GOOD

MORNING !

WAKE UP ! RENAL
REPLACEMENT
THERAPY
 WHO ?
Renal Replacement Therapy
WHEN ?
HOW ?
 Consensus

Patients with serum creatinine >

2 mg/dl with / or GFR < 50
cc/minute have a poor prognosis
and should be consulted to
nephrologists.
WHO?

INDONESIAN CONSENSUS ON HEMODIALYSIS, 2003

 Consensus

All patients with GFR < 15 cc/minute

should be initiated for dialysis. As a
clinical consensus dialysis could be
initiated on patients with :
1. GFR < 10 cc/minute with uremic
syndrome or malnutrition.
2. GFR < 5 cc/minute without any
syndrome.
3. Special indication for acute
complication such as pulmonary
INDONESIAN CONSENSUS ON HEMODIALYSIS,
edema, hyperpotassiumemia, 2003
metabolic
acidosis, etc
 management of CRF
MEDICAMENTOSA
(PREVENTION OF PROGRESSION OF RENAL DISEASE)

- Protein restricting diet ( 0.6-0.8 gr/kgBB/day)

- Blood pressure control
- Managing Fluid and Electrolyte disorders
- Managing hyperphosphatemia, hyperkalemia, etc)
- Treating anemia
- Managing hyperlipidemia

RENAL REPLACEMENT THERAPY

In cases of GFR reduced to < 10 – 15 cc/min (= s creat 8-10 mg/dl
or 20 cc/min in DM ( s creat 6-8 mg/dl)

WHEN?
 Bicarbonate supplement
Erythropoietin as needed
Establish
good rapport Restrict dietary phosphorus. Ca binders. ? Vitamin D
with PCPs DPI decrease

100 75 GFR 50 25 10

Vitamin D levels fall, Net acid

PTH starts to increaseExcretion falls

Anemia may be present

Institute measures to slow progression and treat comorbid conditions

Evaluate cause for CRF Select site for dialysis Place an AVF Place graft or
Access and preserve veins PD catheter

Timeline shows the course of chronic renal failure (CRF) leading to end stage renal disease
(AVF, arteriovenous fistula; Ca, Calcium; DPI, dietary protein intake, GFR glomerular filtration
rate; PCP, primary care provider; PD, peritoneal dialysis; PTH, parathyroid hormone.)
 Modalities of
Renal Replacement Therapy (RRT)

DIALYSIS TRANSPLANTATION

HEMODIALYSIS LIVING DONOR

HEMOFILTRATION

PERITONEAL CADAVERIC DONOR

Differences between DIALYSIS & TRANSPLANTATION

: - Replace renal function artificially

DIALYSIS
DIALISIS
(using dialyzer)
- Replace excokrine function only

TRANSPLANTASI : - Replace renal funtion naturally

- (using kidney donor)
- Replace excokrine and endokrine function

Excokrine function Endokrine function

- Body fluid regulation - Blood Pressure regulation
- Waste products regulation - Hormon regulation
- (sisa metabolisme)
 HEMODIALYSIS
PERITONEAL DIALYSIS
HEMOFILTRATION
 INDICATION FOR
INITIATING RRT
- Acute Renal Fail : emergency cases
- Azotemia ureum> 200 mg/dl
- Overhidration/anuria urine < 100 cc/d
- Metabolic Asidocis pH < 7.1
- Hiperkalemia K >7

-Chronic Renal Fail : - Creatinine clearence <5-10 cc/menit

- on emergency cases
 RRT Modalities
INTERMITTENT THERAPIES :

Haemodialysis (HD)
Peritoneal Dialysis (IPD)
Hemofiltration (IHF)
Ultrafiltration (UF)

CONTINOUS THERAPIES :

Chronic Ambulatory Peritoneal Dyalisis (CAPD)

Slow Continous Ultrafiltration (SCUF)
Continous Veno-Venous Hemofiltration (CVVH)
Continous Arterio-Venous Hemofiltration (CAVH)
Continous Arterio-Venous Hemofiltration-Dialysis
Veno (CVVH-D / CAVH-D)

Seminars in Dialysis ,9:469-475,1996

Table. Glossary of term for renal
replacement therapy (RRT)

• CAVH Continuous arteriovenous haemofiltration.

Depends upon patients blood pressure
• CVVH Continuous venoveous haemofiltration. Pump-
driven system
• CAVHD Continuous areriovenous haemofiltration and
dialysis (haemodiafiltration)
• CVVHD Continuous venovenous haemofilration and
dialysis
• HD Standard machine-driven haemodialysis
• HF Standard machine-driven haemofiltration
• PD Peritoneal dialysis
 Factors Influencing Choice of
Dialysis Modalities
PATIENT : - Indication for dialysis
- Presence of MOF
- Acces
- Mobility and location of patients
- Anticipated duration of therapy

DIALYSIS PROCESS : - Efficacy for solute and fluid balance

- Outcome and complications
- Type : Intermittent vs Continous
- Components (membrane, heparin,etc)

NURSING & OTHER : - Availibility of machines

SUPPORT - Nursing support & skill

Seminars in Dialysis ,9:469-475,1996

 RECOMENDATION FOR INITIAL CHOICE OF DIALYSIS MODALITY

Indication Clinical Condition Preffered Therapy

Uncomplicated ARF Antibiotic nephrotoxicity IHD, IPD

Fluid Removal Cardiogenic Shock, CP bypass SCUF,CAVH

Uremia Complicated ARF in ICU CVVH-DF,CAVH-DF

IHD

Shock Sepsis, ARDS CA/VH-DF, CVVH

Nutrition Burns

Electrolyte abnorma-Marked Hyperkalemia IHD, CVVH-DF

Lities

ARF in pregnancies Uremia in 2nd or 3rd trimester IPD

Seminars in Dialysis ,9:469-475,1996
 Circuit of
emodialysis , Hemofiltration, and Peritoneal Dialys

HOW?
 DIALYSIS FACILITIES & BLOOD ACCESS

BLOOD ACCESS
access for blood to enter the body
( via blood vessels) in the process
Sub-clavia / Jugular of dialysis

femoral
DIALYSIS FACILITIES
cimino
- Dialysis wards
- Water treatment & water disposal
- Dialysis machines
- Consumables (dialyzer,AV-fistula, dialysate)
- Dialysis nurses
 Dengan dialisis darah dibersihkan dengan proses difusi dan filtrasi
Melalui membran semi-permeable dalam Ginjal Buatan
BLOOD
BLOOD dialisat (exit)
enter
DIFFUSION
(concentation)

DIALYSATE
enter
DIALYSIS PROCESS FILTRATION
(pressure)
ULTRAFIL
TRATE
exit Ultra- BLOOD
Filtrat (enter)

BLOOD
exit (counter – current)
Semi-permeable Membrane
DIALYZER
Circuitry for Hemodialysis
Circuitry for SCUF
Circuitry for CVV -HD
 Peritoneal Dialysis
PERITONEAL DIALYSIS a dialysis process using peritoneum membrane
as the semi-permeable membrane for difusion dan filtration

PERITONEAL DIALYSIS TECHNIC

1.Dialisate (1-2 Liter) enter the peritoneum

Dialisate cavity via Peritoneal Cathether
enter 2.Dialysate kept for some hours
to allow the difusion & filtration process
3.Ultrafiltrate exit the cavity
Ultrafiltrate 4.Change with new dialisate
exit 5.Recycling every 4 -8 hours
 modalities of
Peritoneal Dialisis
ACUTE/INTERMITTENT CHRONIC AMBULATORY
PERITONEAL DIALYSIS PERITONEAL DIALYSIS
(IPD) (CAPD)

Indication : ARF Indication : ESRD

Hospitalized Ambulatory
Only for days/week Long term (chronic)
 please
continue
SLEEPING !