aluminum
0.0100
0.0100
Chloramines
0.1000
0.1000
Free chlorine
0.5000
0.5000
Copper
0.1000
0.1000
Fluoride
0.2000
0.2000
Lead
0.0050
0.0050
Nitrate
2.0000
2.0000
Sulfate
100
100
Zinc
0.1000
0.1000

Calcium
2 (0.05 /)
2 (0.05 /)
Magnesium
4 (0.16 /)
2 (0.08 /)
Potassium
8 (0.2 /)
2 (0.08 /)
Sodium
70 (3.0 /)
50 (2.2 /)

Antimony
0.0060
0.0060
Arsenic
0.0050
0.0050
AA spectrometry
AA spectrometry

AA spectrometry
AA spectrometry
Flame photometry
Flame photometry

AA spectrometry
Colorimetry
Colorimetry
AA spectrometry
Molecular photoluminescence
AA spectrometry
Colorimetry
Turbidimetric method
AA spectrometry

2. AAMI (2011)
European Pharmacopoeia

43

(./)
AAMI
European Pharmacopoeia
0.1000
0.1000
0.0004
0.0004
0.0010
0.0010
0.0140
0.0140
0.0200
0.0200
0.0002
0.0010
0.0900
0.0900
0.0050
0.0050
0.0020
0.0020

AA spectrometry
AA spectrometry
AA spectrometry
AA spectrometry
Spectrophotometric
AA spectrometry
AA spectrometry
AA spectrometry
AA spectrometry

European Pharmacopoeia
Regular
Ultrapure
Sterile water for
water
water
substitution
<100
<0.1
<0.000001

<100
(CFU/ml)1
Action level
<50
2
<0.25
<0.25
<0.03
<0.03
endotoxin (EU/ml)
Action level
<0.125
1 spread plate membrane filtration low nutrient media Tryptone glucose
extract agar (TGEA) Reasoners agar No. 2 (R2A) 20o-22o 7
2 Limulus amebocyte lysate test turbidimetric kinetic assay gel clot

AAMI
(2011)

2. endotoxin

Barium
Beryllium
Cadmium
Chromium
Cyanide
Mercury
Selenium
Silver
Thallium

5.
5.1
unfractionated heparin low
molecular weight heparin
(++/II)



unfractionated heparin
(1) 50 IU/.
loading dose maintenance dose
800-1,500 IU 2
(constant infusion)
infusion pump (repeated bolus)
30
heparin kinetics heparin
activated clotting time
(ACT) 80% low molecular
weight heparin
unfractionated heparin (
bolus ) (
)

44

.. 2557


heparin
protamine sulfate
1 protamine sulphate 100
unfractionated heparin
heparin kinetics heparin

5.2


(++/II)



100-300 .
30 citrate

citrate unfractionated heparin
ACT
40% low molecular weight hepain
anti-Xa-level 0.2-0.3 0.4 IU/mL(2)

45

 5.3 heparin (heparin-

induced thrombocytopenia, HIT) 2

(++/II)
HIT 0.32
100
50%
150,000/. heparin
2 HIT 1
1-2
heparin
(immune-mediated reaction)
heparin HIT 2
heparin
platelet factor 4
4-20 ( 10)
(
3 4Ts Scoring System HIT 2)(2)
heparin low molecular
weight heparin cross-reaction

citrate ( 3
1 50 blood
flow 250 ) (3)

46

.. 2557

 5.4

(++/IV)
(thrombus)

heparinized saline 1,000 IU/mL

4% citrate

(4)

1. Shen JI, Winkelmayer WC. Use and safety of unfractionated heparin for anticoagulation during maintenance hemodialysis. Am J Kidney Dis 2012; 60:473-86.
2. Warkentin TE, Heddle NM. Laboratory diagnosis of
immune heparin-induced thrombocytopenia. Curr
Hematol Rep 2003; 2:148-57.
3. Syed S, Reilly RF. Heparin-induced thrombocytopenia:
a renal perspective. Nat Rev Nephrol 2009; 5:501-11.
4. Besarab A, Pandey R. Catheter management in
hemodialysis patients: delivering adequate flow. Clin
J Am Soc Nephrol 2011; 6:227-34.

47

48

.. 2557

Other causes of
thrombocytopenia

1-3, 4-5, 6-8 HIT 2 ,

()

1 ( )
heparin 30-100 )

Thrombosis or other

sequelae
(skin necrosis)

heparin

30 )

Timing of thrombo- 5-10 5-10 5

1 ( heparin
10 ( heparin
cytopenia

30-50% <30%
Thrombocytopenia >50%
9
20-100x10 / 10-19x109/ <10x109/

3 4Ts Scoring System Heparin (HIT) 2

6.
6.1
(first few sessions)
(++/IV)







(1) ( 4
)
6.2
(dialysis
disequilibrium syndrome)
40
(++/III)


24


urea

49

 paradoxical
acidemia

(
malignant hypertension )

40
2-3
150-200 .
500 .
sodium ( 140
) 35-36
(ultrafiltration rate) 1
10 ./.
ultrafiltration dialysis
(2)


hypertonic saline
15-20 . 50% glucose 25-50 .

glucose diazepam 5-10 .
5

50

.. 2557

30 . phenytoin

24 (3)

1. Daugirdas JT, Ross ED, Nissenson AR. Complications

during hemodialysis: In: Daugirdas JT, Blake PG, Ing
TS, eds. Handbook of dialysis fourth edition. New York:
Lippincott Willium & Wilkins Inc., 2007; 170-191.
2. Patel N, Dalal P, Panesar M. Dialysis disequilibrium
syndrome: a narrative review. Semin Dial 2008; 21:493-8.
3. Zepeda-Orozco D, Quigley R. Dialysis disequilibrium
syndrome. Pediatr Nephrol 2012; 27:2205-11.

51

52

.. 2557

( 40)

( 30 )

( 30 )

EKG

7.
7.1

(++/I)


(1)



(.. 2554)
1.

2. 4
1.8
3.

4.

53

5.

6.
0.5-1.0 % sodium hypochlorite

7.2


(+/IV)

7.3

(standard precaution)
(++/I)





54

.. 2557

1)

2) (
)
3)


4)

0.5% sodium
hypochlorite (Virkon) 10

5)
6)


7)

7.4


(++/I-2)

55





( area puncture
rope ladder) AVF
( buttonhole)
hematoma pseudoaneurysm

(2,3) ( 5
)
7.5 external pressure
transducer
internal pressure transducer


(+/IV)
pressure transducer
venous
pressure
internal pressure transducer
internal circuit

56

.. 2557

 7.6
clamp

(disinfection)

(+/IV)
extracorporeal circuit
dialyzer port

7.7
HIV 6-12


(+/I)

HIV


(
3 B C
)

57

1. Centers for Disease Control and Prevention and

Healthcare Infection Control Practices Advisory
Committee. Guidelines for environmental infection
control in healthcare facilities. [cited January 1, 2014].
Available at: http://www.cdc.gov/hicpac/pubs.html
2. Macrae JM, Ahmed SB, Hemmelgarn BR, Alberta
Kidney Disease Network. Arteriovenous fistula survival
and needling technique: long-term results from a
randomized buttonhole trial. Am J Kidney Dis 2014;
63:636-42.
3. MacRae JM, Ahmed SB, Atkar R, Hemmelgarn BR.
A randomized trial comparing buttonhole with rope
ladder needling in conventional hemodialysis patients.
Clin J Am Soc Nephrol 2012; 7:1632-8.

58

.. 2557

1. AVF
Native
arteriovenous (bacteremia)
fistula (AVF) 2
2. AVF /

subacute bacterial endocarditis
6
3. infected thrombi septic emboli
AVF
Arteriovenous 1. infected AVG
graft
4-6
(AVG)
infected thrombi
AVG
2.

3. incision drainage

4.
(anastomotic infection)

AVG

59

Hemodialysis 1. (exit site

infection)1
catheter

/
2.


1
2 4 bacteremia
- non-tunneled
catheter
- tunneled catheter

1.
2.

3. fungus, Staphylococcus
aureus gram negative bacteria (
36 )
4.
48-72
5. tunnel infection2
( vascular access )


48-72

1 Exit

site infection
2 ..
2 Tunnel infection

60

.. 2557

 3 B C

Anti-HBs (+) > 10 IU/L /
HBsAg (-) / anti-HBc (+/-)

Negative for all

serologies

Anti-HBc (+) /
anti-HBs (-) / HBsAg (-)
Test for HBV DNA, if available
-ve

VACCINATION

+ve
HBsAg (+)

Test for immune response

1-2 months after the last dose
Yes



1

Anti-HBs (+)
> 10 IU/L

No

RE-VACCINATION
(double dose)
Yes

Anti-HBs (+)
> 10 IU/L

No

1
Anti-HCV
antibody test

(+ve)

(-ve)

Liver
function test

(-ve)
HCV
RNA levels
(+ve)

HCV genotyping

61

8.

8.1

3

(++/IV)







3

(-)

8.2
(Hb) 1

(++/IV)

62

.. 2557


1

Hb (11 /.)

( 15)
8.3 (iPTH)
6

(++/IV)

(metabolic bone disease)
iPTH 6


ferritin, iron total iron binding
capacity 3-6 ( 13
14 )
8.4
18-24 /
(++/III)

(metabolic acidosis)
( )

63




lactate
(catabolism) (anabolism)


thyroxine leptin
beta-2-microglobulin

(16-24 /)

(1,2)



(sodium load)

18-24 /
8.5
4-5.5 /
(++/III)


64

.. 2557

 3-5(3)
/

angiotensin coverting enzyme inhibitor (ACEI) angiotensin II receptor blocker (ARB), beta-blockers, NSAIDs

5.6 4 /
(4)
cation
exchange resin
8.6
Kt/V
/ urea reduction ratio 3 (++/II)

urea Kt/V
single pool (spKt/Vurea) urea reduction ratio

65

(URR)
spKt/V = -ln(R-0.008xt) + (4-(3.5xR))xUF/BW
R postdialysis/predialysis BUN ratio
t dialysis session ()
UF ultrafiltration volume ()
BW predialysis weight ()
URR = 100x(predialysis BUN-postdialysis BUN)/
predialysis BUN

(GFR 5 ./)
3 spKt/V 1.2 URR
65%
(5) 3
spKt/Vurea URR
2
spKt/V 1.8
spKt/V 1.8 5
spKt/V 1.8-2.1
spKt/V (6)
2

66

.. 2557

1. Lowrie EG, Lew NL. Death risk in hemodialysis patients:

The predictive value of commonly measured variables
and an evaluation of death rate differences between
facilities. Am J Kidney Dis 1990; 15: 458-82.
2. Bommer J, Locatelli F, Satayathum S et al. Association
of predialysis serum bicarbonate levels with risk of
mortality and hospitalisation in the Dialysis Outcomes
and Practice Patterns Study (DOPPS). Am J Kidney Dis
2004; 44:661-71.
3. Morduchowicz G, Winkler J, Drazne E et al. Causes of
death in patients with end-stage renal disease treated
by dialysis in a centre in Israel. Isr J Med Sci 1992;
28:776-9.
4. Kovesday CP, Regidor DL, Mehorta R et al. Serum and
dialysate potasium concentrations and survival in
haemodialysis patients. Clin J Am Soc Nephrol 2007;
2:999-1007.
5. Lowrie EG, Zhu X, Lew NL. Primary associates of mortality
among dialysis patients: trends and reassessment of
Kt/V and urea reduction ratio as outcome-based
measures of dialysis dose. Am J Kidney Dis 1998;
32(Suppl 4): S16-S31.
6. Krairittichai U, Supaporn T, Aimpun P, et al. Thailand
registry patient survival report on chronic hemodialysis.
J Am Soc Nephrol 2005; 16:292A.

67

9.
9.1

6

(++/III)




6

(
), , subjective global assessment malnutrition inflammation
score (1) ( 6
)



normalized
protein catabolic rate normalized protein nitrogen
appearance (nPNA) two-BUN, single-pool, variable-
volume model
68

.. 2557

Midweek PNA = predialysis BUN/[25.8 + (1.15)/(spKt/V)

+ (56.4)/(spKt/V)] + 0.168
spKt/V Kt/V
single pool
nPNA (g/kg/d) = (PNA)/(TBW/0.58)
TBW total body water

- Watson formula:
Males: TBW = 2.447-(0.09156xage) +
(0.1074xheight) + (0.3362xweight)

Females: TBW = -2.097 + (0.1069xheight) +
(0.2466xweight)
- Hume-Weyer formula:
Males: TBW = (0.194786xheight) +
(0.296785xweight)-14.012934

Females: TBW = (0.34454xheight) +
(0.183809xweight)-35.270121
nPNA 1.2

nPNA
(2)

69

 9.2
30-35 / 1 /
1.2 / 1 /
(++/I)

.. 2553(3)

30-35 / 1 /
1.2 / 1 /
(high biological
value)

negative nitogen calcium balance

9.3


(++/III)


(protein energy wasting)
18-75 International Society

70

.. 2557

of Renal Metabolism and Nutrition (ISRMN)

3 4 (1)
, (2) , (3) ,
(4) (4)







(systemic inflammation)

71

 androgen,
growth hormone carnitine


(5) ( 4
)

1. Pupim LB, Cuppari L, Ikizler TA. Nutrition and metabolism in kidney disease. Semin Nephrol 2006; 26:134-57.
2. Combe C, McCullough KP, Asano Y, Ginsberg N,
Maroni BJ, Pifer TB. Kidney Disease Outcomes Quality
Initiative (K/DOQI) and the Dialysis Outcomes and
Practice Patterns Study (DOPPS): nutrition guidelines,
indicators, and practices. Am J Kidney Dis 2004; 44(5
Suppl 2):39-46.
3. .
.. 2553.
: ; 2553.
4. Leinig CE, Moraes T, Ribeiro S, et al. Predictive value
of malnutrition markers for mortality in peritoneal
dialysis patients. J Ren Nutr 2011; 21:176-83.
5. Ikizler TA, Cano NJ, Franch H, et al. Prevention and
treatment of protein energy wasting in chronic kidney
disease patients: a consensus statement by the International Society of Renal Nutrition and Metabolism.
Kidney Int 2013; 84:1096-107.
72

.. 2557

3
(BMI)

3
Subjective global

assessment (SGA) 6

3

<30-35 /../
<1.2 /../
7-10
3-6
18.5 ../2
B/C on 3-point scale (A/B/C)
1-5 on 7-point scale
3.5 /.

: serum
creatinine, serum cholesterol

serum
cholesterol

73

Subjective Global Assessment Rating Form

- : ______________ HN : _______ : _______

() :

Severe Mild- Normal

Moderate
RATING
1 2 3 4 5 6 7

6
2
< 5
5-10

> 10

(.) =
. (6 )-. x100 / . (6 )

RATING

1 2 3 4 5 6 7


________
()

RATING
1 2 3 4 5 6 7

_________
_________
_________
_________
_________
_________
_________
_________
<2 , ,
>2 1-2 /,
3-4 /,

-Normal: <2
-Mild to Moderate: <2
-Severe: >2

74

.. 2557


()
6
2 1 2





/
__________________
1 2
__________________

-

() :
Severe

RATING
3 4 5 6 7

RATING
3 4 5 6 7

Mild- Normal
Moderate

RATING
, triceps, 1 2 3 4 5 6 7


, , , ,
,

() :
OVERALL RATING
A.
(Rating 6-7 )
B. -
(Rating 3-5 )
C.
(Rating 1-2 )

75

Modified Subjective Global Assessment-

Dialysis Malnutrition Score

- : _________________ HN : _______ : _______

(A) :
1. ( 6 ) :
1
2
3
4
5

<5%
5-10%
10-15%
>15%
2. :
1
2
3
4
5

3. :
1
2
3
4
5

4. () :
1
2
3
4
5

76

.. 2557

5. :
1
2
3
4
5

1-2 2-4 >4

<1
>75

(B) :
1. (, triceps, ) :
1
2
3
4
5

()

2. (, , , , ,
, ) :
1
2
3
4
5

()

= ( 35 ) 1, 2 (A) 3-5 (B) >6 (C)

77

Malnutrition Inflammation Score (MIS)

- : _________________ HN : _______ : _______

(A) :
1.
( 3-6 ) :
0
1
2
3

>5%
1 .

<5%
(0.5-1 .)
<0.5 .
2. :
0
1
2
3

3. :
0
1
2
3

4. ( ) :
0
1
2
3

( )
5. :
0
1
2
3
>4

1-4
<1

(
(
( MCC*) MCC* 1 ) MCC* >2 )

78

.. 2557

(B) ( SGA criteria):

6. (, triceps, ) :
0
1
2
3
()

7. (, , , ,
, , ) :
0
1
2
3
()

(C) :
8. : BMI = Wt (kg)/Ht 2 (m)
0
1
2
3
BMI >20
BMI 18-19.99 BMI 16-17.99
BMI <16
(D)
9. (/.) :
0
1
2
3
>4.0
3.5-3.9
3.0-3.4
<3.0
p
10. total iron binding capacity (TIBC, ./.) :
0
1
2
3
>250
200-249
150-199
<150
10 =
( 30 )

1, 2 (A) 3-5 (B) >6 (C)

* MCC (Major Comorbid Conditions) CHF class III or IV, full

blown AIDS, severe CAD, moderate to severe COPD, major
neurologic sequelae, metastatic malignancies s/p recent
chemotherapy.
P transferrin (./.) : >200 (0), 170-200
(1), 140-170 (2), < 140 (3)

79

80

.. 2557
Intensified therapies
dialysis prescription

parenteral
( S.Albumin < 3.0 g/dl)
IDPN TPN

Poor appetite and/or poor oral intake
Unintentional weight loss > 5% of IBW EDW 3
S.Albumin < 3.8 g/dl
DPI < 1.2 g/kg/day
SGA in PEW range

Maintenance nutritional therapy goals

S.Albumin > 4.0 g/dl
DPI > 1.2 g/kg/day
DEI 30-35 kcal/kg/day

S.Albumin > 3.8 g/dl

Adjunct therapies (optional)

Anabolic hormones,
Androgens, Growth hormone
Appetite stimulants
Anti-inflammatory inventions
Exercise (as tolerated)

Nutritional Scoring:
MIS, SGA, anthropometrics

Continuous nutritional counseling
Optimize hemodialysis treatment and dietary nutrient intake
Manage comorbidities (acidosis, DM, inflammation, CHF, depression)

:
, , BMI, S.Albumin

10.
10.1



(++/I)
33-86
(plasma osmolarity)
/ (plasma volume)



( )
()
hyponatremia
()
hypomagnesemia, hypocalcemia,
hypokalemia, carnitine deficiency (1)





145-155 mEq/L

81

135-140 mEq/L (
vitamin E, vitamin C carnitine)
(2)

(stretching)
50% glucose
25-50 . hypertonic saline 15-20 .

disequilibrium


(3)



10


disequilibrium

metoclopramide 5-10 mg

82

.. 2557



/ proinflammatory cytokine
hyperparathyroidism
(4)




emollient moisturizer

10.2

(acute coronary syndrome)
aspirin nitroglycerin


(++/IV)


(air embolism)

83









(stable angina)
(chronic stable angina)
nitroglycerin





20

aspirin 160-325 .
nitroglycerin
(5)
10.3
(cardiac arrhythmia)
84

.. 2557




(++/IV)

5-75
( )

ventricular
arrhythmias ectopies atrial fibrillation(6,7)

10.4
(air embolism) clamp
blood pump 100%


(++/IV)

85




(8)

1) air
detector
2)

3)

4)
double clamp
5)
air detector

1) clamp blood pump

86

.. 2557

2)

3) 100% (mask)

4) (disconnect
blood line)
5) syringe 20 .
double lumen

6)

10.5
(anaphylaxis) A clamp blood line

B

(++/IV)
(allergic reaction)

First Use
Syndrome
endotoxin

87

 (natural rubber latex)

2 (9)
A
pre-formed Ig E antibody
5 30

(bronchospasm)

ethylene oxide
AN69 membrane ACEI ARB
clamp
antihistamine, steroid, epinephrine
10-15



B complement

20-60
antihistamine,


88

.. 2557

 10

1. Canzanello VJ, Burkart JM. Hemodialysis-associated

muscle cramps. Semin Dial 1992; 5:299.
2. Raymond CB1, Wazny LD. Treatment of leg cramps in
patients with chronic kidney disease receiving hemodialysis. CANNT J 2011; 21:19-21.
3. Bana DS, Yap AU. Giaham JR. Headache during
hemadialysis. Headache 1972; 12:1-14.
4. Narita I, Iguchi S, Omori K, Gejyo F. Uremic pruritus in
chronic hemodialysis patients. J Nephrol 2008; 21:161-5.
5. .

2551. [ 1 .. 2557]. : http://http://
www.thaiheart.org//guideline.html
6. Burton JO, Korsheed S, Grundy BJ, McIntyre CW.
Hemodialysis-induced left ventricular dysfunction is
associated with an increase in ventricular arrhythmias.
Ren Fail 2008; 30:701-9.
7. Genovesi S, Vincenti A, Rossi E, Pogliani D, Acquistapace I, Stella A, et al. Atrial fibrillation and morbidity and mortality in a cohort of long-term hemodialysis patients. Am J Kidney Dis 2008; 51:255-62.
8. Muth CM, Shank ES. Gas Embolism. N Engl J Med
2000; 342:476-82.
9. Sherman RA, Daugirdas JT, Ing TS. Complications during
hemodialysis. In: Daugirdas JT, Blake PG, Ing TS, editors.
Handbook of Dialysis. 4th ed. Philadelphia: Lippincott
Williams & Wilkins; 2007. p.170-91.

89

11.
11.1

30
(++/IV)





(reverse epidemiology)(1)





11.2
140/90 . 130/80 .

(++/III)


(2)
24 (ambulatory blood pressure
90

.. 2557

monitoring ABPM)
1-2
Kidney Disease Outcomes Quality
Initiative (KDOQI) 140/90
. 130/80 . (3)
(systolic)


(4)

11.3 (non
pharmacological therapy)
/
1. 2-3

2. 18.5-23 .
3.

4.
(probing dry-weight)
5.
sodium profile
(++/IV)

91

2-3

0.5-1 ./(5)
11.4 angiotensin coverting enzyme inhibitor (ACEI) angiotensin
II receptor blocker (ARB)
-blocker calcium
channel blocker
(++/III)
2-3


ACEI ARB



( )
-blocker - -blocker
calcium
channel blocker
92

.. 2557

 vasodilator
( 5
)


1


(6)
11.5 (intradialytic hypertension)

(++/II)
5-15
(dry weight)

(7.8)

1) (mean arterial blood pressure)

15 .

2) 10 .

93

3) 2-3

4)

5) erythropoietin stimulating agents

cardiac output, renin-
angiotensin-aldosterone sympathetic,
()
, endothelial dysfunction

11.5




(++/III)

94

.. 2557


(7)

1)

ESA
2)
ACEI, ARB adrenergic receptor blocker

captopril, enalapril, lisinopril, perindopril, atenolol, nadolol,
sotalol, hydralazine, methyldopa (6)
3)

4)

5)

( 7 )

95

 11

1. Kalantar-Zadeh K, Kilpatrick RD, McAllister CJ, Greenland S, Kopple JD. Reverse epidemiology of hypertension and cardiovascular death in the hemodialysis
population: the 58th annual fall conference and
scientific sessions. Hypertension 2005; 45:811-7.
2. Agarwal R. The controversies of diagnosing and treating hypertension among hemodialysis patients. Semin
Dial 2012; 25:370-6.
3. NKF. K/DOQI clinical practice guidelines for cardiovascular
disease in dialysis patients. Am J Kidney Dis 2005; 45
(4 Suppl 3):S1153.
4. Tozawa M, Iseki K, Iseki C, Takishita S. Pulse pressure
and risk of total mortality and cardiovascular events
in patients on chronic hemodialysis. Kidney Int 2002;
61:717-26.
5. Ararwal R. Management of hypertension in hemodialysis patients. Hemodialysis Int 2006; 10:241-8.
6. Inrig JK. Antihypertensive agents in hemodialysis patients: a current perspective. Semin Dial 2010; 23:290-7.
7. Inrig JK. Intradialytic hypertension: a less-recognized
cardiovascular complication of hemodialysis. Am J
Kidney Dis 2010; 55:580-9.
8. Locatelli F, Cavalli A, Tucci B. The growing problem
of intradialytic hypertension. Nat Rev Nephrol 2010;
6:41-8.

96

.. 2557

 7
(Intradialytic Hypertension)

Reduce volume
overload

- Increase ultrafiltration
- Reduce cardiac output
- Restrict dietary salt
Control electrolyte - Ensure an adequate intradialytic sodium
changes
balance
- Reduce dialysate calcium concentration
Reduce sympathetic - Administer angiotensin converting enzyme
overactivity
inhibitors
- Administer angiotensin II receptor blockers
- Administer adrenergic receptor blockers
(-blockers and -blockers)
- Increase frequency of dialysis
- Increase duration of dialysis
Inhibit renin
- Administer angiotensin converting enzyme
angiotensin
inhibitors
aldosterone system - Administer angiotensin II receptor blockers
Evaluate concurrent - Consider whether the patients
therapies
antihypertensive drugs might be being
removed by dialysis
- Consider erythropoietin stimulating agent
dosage

97

> 140/90 .
> 130/80 .

1 Non-pharmacological therapy
1. < 2-3 / 0.5-1 ./
( 18.5-23 . )
2. ( 0.3 .)
3. sodium profile
( 1 mEq/L 140 136 mEq/L Sodium ramp)

2 Pharmacological therapy

-ve

140-159/90-99 .
- ACEI ARB
> 160/100 .
- 2 ACEI ARB
calcium channel blocker
- Furosemide

+ve

-
- - / -blockers
- 2o cause(s)
- vasodilators

98

.. 2557

12.
12.1 (intradialytic hypotension)

(++/I)

15-55

20 .
10 .
(1)



2

/

( 8
)

99

 12.2

(++/II)

1) (supine)
(Trendelenburg position)
2)
3)
4) normal saline 100-250 . 50%
glucose 50-100 . hypertonic
saline albumin
5) dopamine
norepinephrine


(2,3)
1)
bioimpedance
inferior vena cava

100

.. 2557

2)
( 0.5-1 .)

3)

4)

5) sodium
modeling

6) 35-36o

7)

Midodrine (alpha agonist) 5-10 . 30
(), Sertraline
(serotonin uptake inhibitor) 50-100 ./ carnitine
20-30 ././

101

 12.3


(++/II)


/

12

1. NKF. K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. Am J Kidney Dis 2005;
45 (4 Suppl 3):S1153.
2. Palmer BF1, Henrich WL. Recent advances in the
prevention and management of intradialytic hypotension. J Am Soc Nephrol 2008; 19:8-11.
3. Agarwal R. How can we prevent intradialytic hypotension? Curr Opin Nephrol Hypertens 2012; 21:593-9.

102

.. 2557

 8
(Intradialytic Hypotension)

- Excessive interdialytic
weight gain (more than
3% of body weight)
- Interdialitic food consumption
- Autonomic neuropathy
- Myocardial infarction
- Left ventricular hypertrophy
- Diastolic dysfunction
- Arrhythmia
- Pericardial tamponade
- High ultrafiltration rate
- Dialysis with acetate
- High dialysate temperature
- Electrolyte abnormalities

- Prescribe antihipertensive
or other medications
that lower blood pressure before dialysis
- Incorrect calculation of
dry weight

- Limit interdialytic weight

gain by reducing salt
and water intake
- Prohibit food ingestion
during hemodialysis
- Midodrine, sertraline,
l-carnitine
- Treat underlying cardiovascular diseases
- Reduce ultrafiltration
rate
- Dialysis with bicarbonate
- Cool dialysate
- Ultrafiltration modeling
- Dialysate sodium modeling
- Increase dialysate calcium
- Consider adjusting antihypertensive medications or timing
- Establish an accurate
dry weight

103

13.

13.1

3


(++/IV-1)

3

3 6
1

13.2
2.7-4.9 ./. 9.0-10.2
./.
(++/IV-2)

104

.. 2557



(bone turnover)
(vascular calcification)

(1,2)

2.7-4.9 ./. 9.010.2 ./.
13.3 (intact parathyroid hormone, PTHi) 2 9
130-600 /.
(++/IV-2)

(second generation) N-terminal
(bio-active) C-terminal (inactive) PTH
C-terminal PTH (3)
15 40(4)

(5)



(6,7)
PTHi 2

105

 9 130-600 /.
adynamic bone disease
PTHi
13.4

(phosphate binder)

(++, III-2)

(8) (9)

-

coronary calcification
(10,11)

106

.. 2557

 ( 9
)
calcium carbonate
elemental
calcium 1,500 ./ 1)

, 2) Ca x P 63 (./.)2, 3)
2
2 4)

osteomalacia
7 ./.
4
13.5 2

active
(+, IV-1)

2 active

107

 2 ( 300
/.)

active alfacalcidol (1-a-hydroxyvitamin
D3) calcitriol
(pulse)
(12)
1)
, 2)
, 3)
, 4) adynamic bone disease
5)

13.6


(+, IV-2)

( 900 /.)
(1)

(active vitamin D pulse therapy)
subtotal
total parathyroidectomy with autotransplantation
108

.. 2557

(13,14)


calcimimetics(15) ( 6
)

13

1. Block GA, Klassen PS, Lazarus JM, Ofsthun N, Lowrie

EG, Chertow GM. Mineral metabolism, mortality, and
morbidity in maintenance hemodialysis. J Am Soc
Nephrol 2004; 15:2208-18.
2. Tentori F, Blayney MJ, Albert JM, et al. Mortality risk
for dialysis patients with different levels of serum
calcium, phosphorus, and PTH: the Dialysis Outcomes
and Practice Patterns Study (DOPPS). Am J Kidney Dis
2008; 52:519-30.
3. Herberth J, Fahrleitner-Pammer A, Obermayer-Pietsch
B, et al. Changes in total parathyroid hormone (PTH),
PTH-(1-84) and large C-PTH fragments in different
stages of chronic kidney disease. Clin Nephrol 2006;
65:328-34.
4. Souberbiel e JC, Boutten A, Carlier MC, et al. Inter-method
variability in PTH measurement: implication for the care
of CKD patients. Kidney Int 2006; 70:345-50.

109

5. Herberth J, Branscum AJ, Mawad H, Cantor T, MonierFaugere MC, Malluche HH. Intact PTH combined with
the PTH ratio for diagnosis of bone turnover in dialysis
patients: a diagnostic test study. Am J Kidney Dis 2010;
55:897-906.
6. Coco M, Rush H. Increased incidence of hip fractures
in dialysis patients with low serum parathyroid hormone.
Am J Kidney Dis 2000; 36:1115-21.
7. Danese MD, Kim J, Doan QV, Dylan M, Griffiths R,
Chertow GM. PTH and the risks for hip, vertebral, and
pelvic fractures among patients on dialysis. Am J
Kidney Dis 2006; 47:149-56.
8. Shinaberger CS, Greenland S, Kopple JD, et al. Is
controlling phosphorus by decreasing dietary protein
intake beneficial or harmful in persons with chronic
kidney disease? Am J Clin Nutr 2008; 88:1511-8.
9. Kalantar-Zadeh K, Gutekunst L, Mehrotra R, et al.
Understanding sources of dietary phosphorus in the
treatment of patients with chronic kidney disease. Clin
J Am Soc Nephrol 2010; 5:519-30.
10. Daugirdas JT, Finn WF, Emmett M, Chertow GM. The
phosphate binder equivalent dose. Semin Dial 2011;
24:41-9.
11. Block GA, Raggi P, Bellasi A, Kooienga L, DM S.
Mortality effect of coronary calcification and phosphate
binder choice in incident hemodialysis patients. Kidney
Int 2007; 71:438-41.

110

.. 2557

12. Duranton F, Rodriguez-Ortiz ME, Duny Y, Rodriguez M,

Daurs JP, Argils A. Vitamin D treatment and mortality
in chronic kidney disease: a systematic review and
meta-analysis. Am J Nephrol 2013; 37:239-48.
13. Iwamoto N, Sato N, Nishida M, et al. Total parathyroidectomy improves survival of hemodialysis patients
with secondary hyperparathyroidism. J Nephrol 2012;
25:755-63.
14. Sharma J, Raggi P, Kutner N, et al. Improved long-term
survival of dialysis patients after near-total parathyroidectomy. J Am Coll Surg 2012; 214:400-7.
15. Garside R, Pitt M, Anderson R, et al. The effectiveness
and cost-effectiveness of cinacalcet for secondary
hyperparathyroidism in end-stage renal disease patients
on dialysis: a systematic review and economic evaluation.
Health Technol Assess 2007;11:iii, xi-xiii, 1-167.

111

pH
depen dence
*
1.0
pation,
Consti
GI discomfort
Soft tissue
and vascular
calcification
Hypercalcemia
1.0
Metal
Elemental
Constilipcatitaste
on,
Ca 25%
GI discomfort
.
Soft tissue and
vascular
calcification
Hypercalcemia
1.5
Aluminum
X Constipation
Osteomalacia
138 mg
Adynamic bone
(500 mg
disease
tablet)
Microcytic anemia
Encephalopathy

Calcium Capsule, Elemental

carbonate tablet
Ca 40%
.
Calcium
acetate

Tablet

Aluminum Liquid,
hydroxide Tablet

Lanthanum Chewable Lanthanum

carbonate tablet
418 mg

1.2

GI discomfort

Sevelamer Film
carbonate coated
tablet

0.75

GI discomfort

* RPBC: relative phosphate-binding coefficient

calcium carbonate(10)

112

.. 2557

S. albumin, corrected calcium,

phosphate 3
Phosphate

Calcium

intact
PTH

Phosphate restricted diet

Phosphate binder

calcium

Serum calcium,
phosphate

2-9

> 2-9

Follow up

Calcitriol 0.25-0.5 g
Alfacalcidol 0.5-1 g
twice thrice a week, post HD
( 12 g/week of Calcitriol)

Phosphate
- calcium
containing phosphate
binder (elemental Ca
1,500 ./)
- calcium free phosphate
binder
-

- low dialysate
calcium 2.5 mEq/L
- Calcium free
phosphate binder

Serum calcium /
phosphate

calcitriol / alfacalcidol
Serum calcium /
phosphate
Parathyroidectomy PTHi

113

14.
14.1
(hemoglobin, Hb)
13.0 /. 12.0 /.
15
(++/IV-1)


(hemoglobin, Hb) 2
Hb 13.0 /. 12.0 /.
15 (1)
normocytic, normochromic anemia
erythropoietin (EPO)




(2)
1. Complete blood count (CBC) Hb, red
blood cell indices (mean corpuscular haemoglobin [MCH],
mean corpuscular volume [MCV], mean corpuscular
haemoglobin concentration [MCHC]),

114

.. 2557

2. peripheral blood smear

3. Red cell distribution width (RDW) corrected
reticulocyte count
4.
ferritin transferrin saturation (% TSAT)
5. ( vitamin
B12 folate
)
14.2
(erythropoiesis stimulating agent, ESA)
Hb 10 /.

(+/IV-1)
Hb
10 /.
Hb
(blood transfustion)
Hb

ESA Hb 10 /.
(2,3)
ESA
ferritin

115

 100 (
200-500
) % TSAT 20
ESA 3-6 (2)
14.3 ESA
Hb 10-11.5 /. 13 /. (+/I-1)
Hb ESA

/


Hb
ESA 10-11.5 /.(4)
ESA
Hb 10-11 /.(5)
Hb 13 /.

(4)
ESA Hb
1-2 /.

116

.. 2557

 Hb short acting
ESA (epoetin alfa epoetin beta) 80-120
( 6,000 ) 2-3
2-4
25 Hb 11 /. ESA

ESA
19-25
. 5-11 .
30
(antibody) ESA
(pure red cell aplasia)
ESA biosimilar(6)
14.4 ESA
ferritin 500 % TSAT
30
1-3

(++, III)

ferritin 500 % TSAT
50 ESA

117





1-3 elemental
iron 200 1
2



iron sucrose iron gluconate (non-dextran
iron) iron sucrose 100
10 maintenance
dose 50-100 1-2 iron gluconate 125
8 62.5-125 1-2

60
non-dextran iron anaphylactoid anaphylaxis iron dextran

ferritin 800
% TSAT 50

118

.. 2557

 3
(iron overload) (4)

14.5 epoetin 300

( 450
) Hb
ESA

(+, IV-1)
ESA

ESA





Hb
pure red cell aplasia (PRCA)
(7)

119

1. ESA 3
2. Hb 0.5-1 /.
1-2
3. absolute reticulocyte count 10,000

4.
- erythroblast
5
- neurtalizaing anti-erythropoietin antibodies
PRCA ESA

(corticosteroids cyclophosphamide cyclosporine)
PRCA





(cold-chain)

120

.. 2557

 14

1. World Health Organization, Centers for Disease Control

and Prevention. In: de Benoist B, McLean E, Egli I,
Cogswell M, eds. Worldwide prevalence of anaemia
19932005. Geneva, World Health Organization, 2008.
2. NKF. K/DOQI clinical practice guidelines and clinical
recommendations for Anemia in Chronic Kidney
Disease. Am J Kidney Dis 2006; 47(Suppl. 3):S9145.
3. http://www.fda.gov/Drugs/DrugSafety/ucm259639.htm
(Accessed on July 1, 2014).
4. KDIGO Anemia Work Group. KDIGO clinical practice
guideline for anemia in chronic kidney disease. Kidney
Int Suppl 2012; 2: 279335.
5. Thaweethamcharoen T, Sakulbumrungsil R, Nopmaneejumruslers C, Vasuvattakul S. Cost-utility analysis of
erythropoietin for anemia treatment in Thai end-stage
renal disease patients with hemodialysis. Value Health
Regional Issue 2014; 3:44-49.
6. Praditpornsilpa K, Tiranathanagul K, Kupatawintu P, et
al. Biosimilar recombinant human erythropoietin induces
the production of neutralizing antibodies. Kidney Int
2011; 80:88-92.
7. Pollock C, Johnson DW, Hrl WH, et al. Pure red cell
aplasia induced by erythropoiesis-stimulating agents.
Clin J Am Soc Nephrol 2008; 3:193-9.

121

15.
15.1
(residual renal function)

(+, IV-1)


(middle molecule)

eGFR 5 .//1.73 (1,2)

24
urea clearance

Urea Clearance (Kr) = UUN x urine flow rate (./)

0.9 x BUN

(0.9 blood urea nitrogen (BUN)

90 BUN )
Kr 3 ./ eGFR 5
.//1.73 24 .
800 . urine urea nitrogen (UUN) 300 .
. BUN 60 .. Kr = (300 x
0.56) / 0.9 x 60 = 3.1 ./
122

.. 2557

 15.2

(++, IV-2)

(3)
1.
-
(biocompatibility)
- (bicarbonate-based) (ultrapure)
-

-

2.
-
-
140/90 . 130/80 .
ACEI / ARB (4)

123

-
NSAIDs, COX-2 inhibitors, aminoglycosides, radiocontrast media
-

15

1. Chandna SM, Farrington K. Residual renal function:

considerations on its importance and preservation in
dialysis patients. Semin Dial 2004; 17:196-201.
2. Termorshuizen F, Dekker FW, Van Manen JG, Korevaar
JV, Boeschoten EW, Krediet RT. Relative contribution
of residual renal function and different measures of
adequacy to survival in hemodialysis patients: An
analysis of the Netherlands Cooperative Study on the
Adequacy of Dialysis (NECOSAD)-2. J Am Soc Nephrol
2004; 15:1061-70.
3. Brener ZZ1, Kotanko P, Thijssen S, Winchester JF, Bergman M. Clinical benefit of preserving residual renal
function in dialysis patients: an update for clinicians.
Am J Med Sci 2010; 339:453-6.
4. Xydakis D, Papadogiannakis A, Sfakianaki M, et al.
Residual renal function in hemodialysis patients: the
role of Angiotensin-converting enzyme inhibitor in its
preservation. ISRN Nephrol 2012; 2013:184527.

124

.. 2557

16.
16.1

(++, IV-1)






(drug interaction)

(1,2)
( 10
)
16.2
(narrow therapeutic index)
(++, III)
(therapeutic index, TI)

(median toxic dose, TD 50)
(median effective dose,
ED 50) TI 2

125





aminoglycoside




(3) ( 11

)
16.3

(++, III)





30
(4)

126

.. 2557

 16

1. Pai AB, Cardone KE, Manley HJ, et al. Dialysis Advisory

Group of American Society of Nephrology. Medication
reconciliation and therapy management in dialysisdependent patients: need for a systematic approach.
Clin J Am Soc Nephrol 2013; 8:1988-99.
2. Cardone KE, Bacchus S, Assimon MM, Pai AB, Manley
HJ. Medication-related problems in CKD. Adv Chronic
Kidney Dis 2010; 17:404-12.
3. Dosage of antimicrobial drugs in adult patients with
renal impairment. In: Gilbert DN, Moellering RC, Eliopoulos
GM, Sande MA, editors. The Sanford Guide to Antimicrobial Chemotherapy 2010. 40th ed. Antimicrobial
Therapy Inc.; 2008. p.186-93.
4. Bailie GR, Mason NA. 2013 Dialysis of Drugs. Renal
Pharmacy Consultants, LLC, Saline, Michigan, USA.

127

 10

Aminoglycosides Furosemide

Antacids

Iron, fluoroquinolone,
ketoconazole,
tetracycline

Beta-blockers

Prazosin

first-dose syncope

Calcium acetate Fluoroquinolone

antibiotics

chelation

NSAIDs

Diuretic

Phenobarbital

Calcium channel
blockers, propranolol,
quinidine, warfarin

Salicylates

Heparin, warfarin

128

.. 2557

 11

Acyclovir
Aminoglycosides
Cyclosporin
Carbamazepine
Digoxin
Fluoroquinolones
Lidocaine
Lithium
Phenobarbital
Phenytoin
Procainamide
Quinidine
Tacrolimus
Theophylline
Valproic acid
Vancomycin

Delirium, tremor, seizures, hypotension

Auditory or vestibular nerve damage,
curare-liked block
Hypertension, neurotoxicity, liver dysfunction
Diplopia, ataxia, blood dyscrasias
Arrhythmia, nausea, vomiting, diarrhea,
hallucination, visual aberrations
GI distress, headache, dizziness, insomnia
Arrhythmia, cardiovascular depression,
seizure
Tremor, sedation, ataxia, aphasia
Sedation
Nystagmus, diplopia, ataxia, sedation
Drug-induced lupus erythematosus,
torsade de pointes
Headache, tinnitus, cardiac depression,
GI upset, torsade de pointes
Peripheral neuropathy, gastrointestinal
distress, hyperglycemia
GI distress, tremor, insomnia, vomiting,
hypotension, arrhythmia, seizure
GI distress, hepatotoxicity
Fever, chill, phlebitis, ototoxicity, red man
syndrome

129

17.
17.1

(++, IV-1)
17.2
(withhold) (withdraw)
(1,2)

1.

2.


3.


4.

5. ( )

130

.. 2557

6. 75
2 4
1

1)

2) comorbidity score ( Charleson

comorbidity score > 8 French Renal Epidemiology and
Information Network (FREIN) 6-Month Prognosis Clinical
Score > 9)
3)
(Functional Status) ( Karnofsky Performance Status score 40)
4)

(++, IV-1)

131


(terminal stage)


(2,3)

17

1. Moss AH. Revised dialysis clinical practice guideline

promotes more informed decision-making. Clin J Am
Soc Nephrol 2010; 5:2380-3.
2. Swidler M. Considerations in starting a patient with
advanced frailty on dialysis: complex biology meets
challenging ethics. Clin J Am Soc Nephrol 2013; 8:1421-8.
3. Moss AH. Ethical principles and processes guiding
dialysis decision-making. Clin J Am Soc Nephrol 2011;
6:2313-7.

132

.. 2557

 (Strength of Recommendation)
++

(cost
effective)
/ (strongly recommend)
+

/ (recommend)
+/-

(neither recommend nor against)

-

(against)
--

(strongly against)

133

 (Quality of Evidence)
I
I-1 (systematic review)
- (randomize-controlled
clinical trials)
I-2 -

1 (a well-designed, randomize-controlled,
clinical trial)
II
II-1
(non-randomized, controlled, clinical trials)
II-2 (well-
designed, non-randomized, controlled clinical trial)
II-3
(cohort) (case
control analytic studies)
/
II-4 (multiple time series)

III
III-1 (descriptive studies)
III-2
(fair-designed, controlled
clinical trial)
IV
IV-1
(consensus)

IV-2
2

134

.. 2557


.. 2553-2555
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

135


.. 2555-2557
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

136

.. 2557


.. 2553-2555
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

137


.. 2555-2557
1.
2.
3.
4.
5.
( )
6.
7.
8.
9.
10.
11.
12.
13.
14.

138

.. 2557