HEMODIALYSIS

GROUP 7 :
MAHARANI INDRIATY (1411012068)
DIANDA APRILIA (1411012070)
AFIFAH (1411012071)
ANNISA FITRI FEBRIANTI (1411011004)
 Dialysis
Definition
Artificial process that partially replaces renal
function
Removes waste products from blood by
diffusion (toxin clearance)
Removes excess water by ultrafiltration
(maintenance of fluid balance)
Types
Haemodialysis (HD)
Peritoneal Dialysis (PD)
HD and PD has similar principles: Movement of solute or water
across a semipermeable membrane (dialysis membrane)
Diffusion
Movement of solute
Across semipermeable membrane
From region of high concentration to one of low concentration
Ultrafiltration
Made possible by osmosis
Movement of water
Across semipermeable membrane
From low osmolality to high osmolality
Osmolality number of osmotically active particles in a unit
(litre) of solvent
Selection for HD/PD
Clinical condition
Lifestyle
Patient competence/hygiene (PD - high risk of infection)
Affordability / Availability
1.

2.

Blood cells are too big to pass through the dialysis membrane,
but body wastes begin to diffuse (pass) into the dialysis solution.

3.

Diffusion is complete. Body wastes have diffused through the membrane,

and now there are equal amounts of waste in both the blood and the
dialysis solution.
The process of ultrafiltration in PD
11.

2
2.

Blood cells are too big to pass through the semi-permeable membrane,
but water in the blood is drawn into the dialysis fluid by the glucose.

3.

Ultrafiltration is complete. Water has been drawn through the peritoneum

by the glucose in the dialysis fluid by the glucose in the dialysis fluid. There is
now extra water in the dialysis
fluid which need to be changed.
 Haemodialysis
Dialysis process occurs outside the body in a machine
The dialysis membrane is an artificial one: Dialyser
The dialyser removes the excess fluid and wastes from the
blood and returns the filtered blood to the body
Using low-flux filters, hemodialysis is usually performed for 34
hours three times weekly.
Hemodialysis is a very efficient procedure to remove toxic
waste from the blood of renal failure patients.
Blood is pumped out of the patient at the rate of 300400
mL/min and through one side of the semipermeable
membrane of the artificial kidney by the hemodialysis machine
When assessing the hemodialysis removal characteristics of a
drug and the need for postdialysis replacement doses, it
should be recognized that the majority of information available
is for low-flux artificial kidneys.
If a high-flux dialysis coil is used, the primary literature is
probably the best source of information, but in many cases
studies have not been conducted using this technology.
Computation of Initial Doses and Modification of
Doses Using Drug Serum Concentrations
can be based on expected pharmacokinetic parameters for
this population when published information for a drug is
inadequate or the agent has a very narrow therapeutic index.
Requirements for HD
Good access to patients circulation
Good cardiovascular status (dramatic changes in BP may
occur)
HD Access
2 types of access for HD:
Must provide good flow
Reliable access
A fistula: arterio-venous (AV)
Vascular Access Catheter
AV Fistula
The intradialysis elimination rate constant can be determined
by obtaining postdose (C postdose(1)) and predialysis (C
Predialysis ) concentrations [ke=(C
postdose(1)Cpredialysis)/t,]
Fraction eliminated =[(C predialysis Cpostdialysis /
Cpredialysis], and the volume of distribution can be calculated
using postdialysis and postdose concentrations: V=D/
(Cpostdose(2)Cpostdialysis).
 Peritoneal Dialysis
(PD)
Uses natural membrane (peritoneum) for dialysis
Access is by PD catheter, a soft plastic tube
Catheter and dialysis fluid may be hidden under
clothing
Suitability
Excludes patients with prior peritoneal scarring e.g.
peritonitis, laparotomy
Excludes patients unable to care for self
Hemodialysis in patient take aminoglycoside
Hemodialysis Dosing Aminoglycoside antibiotics are
eliminated by dialysis, so renal failure patients receiving
hemodialysis must have aminoglycoside dosage regimens that
take dialysis clearance into account.
SPECIAL DOSING CONSIDERATIONS

Hemodialysis Dosing
Aminoglycoside antibiotics are eliminated by dialysis, so renal
failure patients receiving hemodialysis must have aminoglycoside
dosage regimens that take dialysis clearance into account.
Example 1 A 62-year-old, 65-kg (5 ft 8 in) male who has chronic
renal failure, and receives hemodialysis three times weekly with a
low-flux dialysis filter. An initial dosage regimen for tobramycin
needs to be computed for a patient to achieve peak
concentrations of 67 mg/L and postdialysis concentrations 12
mg/L.
Initial Dosage Determination
1. Patients with renal failure are prone to having poor fluid balance
because their kidneys are not able to provide this important function.
Because of this, the patient should be assessed for overhydration (due
to renal failure) or underhydration (due to renal failure and increased
loss due to fever). Weight is a good indication of fluid status, and this
patients weight is less than his ideal weight [IBWmale = 50 kg +
2.3(Ht 60 in) = 50 kg + 2.3(68 60) = 68 kg]. Other indications of
state of hydration (skin turgor, etc.) indicate that the patient has
normal fluid balance at this time. Because of this, the average volume
of distribution for aminoglycoside antibiotics equal to 0.26 L/kg can be
used.
2. A loading dose of tobramycin would be appropriate for this patient because the
expected half-life is long (~50 h); administration of maintenance doses only
might not result in therapeutic maximum concentrations for a considerable time
period while drug accumulation is occurring. The loading dose is to be given after
hemodialysis ends at 1300 H on Monday (hemodialysis conducted on Monday,
Wednesday, and Friday from 0900 1300 H).
Because the patient is expected to have a long half-life compared to the infusion
time of the drug (1/2 1 h), little drug will be eliminated during the infusion
period, and IV bolus one-compartment model equations can be used. The loading
dose for this patient would be based on the expected volume of distribution: V =
0.26 L/kg 65 kg = 16.9 L; LD = Cmax V = 6 mg/L 16.9 L = 101 mg, rounded to
100 mg (LD is loading dose, Cmax is the maximum concentration after drug
administration). This loading dose was given at 1400 H.
3. While the patient is receiving hemodialysis, tobramycin is eliminated by the
patients own mechanisms plus dialysis clearance. During hemodialysis with a low-
flux filter, the average half-life for aminoglycosides is 4 hours. Because the patient is
dialyzed for 4 hours, the tobramycin serum concentration should decrease by 1/2
1.7 mg/L, or using formal computations: ke = 0.693/(t1/2) = 0.693/4 h = 0.173 h1;
C = C0eket = (3.3 mg/L)e(0.173 h1)(4 h) = 1.7 mg/L.
At this time, a postdialysis replacement dose could be given to increase the
maximum concentration to its original value of 6 mg/L: Replacement dose = (Cmax
Cbaseline)V = (6 mg/L 1.7 mg/L)16.9 L = 73 mg, round to 75 mg (where Cmax
is the maximum postdose concentration and Cbaseline is the predose
concentration). The postdialysis replacement dose of 75 mg was administered at
1400 H on Wednesday. Because all time frames and pharmacokinetic parameters
are the same for Monday to Wednesday and Wednesday to Friday, the postdialysis
replacement dose on Friday at 1400 H would also be 75 mg.
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