Optimal prescription order for long-term hemodialysis รศ.นพ.ขจร ตีรณธนากลุ ภาควิชาอายรุ ศาสตร์ คณะแพทยศาสตร์ โรงพยาบาลจฬุ าลงกรณ์ และ จฬุ าลงกรณ์มหาวิทยาลยั The 5th Renal and Nutritional Conference 2020 17th January 2020
Topics • Target for HD prescription • Efficient uremic toxin removal -- SMmidadlllemmooleleccuulele • O•pAtipmparol pHrDiatperdedsicarlyipstaitoencomposition and volume control • Time and frequency • Increase urea clearance: • Vascular access • Effective blood flow rate • Dialyzer • D•iaDlyiasliyssifslufloidwqrautaelity and composition • VCoolnuvmeectcivoentthroelrapy •
HD Prescription for Adequacy KI 2000;56(S76):S19-S27
Small solute target: KDOQI 2015 Dialysis clearance
Continuous Clearance: EKR and StdKt/V Equivalent renal urea clearance EKR (Equivalent renal urea clearance) = Time-averaged urea removal (R = G) Time-averaged concentration of urea (TAC) - EKRc 13 Correlated with spKt/V 1.2 (x3/wk ≥ 13 Associated with treatment success)
Kt/V optimal dose for twice-a-week HD Correlation between EKRc and Kt/V in twice-a-weekly HD r = 0.81 2.11 Chulalongkorn Hospital
Continuous Clearance: EKR and StdKt/V Standard Kt/V Standard equivalent renal urea clearance (R = G) = Time-averaged urea removal (avCpre) Average predialysis BUN Calculate for t=7 days, fixed V and no Kru Leypoldt JK, et al. Semin Dial. 2994;17:142-5.. When included UF and Kru, Daugirdas et al. generated the formula for calculation Daugirdas JT, et al. Kidney Int.2010;77:637-44.
Small solute target: KDOQI 2015 Dialysis clearance Kidney clearance Body clearance
Middle-molecule target: ᵦ2 microglobulin Cheung AK, et al. J Am Soc Nephrol. 2006 Feb;17(2):546-55. Cheung AK, et al. Clin J Am Soc Nephrol. 2008 3:69-77.
UF rate, Dialysis time, and survival ▪ Secondary analysis of the HEMO study ▪ Compared – UFR < 10 ml/kg/hr – UFR 10-13 ml/kg/hr – UFR > 13 ml/kg/hr Kidney Int . 2011 January ; 79(2): 250–257
Topics • Target for HD prescription • Efficient uremic toxin removal -- SMmidadlllemmooleleccuulele • O•pAtipmparol pHrDiatperdedsicarlyipstaitoencomposition and volume control • Time and frequency • Increase urea clearance: • Vascular access • Effective blood flow rate • Dialyzer • D•iaDlyiasliyssifslufloidwqrautaelity and composition • VCoolnuvmeectcivoentthroelrapy •
UF rate, Dialysis time, and survival • Hemodialysis patients 22,000 in 7 countries • UF rate > 10 ml/h/kg ↑IDH (RR1.30;p=0.045) ↑ mortality (RR 1.09; P 0.02) • Longer HD session duration is independently associated with lower mortality
Incremental HD
Incremental HD Potential Benefits - Preservation residual kidney function - Longevity of vascular access - Economic benefits - Quality of life - Patient survival
Incremental HD
Frequent and long duration HD Longer and/or more frequent HD
Frequent and long duration HD Updated CPG
Frequent and long HD: Home HD (high DFR) (high DFR) (low DFR) NxStage DIMI
Topics • Target for HD prescription • Efficient uremic toxin removal -- SMmidadlllemmooleleccuulele • O•pAtipmparol pHrDiatperdedsicarlyipstaitoencomposition and volume control • Time and frequency • Increase urea clearance: • Vascular access • Effective blood flow rate • Dialyzer • D•iaDlyiasliyssifslufloidwqrautaelity and composition • VCoolnuvmeectcivoentthroelrapy •
Blood flow rate as a Kt/V influence factor
Blood flow rate and Dialysis session length For initial one or two sessions • Reduce the amount of dialysis • Especially when BUN is very high (> 125 mg/dL) • URR of < 40% should be targeted • BFR only 200 mL/min (150 mL/min in small patients) • 2-hour treatment time and relatively low efficiency hemofilter For later regular sessions • BFR up to 400-450 mL/min (150 mL/min in small patients) • at least 4-hour treatment time for intermittent HD
Blood flow rate and Vascular access quality Effective Vascular Access Flow (Qb) • Setting Qb on the machine > actual Qb (effective Qb) • ↑ Setting Qb negative arterial pressure At - 200 mmHg actual Qb ↓8.5% - 400 mmHg actual Qb ↓33%
Blood flow rate and Needle size
Topics • Target for HD prescription • Efficient uremic toxin removal -- SMmidadlllemmooleleccuulele • O•pAtipmparol pHrDiatperdedsicarlyipstaitoencomposition and volume control • Time and frequency • Increase urea clearance: • Vascular access • Effective blood flow rate • Dialyzer • D•iaDlyiasliyssifslufloidwqrautaelity and composition • VCoolnuvmeectcivoentthroelrapy •
Dialyzer Dialyzer membrane: 3 types 1 2 3
Dialyzer
Dialyzer Updated CPG The patients with hypoalbuminemia, diabetes, longer dialysis vintage should be considered a priority for selection of high-flux dialyzer.
Super High-Flux (Medium - High cut-off) Dialyzer
Super High-Flux (Medium - High cut-off) Dialyzer 0.003- 0.01 0.2 0.006
Super High-Flux Dialyzer Classification of dialyzer in Japan High-Flux: Example: - UFR > 20 mL/mmHg/hr -Fresenius HF80 - β2M SC > 0.6 - β2M Cl >20 mL/min Example of class4: -Helixone FX Super High-Flux -Purema(DORA-H) - β2M Cl >70 mL/min -ELISIO
Super High-Flux HD (high BFR) % Reduction 100 High-BFR super high-flux HD vs. 80 High-efficiency post-dilution 60 online HDF 40 - Small, Middle, Protein-bound 20 0 solute removal did not significant difference Urea Beta2 Microglobulin Indoxyl sulfate - Higher albumin loss (4.5 vs. 0.5 HCO HD HDF g/session) but similar stable long-term albumin levels Super High-Flux Hemodialysis (SHF-HD) Provides Comparable Effectiveness with High-Volume Post-dilution Online HDF in Chulalongkorn Hospital Removing Protein-bound and Middle-molecule Uremic Toxins: A Prospective Cross-over Randomized Controlled Trial. Theerachai Thammathiwat, Khajohn Tiranathanagul, et al.
Medium Cut-off Dialyzer
Medium Cut-off HD: Expanded HD (HDx)
Medium Cut-off HD: Expanded HD (HDx)
Topics • Target for HD prescription • Efficient uremic toxin removal -- SMmidadlllemmooleleccuulele • O•pAtipmparol pHrDiatperdedsicarlyipstaitoencomposition and volume control • Time and frequency • Increase urea clearance: • Vascular access • Effective blood flow rate • Dialyzer • D•iaDlyiasliyssifslufloidwqrautaelity and composition • VCoolnuvmeectcivoentthroelrapy •
Dialysate flow
Dialysate quality 1.คุณภาพนํา้ บริสุทธ์ิทใี่ ช้ในการฟอกเลือดด้วยเคร่ืองไตเทยี ม Updated จํานวนแบคทเี รีย CPG endotoxin เกณฑ์ action level เกณฑ์ action level นํา้ บริสุทธ์ิสําหรับการฟอก < 100 50 CFU/mL 0.25 EU/mL 0.125 EU/mL เลือด (dialysis water) CFU/mL นาํ้ ยาไตเทียมมาตรฐาน < 100 50 CFU/mL 0.5 EU/mL 0.25 EU/mL (standard dialysis fluid) CFU/mL นาํ้ ยาไตเทยี มบริสุทธ์ิสูง < 0.1 - < 0.03 EU/mL - (ultrapure dialysis fluid) CFU/mL สารละลายทดแทน < 0.000001 - < 0.03 EU/mL - ปราศจากเชื้อ (sterile CFU/mL substitution fluid)
Dialysate quality Ultra- Ultra- filtration filtration EBPG/ISO, 2009 (JDST) < 10-6 (<0.001) (<0.05) (<0.05) (<0.001) Ultra- filtration Ledebo I et al. NDT plus 2010;3:8-16.
Dialysis solution composition ▪ Sodium (Na) ▪ Potassium (K) ▪ Bicarbonate (HCO3) ▪ Calcium (Ca) ▪ Magnesium (Mg) ▪ Dextrose ▪ Acetate vs Citrate
Dialysis solution: Sodium Usual dialysis solution sodium level is 135-145 mEq/L 1. Sodium balance neutral 2. Sodium balance positive (higher dialysate Na >140): • the profile enhances plasma sodium levels • plasma osmolarity is increased • fluid is shifted from the IC to the EC space. • ↓ IDH 3. Sodium balance negative (lower dialysate Na < 135): • the profile leads to diffusive sodium loss • plasma osmolarity is then decreased • fluid is shifted from the IC to the EC space • ↓ Interdialytic weight gain
Dialysis solution: Potassium ▪ Usual chronic dialysis solution potassium is 2 mEq/L ▪ Use dialysis solution potassium level of 3 mEq/L in patients with : – Predialysis plasma potassium < 4.5 mEq/L – Receiving digitalis ▪ Dialysate K + plasma K = 7-7.5 ▪ Potassium rebound : A marked rebound increase in serum potassium within 3-4 hours after dialysis. – One should resist the temptation to treat a postdialysis hypokalemia unless clinically relevant.
Dialysis solution: Calcium Ca 2.5-3.0 mEq/L Ca 3.0-3.5 mEq/L - Calcium-based phosphate - Intradialytic hypotension binder patient - Suspected adynamic bone Calcium profile - Vascular calcification Ca-d 2.5 3.5 mEq/L Dialytic treatment of acute hypercalcemia • Use at least 2.5 mEq/L of calcium for dialysis solution to minimize overly rapid decrease in iCa • Frequent measurement of iCa during dialysis.
Dialysis solution temperature ▪ Generally 34.5oc – 36.5oc ▪ Individualization : setting dialysis solution temperature 0.5oc lower than tympanic membrane temperature. – Protection from intradialytic hypotension – Shortening of postdialysis recovery time – Reduce myocardial stunning and ischemic damage to brain white matter ▪ A rise in body temperature about 0.5oc during dialysis is normal and not necessarily a sign of infection.
Dialysis solution: Acetate
Acetate-free Dialysis • Citrate-enriched bicarbonate based dialysis CitrasateR DRYalysateR (USA) • Acetate-free dialysis fluid CarbostarR (Japan) ARTSTONR (Korea)
Acetate-free hemodialysis (AFHD) AFHD = Hemodialysis using acetate-free dialysate Composition Regular Acetate-free Sodium (mEq/L) 138 138 Chloride (mEq/L) 108.8 109.8 Caclium (mEq/L) 3.0 3.0 Magnesium (mEq/L) 1.0 1.0 Potassium (mEq/L) 2.0 2.0 Glucose (mg/L) 100 100 Bicarbonate (mEq/L) 32 32 Acetate (mEq/L) 3.0 0 Citrate (mEq/L) 0 2.0 Chulalongkorn Hospital
Acetate-free hemodialysis (AFHD) Improve hemodynamic stability Anticoagution effect Increase reuse Improve nutrition, inflammation, PTH Increase solute removal
Topics • Target for HD prescription • Efficient uremic toxin removal -- SMmidadlllemmooleleccuulele • O•pAtipmparol pHrDiatperdedsicarlyipstaitoencomposition and volume control • Time and frequency • Increase urea clearance: • Vascular access • Effective blood flow rate • Dialyzer • D•iaDlyiasliyssifslufloidwqrautaelity and composition • VCoolnuvmeectcivoentthroelrapy •
Hemodiafiltration Dialysate out Dialysate in Replacement + Convective UF
Benefits of HDF: Large solute clearance • Prospective study: HFHD → OL HDF for 3 year Better Survival Chulalongkorn Hospital
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