hemodialysis adequacy dwi
TRANSCRIPT
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 1/27
Hemodialysis Adequacy
and Prescription
Dwi Lestari Partiningrum
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 2/27
What isAdequacy of Hemodialysis ?
Adequacy of dialysis :
refers to how well we remove toxins and
waste products from the patient’s blood,and has a maor impact on their well!being
"remove # well being$
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 3/27
Adequacy of dialysis
% Adequate dialysis maximi&es well!being,
minimi&es morbidity, and helps a patient retain
social independence'
% Adequate dialysis is not simply a dose of dialysis
exceeding a given number, and should not bedefined by solute clearance alone'
% (ptimum dialysis is a method of delivering
dialysis producing results that cannot be further
improved'
% Dialysis prescription should be individuali&ed,
monitored, and reassessed regularly'
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 4/27
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 5/27
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 6/27
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 7/27
Recommendations for Adequacy
assessment
% )hould be assessed using a combination
"subective, obective and dialysis dose
assessment$
% *he recommended frequency : +!monthly
in stable patients
% onthly in unstable patients
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 8/27
Assessment of Dialysis
Adequacy
Subjective assessment:
% )ense of well being "no tiredness$% -ood appetite "no nausea$
% ore normal weight
% .eeling li/e dialysis is not necessary,except to remove fluid
% ore natural s/in color
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 9/27
Assessment of Dialysis
AdequacyObjective assessment:
% 0olume 1 2lood pressure control
% 3ot Acidotic "mid!wee/ predialysis
bicarbonat level not low$
% 4ontrolled of blood phosphate levels% 3ormal serum albumin level
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 10/27
Assessment of Dialysis
Adequacy
Dialysis dose assessment
% 5s the desired level of urea removal
being met6
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 11/27
nder!Dialy"ed Patients #ay $%perience
% 7ea/ness, *iredness
% Loss of body weight
% Poor appetite
% 3ausea 1 0omiting% .eeling better after treatmen
% 8ellowish s/in color
% ore infections% Prolonged bleeding
% Premature death
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 12/27
Ho& Do We 'no& if a Patient is
Adequately Dialy"ed?
'(DO)* +uidelines
Define Adequate Dialysis as,
% '-(. / 012 or 3reater % RR / 456 or 3reater
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 13/27
RR6 ! rea Reduction Ratio ,
the percenta3e of urea removed
durin3 the treatment
'-(. ,
7ormula utili"in3 dialy"er urea
clearance8 treatment time and totalbody fluid
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 14/27
$%ample RR5nitial "predialysis$ urea level: 9 mg1dL
*he postdialysis urea level: ;9 mg1dL
*he amount of urea removed: 9 mg1dL<;9 mg1dL = +9mg1dL
>??@ = >r pre < >r post x ;@
>r Pre
+919 = 1; = @
?ecommended a minimum >?? of B9 percent'
*he >?? is usually measured only a month'
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 15/27
't(.
C : the dialy&er clearance in millilitersper minute "mL1min$
t : time
Ct : is clearance multiplied by time representing the volume of fluidcompletely cleared of urea during a single
treatment 0 : is the volume of water a patient’s body
contains " 9@$
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 16/27
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 17/27
*he Ct10 is mathematically related to the >??,except that the Ct10 also ta/es into account two additional
factors:
% urea generated by the body during dialysis% extra urea removed during dialysis along with excess
fluid
*he Ct10 is more accurate than the >?? in measuring howmuch urea is removed during dialysis, primarily becausethe Ct10 also considers the amount of urea removed withexcess fluid' "4onsider two patients with the same >??and the same postdialysis weight, one with a weight lossof ; /g during the treatment and the other with a weight
loss of + /g'$
Patients who lose more weight during dialysis will have ahigher Ct10 for the same level of >??'
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 18/27
9lood samplin3 for '#
Predialysis sample Postdialysis sample
*a/e before any dialysis hasbegun from fistula needle
)et the >. rate to &ero
)low blood pump to 9
ml1min for at least ;9s)top blood pump
*a/e sample within the nextEs "Alternatively slow pumpto ; ml1min, over!ridealarm to /eep blood flowing,wait ;9!+s then ta/esample from A line$
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 19/27
Other mar:ers of adequacy,
protein catabolic rate
P4? "usually normali&ed for weight: nP4?:
g1/g1day$ is derived from the urea generation
rate and is usually calculated during >C'% Patients with nP4? F 'G g1/g1day have
increased morbidity and mortality, and generally
patients need an nP4? H;' g1/g1day to maintain
positive nitrogen balance'% Patients with a low nP4? need a careful
assessment for protein malnutrition'
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 20/27
P4? can be calculated approximately from:
P4? = "pre!post 2>3$x"'I91*$
7here * = number of days between blood
samples'
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 21/27
Other mar:ers of adequacy
% Acidosis
% >. should be sufficient to /eep the patient euvolaemic'4ompliance with salt and fluid restriction is important'5ncreased oedema or ascites increases 0, and hence
reduces Ct10 if C and t are not increased' 5ncreaseddialysis time is also necessary to allow redistribution offluid from interstitial compartments into the vascularcompartment during dialysis'
% alnutrition is a /ey mar/er of dialysis inadequacy and iseasily missed' Jarly weight loss is often accompanied byfluid retention as the dry weight is not reduced in linewith loss in muscle mass'
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 22/27
#ethods to increase delivered
dialysis doseost effrctive methods
% 5ncrease dialysis time
% 4hange to dialysis membrane of largersi&e anf1 or permeability
Less effective methods
% 5ncrease blood flow during dialysis
% 5ncrease dialysate flow during dialysis
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 23/27
Hemodialysis Prescription
Determines Adequacy
Kemodialysis Prescription 4omponents:
< Duration of treatment "not F I hours at each
treatment$
< .requency of dialysis
< Desired dry weightM
< embrane type, membrane si&e
< 2lood pump speed < Dialysate flow rate
< Anticoagulation protocol to be used
< Access
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 24/27
Assessment of adequacy should include,
% patient well!being "physically, mentally,socially$N
% nutrition "lac/ of malnutrition$N
% small solute clearance "urea /ineticmodelling: >C$N
% adequacy of >.N
% control of 2PN% control of anaemia, acidosis, and bone
disease'
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 25/27
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 26/27
7/23/2019 Hemodialysis Adequacy Dwi
http://slidepdf.com/reader/full/hemodialysis-adequacy-dwi 27/27
$%ample 't(.,
5f the dialy&er’s clearance is + mL1minand a dialysis session lasts for ;Gminutes "+ hours$
Ct = +mL1min x ;Gmin
Ct = 9I,mL = 9I liters*he body O B@ water by weight' 5f a
patient weighs /ilograms
0 = /g x B = IE litersCt10 = 9I1IE = ;'+