Preskripsi HD

Preskripsi Hemodialisis
Akut dan Kronis
HARNAVI HARUN
Sub-Bagian Ginjal Hipertensi, Bagian Ilmu Penyakit Dalam
Fakultas Kedokteran, Universitas Andalas Padang
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Adekuasi dialisis
Gold
Standar Balance Elektrolit
HD
Regulasi Volume
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2
Dialysis Modality
Dialysis Frequency
Dialysis Duration
Dialysis Dose
• Sodium
Dialysis • Potassium
• Calcium
Prescription Dialysate
• Bicarbonate
• Temperature
Ideal body weight (IBW)
Initial HD Prescription
Chronic HD Prescription
3
Dialysis Modality
4
5
Prinsip Transport Solut
Hemodialisis dan Hemofiltration
6
Dialysis Frequency
Durasi Frekuensi
Waktu (Jam/sesi) (sesi/minggu)
Convensional HD Siang 3-5 3-4

Frekuensi HD
Short Siang <3 5–7
Standar Siang 3–5 5–7
Long Malam >5 5-7
Long HD
Long tiga kali seminggu Malam atau Siang >5 3
Long setiap malam Malam >5 3–5
Long frekuensi Malam >5 5-7
7
Komponen Resep Dialisis
• Hemodialisis merupakan terapi dan dibutuhkan resep

hemodialisis
• Resep hemodialisis diberikan secara individual sesuai dengan

karakteristik dan kebutuhan pasien yang dapat ditolerasi.
• Pemilihan resep secara depenen terhadap modalitas dialisis

yang dikerjakan.
8
Resep Dialisis
Variabel untuk mencapai standar adekuasi nilai Kt/V dan URR :
Durasi
Frekuensi.
Blood flow (Qb)
Dialysate flow (Qd)
Dialyzer size
9
Resep Dialisis
Durasi
• Lama 3 – 4 jam
• 3 kali seminggu
• Waktu bisa ditingkatkan jika
Frekuensi
Kt/V dan atau URR tidak
tercapai
• Intermittent in center HD : 3 kali
seminggu
• Intermittent home HD
• Short daily HD (6 kali seminggu)
• Nocturnal HD ( 6 – 8 jam, 6 kali
seminggu)
10
Resep Dialisis
Guidelines KDOQI merekomendasikan in-center short

frequent hemodialisis sebagai alternatif terapi konvensional
setelah dilakukan pertimbangan :
• Lebih disukai pasien

• Potensial terhadap quality of life
• Keuntungan psikologis
• Resiko dari terapi tersebut.
11
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Resep Dialisis
Blood flow rate
01 Arteriovenous fistulas (AVFs) : terbaik. Flow rate 600 – 800 cc/min. Bisa
maintenen patensi untuk flow 200 cc/min
02 Arteriovenous grafts (AVG): flow rate 1000 – 1500 cc/min
03 Cuffed tunneled dialysis catheters . 350 – 400 cc/min
04 Femoral catheters : flow rate 400 – 500 cc/min untuk fistula dan graft. 350
– 400 cc/min untuk kateter.
05 Dialysate flow : 500 – 800 cc/min

12
Resep Dialisis
Dialyzer size : dializer merupakan rigid polyurethrane shell (≈30 cm long),
campuran hollow fibres (capillaries) dari membran dialisat :
Lebih panjang terekspor surface area bila dapat digunakan untuk

membantu mencapai adekuasi
Dialyser efficiensy : dihitung sebagai KoA (mass transfer urea

coefficient). Bisa High flux > 600 atau low flux <300
13
Electrolyte Balance
Dialysate : A solution of Cl-

ultrapure water
Dextrose
Na+ ( 132 – 150 mmol/L)
Buffer (usually HCO3-)
K+ ( ussually 1.0 – 3.0 mmol/L)
Ultrapure water is
Ca2+ (1.0 – 1.25 mmol/L) generated in treatment
plant
Mg 2+
14
Dialysate Potassium Concentration
1 Depends on the patient’s pre-HD K+ concentration
2 Serum K+ ≥5.5 mEq/L→ a dialysate K+ of 2- 3 mEq/L
3 If propensity toward arrhythmias, 3 mEq/L bath is preferred to avoid precipitating hypokalemia
4 A dialysate K+ of 4 mEq/L →patients with hypokalemia or persistent serum K+ <3.5 mEq/L
5 Serum K+ >6.5 to 7.0 mEq/L or ECG changes hyperkalemia, → 0 or 1 mEq/L dialysate K+.
15
Sodium Modelling
1 140 - 145 mEq/L is appropriate in most cases
2 ↓ serum Na+ levels indicate excessive free water intake and managed through fluid restriction
3 Serum sodium <130mEq/L→ the dialysate sodium conc <= 15 - 20 mEq/L above the serum levels
4 Hypernatremia should also be corrected slowly
5 Dietary Na+ <100mmol/day intake (equivalent to 6g NaCl)
16
Calcium Concentrations
1 Guidelines recommend ↓ dialysate Ca 2+ to maintain neutral or negative Ca 2+ balance to prevent vascular
calcification
2 ↑ patient: dialysate gradients associated with SCD
3 Dialysate Ca 2+ of 1.25mmol/L normally used
4 May be increased to 3-3.5mmol/l in

• persistent hypercalcemia,
• concurrent acidosis
17
Dialysate Bicarbonate
1 Usually of 35 - 38 mEq/L to correct the metabolic acidosis associated with chronic renal failure.
2 For those susceptible to alkalosis, lower bath of 20 - 28 mEq/L can be used. E.g.
• total parenteral nutrition (TPN),
• vomiting or nasogastric suction,
• poor protein intake,
• Respiratory alkalosis.
18
Volume Regulation : Ultrafiltration
Fluid restriction to limit intradialytic weight >4 to 5 L of ultrafiltrate → uncomfortable fluid

gains to <4 kg shifts and intradialytic hypotension
Ultrafiltrate should not be ˃ 10% of Patients with low residual kidney function (< 2
patient’s body water ml/min) undergoing 3x weekly HD require 3 hours
minimum.
19
Volume Regulation : Ultrafiltration
Additional sessions or longer treatment times for pts with
large weight gains

poor metabolic control
(such as hyperphosphatemia,
metabolic acidosis, and/or high ultrafiltration rates
hyperkalemia).
poorly controlled
difficulty achieving
blood pressure
dry weight
20
Anticoagulation
Heparinization during HD minimizes clotting of the dialysis circuit during the treatment
For patients with evidence of bleeding, no heparin is prescribed. This includes :
Uraemic gastritis Haemorrhagic stroke
GI bleeding Recent surgery
Pericardial effusion Post transplant patients
21
Anticoagulation
Risk factors for Clotting include :
high hemoglobin and hematocrit
a high rate of ultrafiltration
low blood flow on dialysis
Both unfractionated and LMWH can be used
22
Dialysis Adequacy
Dialysis can be considered adequate if it :
01 • provides relief of uraemic symptoms

02 • controls acidosis, fluid balance, and serum K +
03 • It should also allow a feeling of physical and psychological well-
being.
Adequacy is mainly modelled by 2 equations :
01 • Kt/V
02 • urea reduction ratio
23
Dialysis Adequacy
Kt/V: is a ratio that relates the volume of cleared
plasma (Kt) to the volume of urea distribution (V)
K = dialyser urea clearance.(ml/min)

t = time on dialysis.(min)
V = volume of distribution of Ur (estimated from patient
size).(ml)
Describes the volume of urea cleared during a dialysis

session relative to the volume of urea distributed
throughout the body.
spKt/V: single pool urea clearance

eKt/V: equilibrated urea clearance
stdKt/V: Weekly standard urea clearance
24
KDOQI guidelines on Adequacy
A target single pool Kt/V (spKt/V) of 1.4 per session for patient treated
thrice weekly, with a minimum delivered spKt/V of 1.2.
If significant residual native kidney function (Kr), the dose of

hemodialysis may be reduced
For hemodialysis schedules other than thrice weekly, a target standard

Kt/V of 2.3 volumes per week with a minimum delivered dose of 2.1
25
Dialysis Adequacy
01 Urea reduction rate (URR) similarly reflects the

removal of urea
02 URR = (BUNpre–BUNpost)/BUNpre
03 K/DOQI guidelines recommend the attainment of a

minimal URR of 65% and a target URR of 70%.
26
Komponen Mayor Dialysis Prescription
Pemilihan biocompatible membrane
Resep Kt/V ≥ 1.3 atau URR ≥ 70%
Ketika dosis hemodialisis tidak mencukupi :

• Tingkatkan blood flow rate ≥ 400 mL/min
• Tingkatkan dialisate flow rate ≥ 800 mL/min
• Gunakan high efficiency dialyzer
• Tingkatkan durasi hemodialisis
Pemilihan komponen dialisate : sodium, potasium, bicarbonate, dan calsium

Ultrafiltasi disesuai dengan berat badan kering
Pemberian eritropoetin sebagai mentenen hematocrit antara 33% sampai 36%.
27
TERIMA KASIH
28

Preskripsi HD

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Preskripsi HD

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Preskripsi Hemodialisis

Akut dan Kronis

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Convensional HD Siang 3-5 3-4

• Hemodialisis merupakan terapi dan dibutuhkan resep

• Resep hemodialisis diberikan secara individual sesuai dengan

• Pemilihan resep secara depenen terhadap modalitas dialisis

Variabel untuk mencapai standar adekuasi nilai Kt/V dan URR :

Guidelines KDOQI merekomendasikan in-center short

• Lebih disukai pasien

Blood flow rate

03 Cuffed tunneled dialysis catheters . 350 – 400 cc/min

05 Dialysate flow : 500 – 800 cc/min

Lebih panjang terekspor surface area bila dapat digunakan untuk

Dialyser efficiensy : dihitung sebagai KoA (mass transfer urea

Dialysate : A solution of Cl-

2 Serum K+ ≥5.5 mEq/L→ a dialysate K+ of 2- 3 mEq/L

3 If propensity toward arrhythmias, 3 mEq/L bath is preferred to avoid precipitating hypokalemia

4 A dialysate K+ of 4 mEq/L →patients with hypokalemia or persistent serum K+ <3.5 mEq/L

4 Hypernatremia should also be corrected slowly

5 Dietary Na+ <100mmol/day intake (equivalent to 6g NaCl)

2 ↑ patient: dialysate gradients associated with SCD

3 Dialysate Ca 2+ of 1.25mmol/L normally used

4 May be increased to 3-3.5mmol/l in

Fluid restriction to limit intradialytic weight >4 to 5 L of ultrafiltrate → uncomfortable fluid

Additional sessions or longer treatment times for pts with

large weight gains

For patients with evidence of bleeding, no heparin is prescribed. This includes :

Uraemic gastritis Haemorrhagic stroke

GI bleeding Recent surgery

Pericardial effusion Post transplant patients

Risk factors for Clotting include :

high hemoglobin and hematocrit

a high rate of ultrafiltration

low blood flow on dialysis

Both unfractionated and LMWH can be used

01 • provides relief of uraemic symptoms

Adequacy is mainly modelled by 2 equations :

02 • urea reduction ratio

K = dialyser urea clearance.(ml/min)

Describes the volume of urea cleared during a dialysis

spKt/V: single pool urea clearance

If significant residual native kidney function (Kr), the dose of

For hemodialysis schedules other than thrice weekly, a target standard

01 Urea reduction rate (URR) similarly reflects the

03 K/DOQI guidelines recommend the attainment of a

Resep Kt/V ≥ 1.3 atau URR ≥ 70%

Ketika dosis hemodialisis tidak mencukupi :

Pemilihan komponen dialisate : sodium, potasium, bicarbonate, dan calsium

Pemberian eritropoetin sebagai mentenen hematocrit antara 33% sampai 36%.

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