HEMODIALISIS

HEMODIALISIS1Sejarah Dialisis Ginjal buatan John Abel1861 : Thomas Graham pertama kali menggambarkan proses difusi1913 : John Abel Mengembangkan ginjal buatan1924 : George Haas manusia pertama yang didialisis.

21943 : Willem Kolff Mesin dialisis bbtk drum1948 :Kolff-Brigham mesin dialisis digunakan pada perang Korea

31960 : Scribner shunt (Seattle)1966 : James Cimino (Brescia)Mengembangkan Internal AV fistula

4Terapi Pengganti GinjalBellomo dan Ronco : Usaha mengambilalih fungsi ginjal yang tlh menurun dengan ginjal buatan (dializer) dengan tehnik dialisis atau hemofiltrasi.Hanya mengganti fungsi ekskresi, tidak fungsi endokrin.Kellum dkk membagi 2 : - Intermiten : waktu terbatas , 6-12 jam - Continous : Berkesinambungan ( 24 jam)5PRINSIP DIALISISDifusi Translokasi solut akibat perbedaan konsentrasi antara kompartemen darah dan dialisat. Solut konsentrasi tinggi dalam darah (K, Urea) akan berpindah ke dialisat. Sedang solut konsentrasi rendah dalam darah berpindah dari kompartemen dialisat ke darah. Ultrafiltrasi Translokasi molekul air melalui membran semi permiabel akibat perbedaan tekanan.6

7

8

9

10

11Terdiri dari beribu-ribu serat halus yg mirip dengan struktur kapiler manusia Tipe membranCelluloseSubstituted celluloseSynthetic

Serat dialyzers

12Tipe tipe akses vascular Permanen Temporer

AV fistulaAV graftCentral venous catheters

13AV fistulaDiletakan subcutaneous antara arteri and vena.Keuntungan Kekuatan terjamin Komplikasi kurang (infeksi, stenosis)

14AV graftSynthetic conduit, usually polytetrafluoroethylene (PTFE, also known as Gortex), between an artery and vein KeuntunganWaktu maturasi singkatMudah kanulisasi dan permukaan area yang luasTindakan pembedahan yg lebih mudahKerugianInferior long term patencyKejadian infeksi lebih tinggi daripada AV FistulaAltenatif pada pasien yang tidakj dapat dilakukan AV fistula

15

16

Tehnik Kanulasi akses vaskuler

Kanulasi langsung ke pembuluh darah besar (V.femoralis,sefalika,radialis Kanulasi dengan kateter lumen ganda(v. Femoralis, jugularis dan subclavia)

17

18

19AntikoagulanDiperlukan antikoagulan dalam dialisis agar tidak terjadi koagulasi diluar tubuh.Heparinisasi konvensional : Menggunakan reguler heparin intra vena ,dosis inisial 1500-3000 IU (25-30 IU/kg BB) dilanjutkan dengan 1000-2500 IU per jam secara kontinyu.Bila ada tanda perdarahan , diberikan dosis rendah 20-25 IU/kgBB (inisial dose) dilanjutkan 0-500 IU per 30 menit atau tanpa heparin.LWMH , Enoxaparin diberikan dosis 100IU/kgBB untuk satu sesi dialisis scr IV.20Indikasi TPG pada pasien dgn GnGA Overload cairanAnuria/oliguriaHyperkalemia (plasma potassium 6.5 meq/L) Metabolic acidosis (pH 1,2 Durasi HD : Idealnya 10-15 jam/minggu.Durasi HD disesuaikan dgn kebutuhan individu.Tiap HD dilakukan 4-5 jam dengan frekuensi 2x perminggu (Indonesia) 24Rumus adekuasi Dialisis

R= Post BUN/Pre BUNUF= Predialisis weight- Postdialisis weight: post dialisis weightW = Post dialisis weight 25Formula Logaritma

26Komplikasi selama dialysisSeringJarang tapi seriusHypotensi(20-50%)Kram otot(5-20%)Mual (5-15%)Sakit kepala (5%)Gatal (5%)Nyeri dada/punggung (2-5%)Demam dan menggigil( Hypertension(15.7%)Total 20,244 patientsKorea Journal of Nephrology (1999)34Peritoneal DialysisIs the process of cleaning the blood by using the lining of the peritoneal cavity (peritoneum) as a filter the peritoneum acts as a dialyzing membrane, permitting wastes from the body to cross it and empty into the instilled dialysate fluid .Is a type of dialysis usually done by the patient at home.

35Types of Peritoneal DialysisCAPD Continuous Ambulatory Peritoneal DialysisManual exchanges (approx. 30 Min. each) done approx. 4 times daily (1st thing in am, around lunchtime, around suppertime, and before bed).Utilizing Baxters ultrabag system.Aseptic technique mandatory in making all connections.APD Automated Peritoneal DialysisUtilizes a machine to perform exchanges at night while the patient sleeps (8-10 Hrs on the machine).

Aseptic technique mandatory in making all connections.36 CAPD indicationAbsolute indications:Poor cardiac functionPeripheral vascular disease Relative indications:Free life style Want to take care themselvesLong distance to hemodialysis center

37 CAPD contra indicationInability to make connections and lack of family member or other person willing or able to help (dementia ,stroke ,arthritis , blindness, debilitation etc) Previous complicated abdominal surgery with adhesions, ostomies etcLack of space to store PD solutions

38

39Phases of Peritoneal DialysisFill Takes approx. 10 minutes.Usual volume is 2000 2500 mls.DwellCAPD usually 4-6 Hrs during the day, and 8-10 Hrs during the night.APD usually shorter dwells while sleeping and longer dwells during the day.DrainTakes approx. 20 minutes.Usual volume may be slightly less, the same as, or more than infused amt. Effluent (drained fluid) is normally clear (colorless or yellow). 40Principles of peritoneal dialysis

41

Scheme of peritoneal solute transport by diffusion through the pores of capillary wall 42

Ramesh Khanna & Karl D. Nolph

Model of transport - 3 sorts of pores 43Ramesh Khanna & Karl D. Nolph Na 132 mmol/lCa 1,25mmol/lMg 0,5 mmol/lCl 100 mmol/llactate 35 mmol/l ev. lactate/bicarbonateglukose 1,36-4,25 g/dlosmolarity 347-486pH5,2GDP (degradation products of glucose)Composition of standard peritoneal dialysis solution44CAPD Exchange

Aseptic technique mandatory in making all connections!Check dialysis orders for % of dextrose, & fill volume.Drained volume must be measured & documented (a spring scale may be used). Dialysate should be warmed to body temperature using dry heat.

Baxters Ultrabag SystemFull & Empty Bags Connected by Tubing45

Peritoneal catheter implanted via laparoscopy, punction or laparotomy (total anesthesy) PD is started 3 weeks following the impantation of catheter46

Types of peritoneal catheters47Access to The PeritoneumConsidered the patients lifeline.Sterile technique required when connecting (or disconnecting) transfer set to catheter.Transfer set is clamped prior to opening to protect the PD catheter (strict aseptic technique is required when minicap is removed).

Peritoneal CatheterExit SiteTitanium AdaptorTransfer SetTwist ClampMinicapAll procedures requiring opening of the closed system will be done by trained staff only48Clearance Across the Peritoneal Membrane

Waste products & excess fluid move from the blood into the dialysate by diffusion & osmosis.Fluid removal can be increased by increasing the amount of dextrose in the dialysate.Some medications will move across the membrane also.BloodDialysateSemipermeable Membrane49

50Kelebihan CAPD

51

52

53Hal yang tidak menyenangkan dari CAPD

54

55

56

Criteria of PD adequacy 57Infectious:exit-site inflammation (flare, suppurative secretion, granulation)peritonitis (turbid dialysate, abdominal pain, fever)Non-infectious:herniashydrothoraxsclerosing encapsulating peritonitis (rare, life threatening complication, mostly after 6 years on PD, peritoneum is massively thickened and calcificated, leading to intestinal obstruction)Complications of PD 158Non-infectious:Leakage of dialysate along the peritoneal catheter Drainage failure of dialysate (dislocation or catheter obstruction by fibrin)Morphologic changes of peritoneum following long-lasting PD (peritoneal fibrisis, mesotelial damage, vasculopathy and neo-angiogenesis) leading to loss of UF capacity reason for PD cessation in 24% of all patients, and in 51% of patients treated above 6 years.

Complications of PD 259

CAPD continual ambulatory peritoneal dialysis

manual exchanges 60

NIPD night intermitent peritoneal dialysis (cycler)61

CCPD continual cyclic PD62

TERIMA KASIH63Chart20.5330.1710.295

Chart10.5330.1710.295

Sheet1HD53.30%PD17.10%Transplantation29.50%

Sheet1000

Sheet2

Sheet3