SIMPOSIUM DIALISIS

2015 Korwil PERNEFRI JAWA -BARAT

SECTION II. Haemodialysis
adequacy

Kt/V

EBPG, Nephrol Dial Transplant (2002) 17 [Suppl 7]: 1

 β2 - M

KoA

EBPG, Nephrol Dial Transplant (2002) 17 [Suppl 7]: 1-96

 Prinsip dasar translokasi
translokasi
ion melalui membrane
semipermeabel

Jenis dan sifat

membran dialiser

Pilihan terapi dialisis

2015
 the molecules

the processes

the membrane

THE BASIC MECHANISM OF REMOVING

REMOVING
2015 MOLECULES
 Molecular Weights
100,000
• Albumin (55,000 - 60,000)
50,000
“large”
• Beta 2 Microglobulin (11,800)
10,000
weight, daltons

5,000 • Inulin (5,200)

• Vitamin B12 (1,355)

molecular weight

1,000 “middle”
• Aluminum/Desferoxamine Complex (700)
500
• Glucose (180)
• Uric Acid (168)
100 • Creatinine (113)
• Phosphate (80)

• Urea (60)
50 “small”
• Potassium (35)
• Phosphorus (31)
• Sodium (23)
10
5
0
 (c) Convection

SIMPOSIUM
THE BASIC MECHANISM DIALISIS
OF REMOVING
REMOVING
2015 MOLECULES
Korwil PERNEFRI JAWA -BARAT
 Kt/V KUF
URR

KoA

SIMPOSIUM DIALISIS SC
2015 Korwil PERNEFRI JAWA -BARAT
 SIMPOSIUM DIALISIS
2015 Korwil PERNEFRI JAWA -BARAT
 Prinsip dasar translokasi
translokasi
ion melalui membrane
semipermeabel

Jenis dan sifat

membran dialiser

Pilihan terapi dialisis

SIMPOSIUM DIALISIS
2015 Korwil PERNEFRI JAWA -BARAT
 SIMPOSIUM DIALISIS
2015 MEMBRANE DIALYZER
Korwil PERNEFRI JAWA -BARAT
 FLUX

KUF

Β2 M
EFFICIENCY

KoA

2015 MEMBRANE DIALYZER

 diameter

SIMPOSIUM DIALISIS
2015 MEMBRANE DIALYZER
Korwil PERNEFRI JAWA -BARAT
 High
High--FLUX = Kuf > 20 ml/h/mmHg
High
High--PERMEABILITY = Kd B2-
B2-M > 20 ml/min
= KoA > 30 ml/min
High – EFFICIENCY = KoA Urea > 600 ml/min

2015 WHICH MEMBRANE YOUR UNIT USE ?

 Prinsip dasar translokasi
translokasi
ion melalui membrane
semipermeabel

Jenis dan sifat

membran dialiser

Pilihan terapi dialisis

SIMPOSIUM DIALISIS
2015 Korwil PERNEFRI JAWA -BARAT
 To remove the solutes

HD Low Flux HD High Flux HDF HF

Diffusione
Convezione

Adsorbimento su membrana

Small molecul
Rimozione piccole molecole

Rimozione
Midle – medio
Large molecole
molecul
 Keterangan :
Pada proses HD akan ada :
Pompa darah
Pompa cairan dialisat
Cairan dialisat

Keterangan :
Pada proses HDF, akan ada :
Pompa darah
Pompa cairan replacement
Pompa cairan dialisat
Cairan Replacement
Cairan dialisat

Keterangan :
Pada proses HF akan ada
Pompa darah
Pompa cairan replacement
Cairan Replacement
 Intermittent Slow Continous Continous
Hemofiltration Ultrafiltration Venovenous
Hemofiltration

Intermittent Intermittent High-

High- Continous Continous
Hemodiafiltration Flux dialysis Venovenous Venovenous
Hemodialysis Hemodiafiltration

INTERMITTENT CONTINOUS
TECHNIQUES TECHNIQUES
t < 12 jam t > 12 jam

Ricci Z, Bellomo R
Kellum JA, Ronco C
CRITICAL CARE NEPHROLOGY
(2009)

2015 THE NOMENCLATURE OF NEW DIALYSIS TECHNIQUE

 HIGH PERFORMANCE EXTRA-
CORPOREAL THERAPIES FOR
END-STAGE RENAL DISEASE

High-efficiency hemodialysis
High-flux hemodialysis
Hemofiltration , intermittent
Hemodiafiltration, intermitent

2015 HIGH PERFORMANCE DIALYSIS

High – efficiency low - flux hemodialysis
High – efficiency high- flux hemodialysis
Low – efficiency high- flux hemodialysis

HOW TO IMPROVE ADEQUACY & QUALITY OF LIFE

2015 HIGH – PERFORMANCE DIALYSIS ?

 EFFICIENCY Kt / V per session
Low-efficiency dialysis < 1.2
Mid-efficiency dialysis 1.2 – 1.4
High-efficiency dialysis > 1.4

Solute FLUX permeability Beta2

Beta2--microglobulin KoA = mass transfer co-
co-
clearence eficient
LOW – flux hemodialyzer < 20 ml/min < 30 ml / min
MID – flux hemodialyzer > 20 ml / min > 30 ml / min
HIGH – flux hemodialyzer > 40 ml / min > 50 ml / min
SUPER – flux hemodialyzer > 60 ml / min > 100 ml / min

2015 THE NEW DIALYSIS ADEQUACY

 Low flux – Mid – flux High – flux Super - flux
Low - High –
efficiency efficiency
Ultrafiltration Kuf < 20 >20<30 >30<50 >50
(ml/mmHg/h)
Urea Ko (ml/min) < 180 >180 <200 >200 <220 >220
KoA (ml/min) < 500 >500 <600 >600 < 700 > 700
Kt/V < 1.2 >1.2 < 1.4 > 1.4 < 1.6 > 1.6
B2 - Kd ( ml/min) < 20 >20 <40 >40 <60 >60
microglobulin KoA (ml/min) < 30 >30 <50 >50 <100 >100
Albumin leak (gram/session) 0 0 <2 2-5

MODALITY LF – HD MF – HD HF – HD HF – HD
HDF off line HDF on line HDF on line
HF offline HF on line HF on line

2015
2015 Blood Flow & Dialysate Flow
How to improve the adequacy of dialysis
 Hemo-dia-filtration
to waste
Blood In
(from patient)
Dialysate
Solution Replacement
Solution

Blood Out

(to patient)

LOW PRESS HIGH PRESS

LOW CONC HIGH CONC

 OPTION FOR REINFUSION

PRE-DILUTION POST-DILUTION MIXED MID-DILUTION

INFUSION INFUSION
PRE PRE

< Hemoconcentration < Hemoconcentration

< TMP < TMP
< Depurative efficiency < Depurative efficiency

INFUSION INFUSION
POST POST
 HFR: HDF with endogenous reinfusion
 Natrium: the biosensor to measure the natremia
on line
 Mathematical model to manage the sodium
balance
 SIMPOSIUM DIALISIS
2015 Korwil PERNEFRI JAWA -BARAT
Ideal therapy for sepsis

Plasma

“bad molecules”

“good molecules”

Dialysate out

Dialysate in
 HFR – What is adsorbed?

 Macrophage inflammatory
protein-a (MIP-a)
 Interleukin 5  Macrophage inflammatory
 Interleukin 6 
protein-b (MIP-b)
Tumor necrosis factor-a (TNF-a)
 Interleukin 7  Monocyte chemotactic protein
 Interleukin 8 
(MCP-1)
Epithelial neutrophil activating
 Interleukin 10 (?) peptide 78 (ENA-78)
 Interleukin 12p70 

Angiogenina
b2 microglobulina
 Interleukin 16  Omocisteina
 Interleukin 18
Midle Molecule
HFR – What is not adsorbed?

 Ca ++
 Urea  Mg ++
 Creatinina  HCO3-
 Acido urico  Aminoacidi essenziali
 Fosfati  Aminoacidi a catena
 Glucosio ramificata
 Na +  Albumina
K+
Small Molecule
Hb (g/L)
11.4

Th/ EPO Stop

11.2

11

10.8

10.6

10.4

10.2

10
06/06 14/07 11/08 03/09 17/09 03/10
β2M (µg/L) β2M (µg/L)
60000 60000
Pre HFR Pre HFR
50000 50000

40000 40000

30000 30000

20000 20000

10000 10000

0 0
25/06 17/07 11/08 17/08 14/09 08/10

Pasien A Pasien B