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RENAL
REPLACEMENT
THERAPY

Renal Replacement Therapy

WHO ?
WHEN ?
HOW ?

Consensus
Patients with serum creatinine >
2 mg/dl with / or GFR < 50
cc/minute have a poor prognosis
and should be consulted to
nephrologists.

WHO?

INDONESIAN CONSENSUS ON HEMODIALYSIS, 2003

Consensus
All patients with GFR < 15 cc/minute
should be initiated for dialysis. As a
clinical consensus dialysis could be
initiated on patients with :
1.
GFR < 10 cc/minute with uremic
syndrome or malnutrition.
2.
GFR < 5 cc/minute without any
syndrome.
3.
Special
indication
for
acute
complication
such
as
pulmonary
INDONESIAN
CONSENSUS ON HEMODIALYSIS,
2003
edema, hyperpotassiumemia,
metabolic
acidosis, etc

management of CRF
MEDICAMENTOSA
(PREVENTION OF PROGRESSION OF RENAL DISEASE)
-

Protein restricting diet

( 0.6-0.8 gr/kgBB/day)
Blood pressure control
Managing Fluid and Electrolyte disorders
Managing hyperphosphatemia, hyperkalemia, etc)
Treating anemia
Managing hyperlipidemia

RENAL REPLACEMENT THERAPY

In cases of GFR reduced to < 10 15 cc/min (= s creat 8-10 mg/dl

or 20 cc/min in DM ( s creat 6-8 mg/dl)

WHEN?

Bicarbonate supplement
Erythropoietin as needed
Establish
good rapport Restrict dietary phosphorus. Ca binders. ? Vitamin D
with PCPs
DPI decrease

100

75

GFR

50

25

10

Vitamin D levels fall,

Net acid
PTH starts to increaseExcretion falls
Anemia may be present
Institute measures to slow progression and treat comorbid conditions
Evaluate cause for CRF

Select site for dialysis

Place an AVF Place graft or
Access and preserve veins
PD catheter

Timeline shows the course of chronic renal failure (CRF) leading to end stage renal disease
(AVF, arteriovenous fistula; Ca, Calcium; DPI, dietary protein intake, GFR glomerular filtration
rate; PCP, primary care provider; PD, peritoneal dialysis; PTH, parathyroid hormone.)

Modalities of
Renal Replacement Therapy (RRT)
DIALYSIS

TRANSPLANTATION

HEMODIALYSIS

LIVING DONOR

HEMOFILTRATION
PERITONEAL

CADAVERIC DONOR

Differences between DIALYSIS & TRANSPLANTATION

DIALISIS
DIALYSIS

TRANSPLANTASI

-: Replace renal function artificially

(using dialyzer)
- Replace excokrine function only

: - Replace renal funtion naturally

- (using kidney donor)
- Replace excokrine and endokrine
function
Excokrine function
Endokrine function
- Body fluid regulation
- Blood Pressure regulation
- Waste products regulation - Hormon regulation
- (sisa metabolisme)

HEMODIALYSIS
PERITONEAL DIALYSIS
HEMOFILTRATION

INDICATION FOR
INITIATING RRT
- Acute Renal Fail : emergency cases
- Azotemia

-Chronic Renal Fail : -

ureum> 200 mg/dl

- Overhidration/anuria urine < 100 cc/d
- Metabolic Asidocis
pH
< 7.1
- Hiperkalemia
K
>7

Creatinine clearence <5-10 cc/menit

on emergency cases

RRT Modalities
INTERMITTENT THERAPIES :
Haemodialysis (HD)
Peritoneal Dialysis (IPD)
Hemofiltration (IHF)
Ultrafiltration (UF)
CONTINOUS THERAPIES :
Chronic Ambulatory Peritoneal Dyalisis (CAPD)
Slow Continous Ultrafiltration (SCUF)
Continous Veno-Venous Hemofiltration (CVVH)
Continous Arterio-Venous Hemofiltration (CAVH)
Continous Arterio-Venous Hemofiltration-Dialysis
Veno
(CVVH-D / CAVH-D)

Seminars in Dialysis ,9:469-475,1996

Table. Glossary of term for renal

replacement therapy (RRT)
CAVH Continuous arteriovenous haemofiltration.
Depends upon patients blood pressure
CVVH
Continuous venoveous haemofiltration. Pumpdriven system
CAVHD
Continuous areriovenous haemofiltration and
dialysis (haemodiafiltration)
CVVHD
Continuous venovenous haemofilration and
dialysis
HD
Standard machine-driven haemodialysis
HF
Standard machine-driven haemofiltration
PD
Peritoneal dialysis

Factors Influencing Choice of

Dialysis Modalities
PATIENT

: - Indication for dialysis

- Presence of MOF
- Acces
- Mobility and location of patients
- Anticipated duration of therapy

DIALYSIS PROCESS : - Efficacy for solute and fluid balance

- Outcome and complications
- Type : Intermittent vs Continous
- Components (membrane, heparin,etc)
NURSING & OTHER : - Availibility of machines
SUPPORT
- Nursing support & skill
Seminars in Dialysis ,9:469-475,1996

RECOMENDATION FOR INITIAL CHOICE OF DIALYSIS MODALITY

Indication

Clinical Condition

Preffered Therapy

Uncomplicated ARF Antibiotic nephrotoxicity

Fluid Removal

IHD, IPD

Cardiogenic Shock, CP bypass

Uremia

Complicated ARF in ICU

IHD

Shock
Nutrition

Sepsis, ARDS
Burns

CVVH-DF,CAVH-DF
CA/VH-DF, CVVH

Electrolyte abnorma-Marked Hyperkalemia

Lities

IHD, CVVH-DF

ARF in pregnancies Uremia in 2nd or 3rd trimester IPD

Seminars in Dialysis ,9:469-475,1996

SCUF,CAVH

Circuit of
emodialysis , Hemofiltration, and Peritoneal Dialys

HOW?

DIALYSIS FACILITIES & BLOOD ACCESS

BLOOD ACCESS
access for blood to enter the body
( via blood vessels) in the process
Sub-clavia / Jugular
of dialysis

femoral
DIALYSIS FACILITIES
cimino
- Dialysis wards
- Water treatment & water disposal
- Dialysis machines
- Consumables (dialyzer,AV-fistula, dialysate)
- Dialysis nurses

Dengan dialisis darah dibersihkan dengan proses difusi dan filtrasi

Melalui membran semi-permeable dalam Ginjal Buatan
BLOOD
BLOOD
dialisat
(exit)
enter
DIFFUSION
(concentation)
DIALYSATE
enter
DIALYSIS PROCESS
ULTRAFIL
TRATE
exit

UltraFiltrat
BLOOD
exit

DIALYZER

FILTRATION
(pressure)

BLOOD
(enter)

(counter current)
Semi-permeable Membrane

Circuitry for Hemodialysis

Circuitry for SCUF

Circuitry for CVV -HD

Peritoneal Dialysis
PERITONEAL DIALYSIS a dialysis process using peritoneum membrane
as the semi-permeable membrane for difusion dan filtration

PERITONEAL DIALYSIS TECHNIC

1.Dialisate (1-2 Liter) enter the peritoneum
Dialisate cavity via Peritoneal Cathether
2.Dialysate kept for some hours
enter
to allow the difusion & filtration process
3.Ultrafiltrate exit the cavity
Ultrafiltrate
4.Change with new dialisate
exit
5.Recycling every 4 -8 hours

modalities of
Peritoneal Dialisis
ACUTE/INTERMITTENT
PERITONEAL DIALYSIS
(IPD)
Indication : ARF
Hospitalized
Only for days/week

CHRONIC AMBULATORY
PERITONEAL DIALYSIS
(CAPD)
Indication : ESRD
Ambulatory
Long term (chronic)

please
continue
SLEEPING !