Akses Dialisis dan Perawatannya

Abdullah

Division of Nephrology and

Hypertension,
Syiah Kuala University/dr.Zainoel
Abidin Centre Hospital ,
Banda Aceh - Indonesia
 98% patient CKD --- Hemodialysis
 2% patient --- Peritoneal dialysis

 Etiology :
 Diabetic nephropathy (52%),
 Hypertension (24%),
 Congenital abnormalities (6%),
 Urid Acid Nephropathy (1%)
 Lupus Nephritis (1%) and Others
Dialysis Options

• There are two form of dialysis.

• One type of dialysis is
performed using the
abdominal cavity (peritoneal
dialysis).
• Another type is performed by
filtering the blood
(hemodialysis).
Peritoneal Dialysis Access

 Peritoneal
One end of dialysis
the
requires
catheteraccess
rests in
tothe
the
peritoneal
peritonealcavity,
cavity.
while the other
 During
extends a minor
from the
outpatient
body. surgery,
 aItsmall
takessoft
a few
tube
weeks
is
put
to heal.
into the
 abdomen
The PD catheter
called astays
PD
in catheter.
place throughout
your time on PD.
Hemodialysis

The recent data of the Dialysis Outcomes and

Practice Patterns Study (DOPPS), it is
recognized that 15–50% of patients in Europe
and 60% of patients in the US start
hemodialysis treatment with a catheter for
vascular access

Hemodialysis Access. 2006. National Kidney Foundation

 Factors Influencing Hemodialysis
Access

Types of Long Term Access: Factors that

• AV Fistula (AVF) (* First choice when possible) influence
• AV Graft (AVG) access include:
• Central Venous Catheter (CVC) Catheter Life expectancy,
time to dialysis,
referral timelines,
Vein Fistula
Right atrium of suitability of
heart
vessels, risk of
complications,
Artery patient choice

Graft
Blood to dialysis
machine Blood from dialysis
machine

1. KDOQI 2006 Clinical Practice Guidelines and Clinical Practice Recommendations, Vascular Access, 2006. 6
2. Graham, J et al. Nephrol. Dial. Transplant 2008 Nov;23(11):3585-91.
 Preparation for Access

• Ideally before you start dialysis a access

should be in placed and ready to use
• Fistula should be placed 6 months prior to
starting dialysis
• Graft should be placed 3-6 weeks prior to
starting dialysis.

Ahmad, Suhail. Manual of clinical dialysis. Springer Science & Business Media, 2009.
 What is a fistula or AVF?

• ItIsiscreated
done as minor outpatient
by directly
surgery
connecting an artery and a
• Usually
vein take 6 to 12 weeks to
• develop
This causes the vein to grow
• Considered
larger andthe best long-term
stronger for easy
vascular access because it provides
access
adequate blood flow, lasts a long
• time,
Fistulas canabe
and has place
lower in
complication
forearm
rate or upper
than other arm
types of access.

Hemodialysis Access. 2006. National Kidney Foundation

Pros of Cons of
AVFs AVFs
• The gold
standard • Visible as a
• Lasts longer than bulge under
other access the skin
types, usually 20 • Takes longer
plus years to develop for
• Fewer infections use
than grafts and • Not always
catheters possible for
• Increased blood all patients
flow means more
effective dialysis
treatment

Hemodialysis Access. 2006. National Kidney Foundation

 If Grafts canare
your veins besmall or
weak theningraft
placed youris arm
a
better
or legoption for dialysis
but most are
access.
placed in the
forearm
 A graft connects an
artery to a vein using a
 soft
Can be used
artificial after
tube
3-6 weeks
implanted of your
under
placement
skin
Hemodialysis Access. 2006. National Kidney Foundation
 Pros of Graft Cons of Graft

 Usually only lasts

 Implanted 3-5 years
during  More likely to get
infected than AVF
minor
 More likely to
outpatient have blood clots
surgery than an AVF
 Can be used  Longer bleeding
time than an AVF
within 3-4 after dialysis
weeks needles are
removed

Hemodialysis Access. 2006. National Kidney Foundation

Santoro, Domenico, et al. "Vascular access for hemodialysis: current perspectives." International journal of nephrology and renovascular disease 7 (2014): 281.
Santoro, Domenico, et al. "Vascular access for hemodialysis: current perspectives." International journal of nephrology and renovascular disease 7 (2014): 281.
 Temporary non Cuffed Catheters

 Short.
 More ridged.
 Easy and fast
insertion.
 Immediate use.
 Higher infection rate.
 Preferred IJ or
femoral.
 Avoid subclavian.
 < 3wks for IJ.
 <5 days for femoral.

Agarwal et al. ASN. 361-375. 2009.

 Cuffed Tunneled Catheters

 Dacron cuff.
 Softer.
 Sheath for insertion.
 Different holes, length
and material.
 Requires sedation.
 Lower neck insertion
site.
 More bleeding.

Agarwal et al. ASN. 361-375.2009.

 The most common type of complication is catheter related
bloodstream infection (CRBSI), with an incidence rate of
0.46 to 30 per 1000 catheter-days, or in 4.3% to 26% of
placed catheters.

Catheter related thrombosis has been reported in

0.6% to 33% of catheters, or 0.06 to 21
episodes/1000 catheter-day

Santoro, Domenico, et al. "Vascular access for hemodialysis: current perspectives." International journal of nephrology and renovascular disease 7 (2014): 281.
Santoro, Domenico, et al. "Vascular access for hemodialysis: current perspectives." International journal of nephrology and renovascular disease 7 (2014): 281.
Infection Control Measures

 Catheter insertion
 Maintenance
Maintenance - Exit Site Care

 Dressing changed at
each HD treatment
 Performed by trained
renal nurse
 Sterile technique is
used
 Mask worn by staff and
patient
Maintenance - Exit Site Care

 Examine for signs of

exit site infection
Maintenance – Exit Site Care

 Cleansing solution: 0.5% chlorhexidine in

70% alcohol, with a minimal contact time of
30 seconds
Maintenance - Exit Site Care

 Cleansing solution on
exit site is allowed to
dry

 Betadine ointment
applied after cleansing
Maintenance - Exit Site Care

 Sterile gauze dressing is used to cover

the exit site
Maintenance - Exit Site Care

 Frequency of dressing changed:

 2-3 times / week before HD
 Weekly if not used for HD – at transitional
period
 Whenever necessary: soiled, bleeding.

 The exit site will not be interfered in between

haemodialysis treatment
During Haemodialysis

 Aseptic technique is used for connecting

and disconnecting the catheter to the HD
circuit to avoid contamination
Use of Catheter

 The catheter is used for haemodialysis

only
 Blood taking is not allowed from the
catheter
 If parenteral nutrition or IV medication
requiring the use the catheter, a triple
lumen catheter with a separate lumen
will be used
Duration of Catheterization

 Catheter will be kept as long as it is

required for HD, before other stable
access for dialysis is available

 Routine change of catheter is not

practiced
Catheter Removal

 If catheter related infection exist:

- Bacteraemia: fever, chills, positive
blood culture
- exit site infection: purulent discharge,
erythema, tenderness, positive
culture swab
 Catheter will be removed and replaced
using a new site
 Femoral catheter will be kept to a
maximum of 7 days and removed
Locking Solution

 Locking solution does not contain

antibiotics, except in special situations:
- It is the last access resort
- Patient has a high risk of infection

 Antibiotic lock:
- Gentamycin 20mg in Citrate
- Cefazolin 2.5mg in Heparin
Patient Education

 Keep dressing dry, avoid disturbance

and contamination to exit site

 Report for abnormal conditions: fever,

discharge, bleeding
Strategies for Maintenance of Central Venous Catheter
TERIMA KASIH