Teknik HD Khusus ( Intermitten Renal,

PIRRT, Hemofiltrasi, Hemodiafiltrasi )

DR. RATIH TRI KUSUMA DEWI , SPPD KGH

FINASIM
Size of Molecules
• Hemodialisis
• Hemofiltrasi
• Hemodiafiltrasi
 Prinsip Terapi Pengganti Ginjal
 Hemodialisis
Mekanisme dasarnya adalah DIFUSI, tujuannya adalah penjernihan darah ( blood
purification ) menjadi translokasi solute. Terjadi translokasi air karena perbedaan
tekanan. Diperlukan cairan dialisat. Ginjal buatan disebut Hemodialiser

 Hemofiltrasi :
Mekanisme dasarnya adalah Ultrafiltrasi. Tujuannya mengurangi dalam tubuh
( volume control ). Dapat terjadi blood purificatiokelebihan cairan n melalui
mekanisme konveksi. Diperlukan cairan substitusi. Ginjal buatan disebut
Hemofilter

 Hemodiafiltrasi :
menggabungkan dua mekanisme diatas
HEMOFILTRATION REINFUSION (HFR)
 HEMODIAFILTRASI (HDF)
- Suatu bentuk RRT yang menggunakan kombinasi kliren konveksi dan
difusi.
- HDF vs HD standart :
* Kliren HD standart sebagian besar lewat difusi  BM kecil.
* Kliren HDF molekul dg BM sedang lebih banyak.
* Lebih kompleks dibandingkan HD standart.
* HD dengan dialiser high flux bisa dianggap sbg HDF bedanya :
volume filtrasi high flux HD tidak dapat diprediksi, diukur dan
berfluktuasi.
- HDF membutuhkan cairan pengganti paling sedikit 15 – 20 liter dan bias
mencapai 150 liter untuk mengganti ultrafiltrasi  cairan harus lebih
steril.
Keuntungan HDF :
1. Kliren solute dengan BM sedang :
- β2- Mikroglobulin.
- PTH
- Homosistein
- Guanidin.
- Poliamin.
- Appetite suppressant : Leptin, cholesistokinin, tryptophan.
2. Menurunkan inflamasi dan stress oksidatif
- IL 6, IL 8, IL 12.
- ROS dan superokside.
- AGEs.
3. Hemodinamik stabil : jarang hipotensi intradialitik
Modality Choice in critically ill setting
Introduction
 RRT Modality Choice in critically ill setting
 Intermittent hemodialysis (IHD),
 Continuous renal replacement therapies (CRRT) and
 Sustained low-efficiency dialysis (SLED)

 Although institutional policies may determine the local

availability of these modalities,
 CRRT and SLED tend to be used in patients with greater
hemodynamic instability

Nephron Clin Pract 2009;112:c222–c229

Major Renal Replacement Techniques
Intermittent Hybrid Continuous

IHD SLEDD CVVH

Intermittent Continuous veno-venous
Sustained (or slow) low haemofiltration
haemodialysis efficiency daily dialysis

CVVHD
IUF SLEDD-F Continuous veno-venous
haemodialysis
Isolated Ultrafiltration Sustained (or slow) low
efficiency daily dialysis
with filtration CVVHDF
Continuous veno-venous
haemodiafiltration

SCUF
Slow continuous
ultrafiltration
AKI classification: RIFLE
 AKI classification systems: AKIN
Stage Creatinine criteria Urine output criteria

1.5 - 2 x baseline (or rise > < 0.5 ml/kg/hour for > 6
1 hours
26.4 mmol/L)

< 0.5 ml/kg/hour for > 12

2 >2 - 3 x baseline hours

> 3 x baseline (or > 354

3 mmol/L with acute rise > 44 < 0.3 ml/kg/hour for 24
hours or anuria for 12 hours
mmol/L)

Patients receiving RRT are Stage 3 regardless of creatinine or urine output

Mortality by AKI Severity

Clermont, G et al. Kidney International 2002; 62: 986-996

 Intermittent IHD Therapies
Hypotension 30-
60%
Limited therapy duration

Renal injury & ischaemia

Cerebral oedema

Gut/coronary ischaemia
Continuous Renal Replacement
Therapies (CRRT)
 CRRT is generally better tolerated than
conventional therapy, since many of the
complications of intermittent hemodialysis are
related to the rapid rate of solute and fluid loss
 CRRT involves either
 Dialysis (diffusion-based solute removal) or
 Filtration
(convection-based solute and water removal)
treatments that operate in a continuous mode
Nomenclature
 Manfaat CRRT
1. Hemodinamik stabil
2. Pengendalian ureum, elektrolit, asam-basa lebih baik
3. Efektif menarik cairan
4. Memungkinkan untuk pemberian parenteral nutrisi
5. Prosedur yang dilakukan nyaman

Kelemahan  biaya besar , waktu lama, SDM lebih

banyak
 Dialiser
1. Untuk CAV-H atau CVV-H
Luas permukaan filter 0.25-0.6 m2
Jenis membrane = PAN, Polysulfone, Polyamide

2. Untuk CAV-HD atau CVV-HD

Luas permukaan filter 0.5-1.8 m2
Jenis membrane : Cuprophane, Polysulfone, PAN
Bentuk filter = flat plate , hollow fibber
Aliran dialisat dan darah
1) Kecepatan aliran dialisat 10-40 L/24 jam
( 417-1665 ml/jam ayau 7-28 ml/menit)

2) Kecepatan aliran darah 100-150 ml/menit

 Ultrafiltra
t1) CVV-H atau CAV-H  volume ultrafiltrat
yang ditarik 10-15 liter/24 jam

2) CAV-HD atau CVV-HD  volume

ultrafiltrat yang ditarik 3-6 liter/24 jam
Antikoagulan
1) Heparin = bolus pertama 2000 unit pada pipa arteri,
kemudian 500 unit/jam untuk pompa infus.
Setiap 4 jam ukur PTT 
- Bila PTT arteri > 45 heparin diturunkan 100
unit/jam, bila < 45 dinaikan 100 unit/jam.

2) Bila tanpa heparin maka kecepatan aliran dialisat

dinaikan jadi 33 ml/menit ( clotting akan terjadi dalam
8 jam )
CRRT versus SLED
 In addition to the absence of a survival advantage, CRRT is
more costly than IHD and is associated with a number of
obstacles such as
 Continuous patient immobilization,
 The requirement for anticoagulation and
 The need for specialized machines and premixed commercial solutions
 This has stimulated a search for a strategy that
 Incorporates the putative hemodynamic benefits of CRRT without the
associated logistic and resource constraints
 SLED meets many of these criteria

Nephron Clin Pract 2009;112:c222–c229

SLED
 SLED
 sometimes referred to as extended dialysis, is
considered a ‘hybrid’ of IHD and CRRT
Administered using conventional dialysis technology
but typical sessions run for 8–12 h using blood and
dialysis flows that are intermediate to those
prescribed in IHD and CRRT

Nephron Clin Pract 2009;112:c222–c229

PIRRT ( Prolonged Intermitten Renal
Replacement Theraphy)

1) Sustained low efficiency (daily) dialysis (SLEDD)

2) Sustained low efficiency (daily) diafiltration
(SLEDD-f)
3) Extended daily dialysis (EDD)
4) Slow continous dialysis (SCD)
5) Go slow dialysis
6) Accelerated venovenous hemofiltration (AVVH)
Nephron Clin Pract 2009;112:c222–c229
 SLED
 Conventional dialysis equipment
 Online dialysis fluid preparation
 Excellent small molecule detoxification
 Cardiovascular stability as good as CRRT
 Reduced anticoagulation requirement
 11 hrs SLED comparable to 23 hrs CVVH
 Decreased costs compared to CRRT
 Phosphate supplementation required
Fliser, T & Kielstein JT. Nature Clin Practice Neph 2006; 2: 32-39

Berbece, AN & Richardson, RMA. Kidney International 2006; 70: 963-968

 CRRT versus SLED
 Kielstein
et al. randomized 39 critically ill patients
with AKI to receive
 Either 24 h of CVVH or 12h of SLED
 Using invasive monitoring, these authors found
 No significant differences in all measured hemodynamic
parameters (mean arterial pressure, systemic vascular
resistance, cardiac output) with comparable removal of
creatinine and urea

Am J Kidney Dis 2004; 43: 342–349.

CRRT versus SLED
 Utilization of slow low-efficiency dialysis may help
to optimize the need for continuous renal
replacement therapy in Indian ICUs
 A Majumdar, S Basu et al, AMRI Hospitals, Kolkata,
 The aim was to study the practice pattern of using the
modern modalities of RRT,
 SLED and CRRT in hemodynamically unstable critically ill patients
in an Indian ICU

Critical Care 2009, 13(Suppl 1):P271

 CRRT versus SLED
 Indian study continued
 Methods A retrospective observational study of
hospitalhemodynamically unstable patients with AKI who needed
RRT in ICUs of a tertiary-care
 All patients who underwent SLED and/or CRRT from September
2005 to April 2008 were taken up for analysis
 To maintain a mean arterial pressure (MAP) >70 mmHg,
 Patients who required noradrenaline >0.5 μg/kg/minute were
treated with CRRT whereas those requiring ≤0.5 μg/kg/minute
received SLED
 Depending on haemodynamic stability patients were switched
from CRRT to SLED, or vice versa
Critical Care 2009, 13(Suppl 1):P271
CRRT versus SLED
 Indian study continued
 Results
From September 2005 to April 2008, 214
haemodynamically unstable AKI patients,
deemed unfit for intermittent haemodialysis,
underwent SLED/CRRT (CVVH/CVVHDF)
 Tenpatients were switched to SLED after a
median 48 hours of CRRT

Critical Care 2009, 13(Suppl 1):P271

CRRT versus SLED
Indian study continued Results

Critical Care 2009, 13(Suppl 1):P271

CRRT versus SLED

 Conclusions the need for RRT in hemodynamically

unstable patients with AKI was significantly higher
in the medical patients, the commonest cause of AKI
being sepsis

 Patients who were equally sick (comparable APACHE II scores)

could be effectively dialysed by SLED, as compared with CRRT
 Hemodynamic stability was maintained in the patients on SLED, as
none needed switchover to CRRT

Critical Care 2009, 13(Suppl 1):P271

Conclusions
 Conceptualadvantages of CRRT, multiple RCTs
have shown no evidence of improved patient
outcomes with this modality, as compared to
conventional IHD
 The logistic challenges associated with CRRT and
the relatively high costs of this modality may
stimulate the increased use of SLED
 However, well-designed RCTs are still needed to
better characterize the reported benefits of SLED
prior to its widespread adoption
“You should listen to your heart, and
the voices in your head”
Marge Simpson
TERIMA KASIH…