HD INITIATION : HOW AND WHEN ?

Arwedi Arwanto

RSUP Dr. Kariadi- FK UNDIP

Semarang
 Inisiasi Dialisis
• Saat inisiasi dialisis yang tepat dapat mencegah
komplikasi yang serius namun semua bentuk TPG
bukanlah tanpa risiko.
• Perlu dipertimbangkan antara manfaat dan risiko.
• Keputusan makin sulit pada usia lanjut.
• Keputusan dipengaruhi : ketrampilan dan
penilaian klinis, sarana, peraturan pemerintah
dan sistim pembayaran.
• Inisiasi Dialisis pada gangguan ginjal akut dan
kronis
 Acute Kidney Injury
Dialysis Treatments

Creatinine
M/l
Urine
l/day

Zöllner,
Innere Medizin,
Time / days modified

1. Damage 2. Oliguria / Anuria 3. Polyuria 4. Recovery

Damage to Complete Loss of Uncontrolled slow Recovery of
Renal Tissue Renal Function Urine Quantities Renal Function
(minutes to (up to 6 weeks) (1 - 2 weeks) (several months)
days)
Definition and Classification (staging) for
Acute Kidney Injury
Benefits and Drawbacks 0f earlier RRT in Critically Ill
Patients with AKI
Indications for RRT in the ICU
Current Clinical Practice Guideline
Recommendations
NICE Clinical Practice Guideline
How to prepare a patient with AKI for
dialysis
• Check hepatitis and HIV serology.
• Assess bleeding risk (coagulation status and platelet count).
• Place CVC for dialysis access. Check position of catheter by
CXR. Consider femoral approach when there is a risk of
bleeding or patient is unable to lie flat.
• Consider phenytoin for patient with low threshold for
seizures.
• Choose the dialysis membrane base on the acuity and
severity of renal failure and medications.
• Reduces the blood flow rate and dialysis times for the initial
treatment patients with severe uremia.
• Choose the dialysate based on serum biochemistry and
comorbidity.
• Choose the anticoagulation regimen based on the bleeding
tendency of the patients.
Criteria for Choosing Dialysis
Modality in AKI
Dialysis Modality Criteria
Intermittent HD Dialysis unit and staff available
Need for rapid solute and toxin
removal
Risk of bleeding
Need for frequent movement
from ward (for tests, surgery)
Need for prolonged dialytic
support
CVVHDF ICU and HND
Fluid overload
Neurological disease
Hemodynamic instability
Sepsis, ARDS
Hypercatabolism and burn
PD When IHD and CVVHDF not
available
 Discontinuation of RRT
 There is a relative paucity of data the
optimal circumstance and time to wean
and or discontinue RRT in critically ill
patients with AKI
 The Best Kidney study :an increase urine
output was the most important of
recovery of kidney.
 Spontaneous urine output > 400-500
mL/day w/o diuretics or >2300 mL/day w/
diuretics
How to assess and manage patients according to the stage
of chronic kidney disease
Stage of Based on Direct assessment and management to(b)
CKD GFR(α)

1. ≥ 90 Primary disease, cardiovascular risk

2. 60–89 Early hyperparathyroidism, progression of CKD

3. 30–59 Anaemia, dyslipidaemia, ECFV

4. 15–29 Electrolyte abnormalities, preparation for dialysis, and transplantation

5. < 15 Complications of advanced CKD and dialysis

(α) In mL/min/1.73 m2.

(b) May apply for any stage beyond that in which first mentioned.
 Inisiasi Dialisis Pada PGK
• Waktu Inisiasi yang tepat dapat mencegah komplikasi PGK,
termasuk malnutrisis, kelebihan cairan, perdarahan, serositis,
depresi, gangguan kognitif, neuropati perifer, infertilitas, dan
kerentanan infeksi.

• Inisiasi dialisis dipengaruhi : ketrampilan tenaga medis, peraturan

pemerintah serta sistem pembayaran.

• Inisiasi Awal :
- meningkatkan biaya pengobatan
- risiko prosedur dialisis
- kehilangan fungsi ginjal sisa lebih cepat
- kelelahan dini terhadap prosedur dialisis

• Inisiasi Lambat :
- komplikasi mengancam jiwa : uremia dan komorbid
 Kapan Saat
Inisiasi Dialisis yang paling tepat ?
• The IDEAL (Initiating Dialysis Early and Late) study
(Cooper dkk 2010): Tidak ditemukan perbedaan
bermakna :mortalitas dan efek samping
(kardiovaskuler, infeksi, komplikasi dialisis).
• Brunori dkk (2007): usia >70 th non-DM, LFG 5-7
ml/menit. Kelompok 1 segera inisiasi dialisis, kelompok
2 konservatif dan akan memulai dialisis bila malnutrisi
dan sindrom uremia. Kelompok kedua memulai dialisis
10 bulan lebih lama dan tidak ada perbedaan
bermakna terhadap mortalitas.
• Inisiasi dialisis lambat adalah aman apabila dimonitor
secara ketat terjadinya gejala uremia.
 Kapan Saat
Inisiasi Dialisis yang paling tepat ?
• Rosanky dkk (2011): apakah inisiasi dialisis
awal memberikan manfaat pada survival ?
Ditemukan peningkatan hazard ratio selama
HD yang dihubungkan dengan inisiasi HD dini.
HR :1,27 (eLFG 5,0-9,9); 1,53 (eLFG 10,0-14,9);
2,18 (eLFG >15)
• Hal ini mencerminkan bahwa inisiasi dialisis
dini dapat membahayakan.
 Guideline Inisiasi Dialisis
• National Kidney Foundation, KDOQI 2006: inisiasi
dapat dimulai lebih cepat, sebelum memasuki
stadium 5 dengan pertimbangan tertentu.
• Canadian Society of Nephrology 2008: inisiasi
dapat dimulai pada eLFG <20 ml/menit jika
disertai sindrom uremia atau malnutrisi.
• Australian and New Zealand Society of
Nephrology, CARI 2005: inisiasi dialisis bila LFG
<10 ml/menit bila disertai uremia atau malnutrisi,
atau kurang dari 6 ml/menit tanpa uremia
 Guideline Inisiasi Dialisis
• ERA-EDTA, 2002: inisiasi dialisis bila eLFG, 15
ml/menit dan adanya sindrom uremia atau
malnutrisi dan pada kondisi apapun bila eLFG
< 6 ml/menit. Diabetisi mendapat manfaat
bila dilakukan dialisis dini. Target memulai
dialisis adalah LFG 8-10 ml/menit.
• United Kingdom Renal Association, 2009:
direkomendasikan untuk inisiasi dialisis bila
eLFG < 6 ml/menit meskipun asimptomatik
KEPUTUSAN MENTERI KESEHATAN REPUBLIK INDONESIA
HK.01.07/MENKES/642/2017
 CAVHD
CVVHD
CAVHF
CVVHF
CAVH CAVHDF
KRAMER CVVHDF
1977
IHD
HYBRID EDD
HD HD CAPD SLED
Renal
Belding SCRIBNER 1960,
Replacement
Willem KOLF 1943-1944 begin chronic dialysis Fred BOEN
Dialysis in 15 pts 1961
(1 survived)l
PD
George Haas 1914-1915 APD
Dialysis in Animal
SELLIGMENT & FINE
1945

9/23/2018 24
 Terapi Pengganti Ginjal
(berdasar lama tindakan)

TERAPI TERAPI BERKESINAMBUNGAN

INTERMITEN (CRRT)
Konvensional Dialisis peritoneal (PD)
Hemodialisis ; konvensional (IHD) Ultrafiltrasi (SCUF)
dgn sorben Hemofiltrasi (CAVH, CVVH)
Hemodiafiltrasi Hemodialisis (CAVHD, CVVHD)
Ultrafiltrasi Hemodiafiltrasi (CAVHDF, CVVHDF)
Tehnik Baru (Hybrid dialysis)
Extended Daily Dialysis (EDD)
Slow Continuous Dialysis
Sustain Low Efficient Dialysis
(SLED)
 Kesimpulan
• Pada AKI dilakukan RRT bila terjadi ancaman
terhadap kehidupan : hiperkalemia, asidosis
metabolik, edema paru, perikarditis,
ensephalopati uremikum, koagulopati
• Inisiasi RRT pada CKD bila : CKD stadium 5 dengan
eLFG < 6 ml/menit walau tanpa gejala , CKD
stadium 5 dengan kondisi khusus : malnutrisi,
sindrom uremik, edema paru, hiperkalemia,
asidosis metabolik, hiperfosfatemia, hipertensi
akibat overload cairan, nefropati diabetik.
Terima
kasih