Practical Dialysis in the Year 2009

Practical Dialysis in the Year 2009 ·≈– “¡“√∂≈¥¢π“¥¢Õß ESA ‰¥â‡©æ“–ºŸâªÉ«¬∑’ˇªìπ macrocytic anemia ·µà„πºâŸªÉ«¬∑’ˇªìπ normocytic red blood cell °“√„Àâ folic acid ‰¡à™à«¬62 °“√ª√–‡¡‘π serum folate ¡’°“√‡ª≈’ˬπ·ª≈ß√–¥—∫‡√Á«‡¡◊ËÕ¡’°“√¢“¥ ·µà√–¥—∫®–·°«àßµ“¡ °“√°‘πÕ“À“√  à«π red blood cell folate ¡’§à“µË”„π¿“«–¢“¥ folic °“√„Àâ folic acid 1-2 mg µàÕ«—𠇪ìπ routine À√◊Õ 5-10 mg µàÕ«—π „πºâŸªÉ«¬∑’Ë¡’¿“«– hyperhomocysteinemia  “¡“√∂≈¥°“√¢“¥ folate ‰¥â Õ“À“√∑’Ë¡’ folic acid ‰¥â·°à grain, fortified cereal,  â¡ ·≈–º—°„∫‡¢’¬«62 7. Failed kidney transplant „πºâŸªÉ«¬∑’Ë failed kidney transplant ·≈–‰¡à‰¥âπ”‡Õ“‰µπ—ÈπÕÕ° ¡’√“¬ß“π«à“ ®”‡ªìπµâÕß„™â ¢π“¥¢Õß ESA  ßŸ ¢÷Èπ Õ“®‡æ√“– low grade inflammation „π graft2 8. ACEI, ARB ACEI Õ“®¡’º≈¬—∫¬—Èß°“√ √â“ß epo ‚¥¬√∫°«π√–∫∫ renin angiotensin system, ‡æ‘Ë¡√–¥—∫ ¢Õß N-acetyl-seryl-aspartyl-lysyl-proline (AC-SDKP) ∑¡Ë’ º’ ≈¬∫— ¬ßÈ— erythroid growth15 ‚¥¬∑”„Àâ pleuripotent hematopoietic stem cell ·≈– normal early progenitor Õ¬àŸ„π G0-phase ‰¡à‡¢â“ àŸ S-phase „πÀπŸ æ∫«à“ Angiotensin II infusion ∑”„Àâ plasma epo  Ÿß¢÷Èπ ‚¥¬ Angiotensin II Õ“®¡’º≈ °√–µÿâπ°“√À≈—Ëß epo ‚¥¬µ√ß À√◊Õºà“π∑“ß vasoconstriction ∑”„À⇰‘¥ renal ischemia ·µà°Á¡’°“√»÷°…“∑’Ë æ∫«à“ ACEI ‰¡à¡’º≈µàÕ epo level43 Parazella ·≈–§≥– æ∫«à“ red blood cell survival ·≈– plasma volume ‰¡à¢÷Èπ°—∫ ACEI · ¥ß «à“°“√´’¥„πºâŸª«¬∑’ˉ¥â√—∫ ACEI ‰¡à‰¥â‡°‘¥®“° hemolysis À√◊Õ hemodilution °“√»÷°…“‚¥¬ Albitar S ·≈–§≥– „πºâŸªÉ«¬øÕ°‡≈◊Õ¥ 40 √“¬ ∑’ˉ¥â√—∫ ESA ·≈–¡’§«“¡¥—π ‚≈Àµ‘  ßŸ ‡ª√¬’ ∫‡∑¬’ ∫√–À«“à ß°≈¡àÿ ∑‰Ë’ ¥â enalapril ·≈– nifedipine æ∫«“à „π°≈¡àÿ ∑‰Ë’ ¥â enalapril µÕâ ߇æ¡Ë‘ ¢π“¥ ¢Õß ESA Õ¬à“ß¡’π—¬ ”§—≠‡¡◊ËÕ‡∑’¬∫°—∫°àÕπ‰¥â ·≈–¢π“¥≈¥≈ß àŸ¢π“¥‡¥‘¡À≈—ßÀ¬ÿ¥„™â enalapril 4 ‡¥◊Õπ · ¥ß«à“ enalapril ‡æ‘Ë¡§«“¡µâÕß°“√ ESA ®“°°“√»÷°…“π’È ·π–π”Õ“®æ‘®“√≥“„™â enalapril ‡©æ“–„πºŸâ ªÉ«¬∑’ˉ¡à “¡“√∂§«∫§ÿ¡§«“¡¥—π‚≈À‘µ¥â«¬¬“Õ◊ËπÀ√◊Õ¡’ heart failure √à«¡¥â«¬43 9. Pure red cell aplasia æ∫¡“°¢÷ÈπÀ≈—ߪï 1998 °“√«‘π‘®©—¬∑’Ë ”§—≠ §◊Õ °“√‡®“–µ√«®‰¢°√–¥Ÿ° √à«¡°—∫°“√æ∫ antiEpo Ab º≈°“√µ√«®‰¢°√–¥Ÿ° æ∫ absolute erythroid precursor, red blood cell maturation arrest ¢≥–∑’Ë WBC, platelet precursor Õ¬àŸ„π‡°≥±åª°µ‘ 10. Non-compliance æ∫√âÕ¬≈– 35-55 ¡—°æ∫„π§π∑’Ë©’¥¬“‡Õß, Õ“¬ÿπâÕ¬ ·≈– ºâŸªÉ«¬≈â“߉µ∑“ß™àÕß∑âÕß∑’Ë noncompliance ®“°°“√»÷°…“æ∫«à“ °“√ identify non-compliance ‚¥¬«‘∏’ direct questioning ®– “¡“√∂ æ∫‰¥â√âÕ¬≈– 58 ·µà∂â“„™â«‘∏’ pharmacy record review ®–æ∫‰¥â√âÕ¬≈– 74  à«π¡“°‡°‘¥®“° °“√≈◊¡ √Õß 188

Current Management of Anemia in Dialysis Patients ≈ß¡“‡ªìπ Õ“°“√ª«¥∑’˵”·Àπàß©’¥¬“ °“√„À⬓∑’Ëßà“¬ ‡™àπ 1 §√—ÈßµàÕ —ª¥“Àå Õ“®™à«¬‡æ‘Ë¡ compliance À√◊Õ¡’«‘∏’∑’˙૬≈¥Õ“°“√ª«¥ °“√„™â„π√ªŸ ª“°°“Õ“®™à«¬‡æ‘Ë¡ compliance ·µà¬—߉¡à¡’¢âÕ¡≈Ÿ  ß‘Ë ∑·’Ë æ∑¬ºå ¥âŸ ·Ÿ ≈§«√∑”§Õ◊ °“√„À§â «“¡√‡Ÿâ °¬’Ë «°∫— ª√–‚¬™π¢å ÕßESA π“à ®–™«à ¬‡æ¡‘Ë compliance 11. Inflammation, infection ¡’°“√»÷°…“æ∫«à“§à“ CRP ∑’ˇæ‘Ë¡¢÷È𠇪ìπµ—«∑”𓬠resistance to epo ¿“«– inflammation ‡°‘¥®“° membrane-induced complement activation, direct cell-membrane interaction, dialysate fluid- containing endotoxin, unrecognized persistent infection, periodental infection, hemodialysis catheter, failed kidney transplant, peritonitis „πºâŸªÉ«¬øÕ°‡≈◊Õ¥ ·¡â‰¡àæ∫µ”·ÀπàߢÕß°“√µ‘¥‡™◊ÈÕ™—¥‡®π ·µà√âÕ¬≈– 30-50 ¬—ß¡’ CRP  ßŸ ‰¥â50 ¡’·À≈àß°“√µ‘¥‡™◊ÈÕ∑’Ë¡’√“¬ß“π«à“ —¡æ—π∏å°—∫ resistance to ESA ®“°°“√»÷°…“¢Õß Nassar GM ·≈– §≥– „πºªâŸ «É ¬øÕ°‡≈Õ◊ ¥ 22 √“¬∑¡Ë’ ’ non-functioned graft ∑‰Ë’ ¡¡à ≈’ °— …≥–°“√µ¥‘ ‡™ÕÈ◊ ®“°°“√µ√«®√“à ß°“¬ ·µà identify °“√µ‘¥‡™◊ÈÕ‚¥¬ Indium scan ·≈–ºà“µ—¥æ∫ÀπÕß æ∫«à“‡¡◊ËÕºà“µ—¥‡Õ“ AV graft ÕÕ° ∑’Ë 2 ‡¥◊Õπ Hb ‡æ‘Ë¡¢÷ÈπÕ¬à“ß¡’π—¬ ”§—≠ ·≈–≈¥¢π“¥¢Õß ESA ‰¥â √âÕ¬≈– 53 63·≈–¡’√“¬ß“πÕ◊Ëπ∑’Ëæ∫ occult infection „π old non-functioned graft √âÕ¬≈– 21 ·≈– √âÕ¬≈– 71 ·µà®”π«πºâŸªÉ«¬¡’πâÕ¬ 12. Malignancy „πºŸâªÉ«¬∑’ˇªìπ¡–‡√Áß µÕ∫ πÕßµàÕ ESA ≈¥≈߇©≈’ˬ√âÕ¬≈– 40 13. Malnutrition „πºªŸâ «É ¬‰µ«“¬‡√ÕÈ◊ √ß— ∑¡Ë’ ¿’ “«–´¥’ ·≈–µÕ∫ πÕ߉¡¥à µ’ Õà ESA §«√¡ÕßÀ“‚√§√«à ¡∑∑Ë’ ”„À‡â °¥‘ malnutrition-inflammation-artherosclerotic syndrome (MIA) ´÷Ëß¡—° —¡æ—π∏å°—∫¿“«–´’¥ „π§πÕâ«π¡—°æ∫ «à“¡’ Hb  ßŸ °«à“ ·≈–µâÕß°“√¢π“¥¢Õß ESA πâÕ¬°«à“§π∑’˺ա33 8. º≈¢Õß Dialysis µàÕ¿“«–´¥’ Dialysis ¡’º≈µàÕ°“√µÕ∫ πÕßµàÕ ESA Õ“®‡ªìπº≈®“° dialysis dose, ™π‘¥¢Õß membrane, treatment time, dialysate 1. ™π‘¥¢Õß membrane ·≈– convective treatment Locatelli F ·≈–§≥– ‰¥â»÷°…“‡ª√’¬∫‡∑’¬∫√–À«à“ߺŸâªÉ«¬∑’Ë„™â high flux membrane (polymethylmethacrylate) °—∫ cellulose membrane æ∫«à“ Hb ‰¡à·µ°µà“ß°—π ·µà√–¬–‡«≈“∑’˵‘¥µ“¡Õ“®  —Èπ‰ª64 ®“° secondary analysis ‚¥¬ Locatelli F ·≈–§≥– „πºâŸªÉ«¬ 380 √“¬ µ‘¥µ“¡ 24 ‡¥◊Õπ æ∫ «à“‰¡à¡’§«“¡·µ°µà“ß„π 4 modalities §◊Õ cuprophane hemodialysis, low-flux polysulfone hemodialysis, high-flux polysulfone hemodialysis, high-flux polysulfone hemodiafiltration10 189

Practical Dialysis in the Year 2009 2. Dialysate fluid contamination ‡≈Õ◊ ¥¢ÕߺªâŸ «É ¬øÕ°‡≈Õ◊ ¥ contact °∫— π”È ∑„Ë’ ™â dialysis 120 l/session À√Õ◊ 19,800 l/ªï ´ßË÷ chronic exposure µàÕ toxic substance ·¡â„πª√‘¡“≥∑’˵˔¡“° ·µàÕ“®∑”„À⇰‘¥¿“«–·∑√°´âÕπ‰¥â contaminant „ππÈ”∑’ËÕ“®∑”„À⇰‘¥¿“«–´’¥‰¥â ‰¥â·°à aluminium, nitrate, copper, fluorine, arsenic, zinc, chloramines ´÷Ëß ≈¥‰¥â‚¥¬°“√„™â reverse osmosis ·≈–°“√„™â activated carbon filter ‡æ◊ËÕ°”®—¥ chloramine ‚¥¬ª°µ‘ dialysate ‰¡à„™à sterile fluid ¬—ß¡’ bacteria, endotoxin ·µà„π√–¥—∫∑’ˬա√—∫‰¥â ·≈–∂Ÿ°°—Èπ‚¥¬ dialyzer membrane ·µà∂â“ membrane ¡’√Õ¬√—Ë« À√◊Õ¡’ bacteria „πª√‘¡“≥¡“° °Á “¡“√∂‡¢â“ àŸ°√–· ‡≈◊Õ¥  à«π endotoxin  “¡“√∂ºà“π membrane ‰¥â‚¥¬ßà“¬  “¡“√∂µ√«®æ∫ Ab µàÕ endotoxin ‰¥â ´÷Ë߇ªì𠓇Àµÿ¢Õß ¿“«– inflammation „πºŸâªÉ«¬øÕ°‡≈◊Õ¥ °“√§«∫§ÿ¡§ÿ≥¿“æπȔլà“߇¢â¡ß«¥À√◊Õ„™â ultrapure dialysate ™à«¬≈¥¿“«–π’ȉ¥â10,65 Sitter T ·≈–§≥– »÷°…“‡ª√’¬∫‡∑’¬∫ conventional dialysate °—∫ online ultrapure dialysate æ∫«à“ °≈ÿà¡„™â ultrapure dialysate ∑’Ë 12 ‡¥◊Õπ √–¥—∫¢Õß IL-6 ·≈– CRP ≈¥≈ßÕ¬à“ß¡’π—¬ ”§—≠ ·≈–≈¥ ¢π“¥¢Õß ESA ‰¥â ·≈–æ∫§«“¡ —¡æ—π∏å√–À«à“ß√–¥—∫ IL-6 °—∫¢π“¥¢Õß ESA26 3. Online Hemodiafiltration (HDF) Online HDF ‡ªìπ°“√√«¡ diffusion °—∫ convection ∑”„Àâ¡’ª√– ‘∑∏‘¿“æ¡“°°«à“ standard HDF ™à«¬„π°“√°”®—¥ medium ·≈– large molecule ·≈–≈¥ microbial, pyrogenic contamination ¢Õß dialysate8 ®“°°“√»°÷ …“‚¥¬ Maduell ·≈–§≥– „πºªŸâ «É ¬øÕ°‡≈Õ◊ ¥ 37 √“¬ ∑‡Ë’ ª≈¬Ë’ π¡“øÕ°‡≈Õ◊ ¥ ¥«â ¬ online HDF 1 ªï æ∫«à“ Hb ‡æ‘Ë¡¢÷Èπ®“° 10.66±1.1 g/dL‡ªìπ 11.4±1.5 g/dL ‚¥¬¢π“¥¢Õß ESA ≈¥≈ß®“° 3,861±2,446 IU/week ‡ªìπ 3,232±2,496 IU/week10 Õ°’ °“√»°÷ …“„πºªŸâ «É ¬ 92 √“¬ À≈ß— „™â online HDF Hct ‡æ¡‘Ë ¢π÷È ®“° 29.5±3.9% ‡ªπì 31.8±4.4%  “¡“√∂≈¥¢π“¥¢Õß ESA ≈߉¥â ·µà„π°“√»÷°…“π’È Kt/V ‡æ‘Ë¡¢÷Èπ®“° 1.28±0.99 ‡ªìπ 1.63±0.26 ·µà°“√»÷°…“‚¥¬ Ward ·≈–§≥– ‰¡àæ∫°“√‡ª≈’ˬπ·ª≈ߢÕß Hb À≈—ß∑” online HDF ¢âÕ¡≈Ÿ ∑’Ë¡’®“°·µà≈–°“√»÷°…“ ¡—°·µ°µà“ß„π‡√◊ËÕß treatment modality, ™π‘¥¢Õß membrane ∑’Ë„™â, ®”π«πºâŸªÉ«¬πâÕ¬ ·≈–Õ“®¢“¥°≈ÿࡧ«∫§ÿ¡ ∑”„À⬗߉¡à “¡“√∂ √ÿª‰¥8â 4. Dialysis dose and frequency ‡πÕË◊ ß®“° uremic toxin Õ“®‡ªπì  “‡Àµ¢ÿ Õß¿“«–´¥’ „πºªŸâ «É ¬‰µ«“¬‡√ÕÈ◊ √ß— °“√∑” dialysis ‡æÕË◊ remove uremic toxin π“à ®– “¡“√∂ improve Hb ‰¥â ´ßË÷ ¡À’ ≈“¬°“√»°÷ …“∑¬Ë’ π◊ ¬π— ª√– ∑‘ ∏¿‘ “æ¢Õß dialysis „π°“√ improve Hb „πªï 1980 Radkt ·≈–§≥– »÷°…“„πºŸâªÉ«¬ 42 √“¬∑’ˇ√‘Ë¡ dialysis æ∫«à“ Hct ‡æ‘Ë¡¢÷Èπ®“° 21.7 ‡ªìπ√âÕ¬≈– 28.6 ·≈– “¡“√∂≈¥¢π“¥¢Õß ESA ‰¥â10 Ifudu ·≈–§≥– æ∫«à“‡¡◊ËÕ‡æ‘Ë¡ urea reduction ratio (URR) √âÕ¬≈– 19 ®–‡æ‘Ë¡ odd ∑’Ë®–¡’ Hct ¡“°°«à“ 30% ¢÷Èπ 2 ‡∑à“ ·≈– URR ‡æ‘Ë¡¢÷Èπ®“°πâÕ¬°«à“√âÕ¬≈– 65 ‡ªìπ√âÕ¬≈– 72 æ∫«à“ Hct ‡æ‘Ë¡¢÷Èπ®“°√âÕ¬≈– 28.4±0.78 ‡ªìπ 32.3±0.71%, p=0.02 ·µà°“√»÷°…“π’È„™â 190

Current Management of Anemia in Dialysis Patients high flux polysulfone ´÷Ë߇ªìπ biocompatible membrane ¥—ßπ—Èπ°“√‡æ‘Ë¡¢Õß Hb Õ“®‡ªìπº≈®“° membrane ¥â«¬ ®“°¢âÕ¡Ÿ≈®“° Tassin Ω√—Ë߇»  æ∫«à“‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫ºâŸªÉ«¬∑’ˉ¥â√—∫ long hemodialysis 8 ™¡. ‡∑’¬∫°—∫ºŸâªÉ«¬∑’ˉ¥â√—∫°“√øÕ°‡≈◊Õ¥ 3-5 ™¡. „π «’‡¥π ·¡â Hct ¢Õß∑—Èß 2 °≈ÿà¡®–¡’§à“‰¡à·µ°µà“ß°—π ·µà °≈ÿà¡∑’ËøÕ°‡≈◊Õ¥ 3-5 ™¡. „™â¢π“¥¢Õß ESA ¡“°°«à“8 Moville E ·≈–§≥– æ∫«à“„π conventional hemodialysis 68 √“¬ √–¥—∫ Hct ‰¡à —¡æ—π∏å°—∫§à“ Kt/V ·µà ESA dose ¡’§«“¡ —¡æ—π∏å°—∫ 1/Kt/V ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫ Kt/V πâÕ¬°«à“À√◊Õ‡∑à“°—∫ 1.2 ·≈– Kt/V ¡“°°«à“À√◊Õ‡∑à“°—∫ 1.4 æ∫«à“ Hct ‰¡à·µ°µà“ß°—π ·µà„π°≈ÿà¡∑’Ë Kt/V µË”°«à“ ®–„™â¢π“¥¢Õß ESA ¡“° °«à“56 ·µà®“°°“√»÷°…“¢Õß Locatelli F ·≈–§≥–‰¡àæ∫§«“¡ —¡æ—π∏套߰≈à“«8 5. Short or nocturnal daily hemodialysis ºâŸªÉ«¬∑’Ë∑” daily hemodialysis (2 ™¡.µàÕ§√—Èß 6 §√—ÈßµàÕ —ª¥“Àå) æ∫«à“¿“«–´’¥¥’¢÷Èπ  “¡“√∂ ≈¥¢π“¥¢Õß ESA ≈߉¥â√âÕ¬≈– 20-50 ·µàÕ“®‡ªìπº≈®“°°“√‡æ‘Ë¡ dialysis dose À√◊Õ§«“¡∂’Ë°Á‰¥â Walsh ·≈–§≥– ‰¥â∑” systematic review »÷°…“º≈¢Õß nocturnal hemodialysis µàÕ¿“«–´’¥ æ∫«à“ 3„π 4 ¢Õß°“√»÷°…“ √“¬ß“πº≈¥’«à“ “¡“√∂∑”„Àâ Hb ¥’¢÷Èπ‰¥â8 Dialysis adequacy ™à«¬·°â‰¢¿“«–´’¥‰¥â §ÿ≥¿“æ¢Õß dialysate °Á¡’§«“¡ ”§—≠ °“√„™â membrane ∑’Ë¡’ permeability  ßŸ ‡ªìπ biocompatible Õ“®™à«¬∑”„Àⷰ≢¿“«–´’¥‰¥â¥’¢÷Èπ  à«πº≈¥’¢Õß online HDF ·¬°¬“°®“°º≈¢Õß dialysis dose, ™π‘¥¢Õß membrane À√◊Õ dialysate10 ·µà‰¡à«à“®–‡ªìπº≈ ®“°ªí®®—¬„¥ °“√‰¥â√—∫ dialysis ∑’ˇ撬ßæÕ·≈–¡’§ÿ≥¿“浓¡¡“µ√∞“π ¡’§«“¡ ”§—≠„π°“√¥Ÿ·≈ºŸâªÉ«¬ ‰µ«“¬‡√◊ÈÕ√—ß 9. °“√√°— …“Õ◊πË „πºâªŸ É«¬‰µ«“¬‡√ÈÕ◊ √—ß °“√„Àâ‡≈◊Õ¥‡æ‘Ë¡§«“¡‡ ’ˬߵàÕ°“√µ‘¥‡™◊ÈÕ‰«√— µ—∫Õ—°‡ ∫ ∫’, ´’, ‰«√— ‡Õ¥ å Õ“®∑”„À⇰‘¥ alloimmunization ∑”„Àâ®”°—¥°“√ª≈°Ÿ ∂à“¬‰µ ¡’º≈°¥°“√∑”ß“π¢Õ߉¢°√–¥Ÿ°∂â“„ÀâÀ≈“¬¬πŸ ‘µæ√âÕ¡°—π πÕ°®“°π’Ȭ—ß¡’¢âÕ§«√√–«—ß„π‡√◊ËÕߢÕß iron overload ‡≈◊Õ¥ 1 ¬Ÿπ‘µ ¡’‡À≈Á° 200 mg9 ¥—ßπ—Èπ§«√À≈’°‡≈’ˬ߰“√„Àâ‡≈◊Õ¥ ‚¥¬‡©æ“–∂â“¡’·ºπ∑’Ë®–ª≈°Ÿ ∂à“¬‰µ„πÕ𓧵 æ‘®“√≥“„Àâ ‡≈◊Õ¥‡¡◊ËÕ¡’Õ“°“√®“°´’¥ À√◊Õ´’¥‡©’¬∫æ≈—π®“°°“√‡ ’¬‡≈◊Õ¥ À√◊Õ severe resistance to ESA33 10.  √ÿª °“√√—°…“À≈—°¢Õß¿“«–´’¥„πºâŸªÉ«¬‰µ«“¬‡√◊ÈÕ√—߇ªìπ°“√„Àâ ESA ·µà‡π◊ËÕß®“°¡’√“§“·æß ∑”„À⺟âªÉ«¬®”π«π¡“°‰¡à “¡“√∂‡¢â“∂÷߬“‰¥â À√◊Õ‰¡à “¡“√∂®à“¬§à“¬“‡µÁ¡∑’ˉ¥â ¥—ßπ—Èπ°“√∑’Ë “¡“√∂ „™â¬“„π¢π“¥∑’˵˔ ÿ¥∑’Ë®– “¡“√∂ maintain target Hb ‰¥â ‡ªìπ«‘∏’∑’˧ÿ⡧à“∑’Ë ÿ¥ ´÷Ëß«‘∏’∑’Ë cost-effectiveness 191

Practical Dialysis in the Year 2009 ¡“°∑ Ë’ ¥ÿ „π°“√„™â ESA §Õ◊ °“√„Àâ IV iron ∑ Ë’ ¡”Ë ‡ ¡Õ7 ‡æÕË◊ „À¡â ’ iron store ∑‡Ë’ 欒 ßæÕ ·≈–·¡®â –¡·’ π«∑“ß „π°“√¥Ÿ·≈¿“«–´’¥„πºŸâªÉ«¬‰µ«“¬‡√◊ÈÕ√—ßÀ≈“¬·π«∑“ß ®“°¢âÕ¡Ÿ≈¢Õß°“√»÷°…“ DOPPS Dialysis outcomes and practice patterns study »÷°…“„π 12 ª√–‡∑» æ∫«à“°“√‡ª≈’ˬπ·ª≈ß·π«∑“ß°“√¥·Ÿ ≈ºŸâ ªÉ«¬µ“¡·π«∑“ߪؑ∫—µ‘‡À≈à“π—Èπ™à«¬„Àâ¿“«–´’¥¥’¢÷Èπ ·µà¬—ß‰¡à‰¥â target Hb ¬—ß¡’√âÕ¬≈– 23-77 (µ—«‡≈¢ ·µ°µ“à ß°π— „π·µ≈à –ª√–‡∑») ∑¬Ë’ ß— ¡’ Hb πÕâ ¬°«“à 11 g/dL ·≈–¬ß— ¡’ iron status ∑‰Ë’ ¡‡à 欒 ßæÕ ·¡„â πª√–‡∑» ∑’Ë¡’°“√„Àâ IV iron ¡“° ¬—ß¡’√âÕ¬≈– 35-40 ¢ÕߺŸâªÉ«¬∑’Ë¡’ TSAT πâÕ¬°«à“√âÕ¬≈– 2017 °“√¥Ÿ·≈ºâŸªÉ«¬‰µ«“¬‡√◊ÈÕ√—ß„π·ßà¢Õß°“√·°â‰¢¿“«–´’¥ ·¡â®–™à«¬„Àâ°“√欓°√≥å‚√§·≈– survival ¥’¢÷Èπ ·µà‡ªìπ‡æ’¬ß aspect ‡¥’¬«¢Õß°“√¥Ÿ·≈ºâŸªÉ«¬°≈ÿà¡π’È ·≈–¬“‰¡à‰¥â‡ªìπ‡æ’¬ß modality ‡¥’¬« °“√¥·Ÿ ≈‚¥¬·æ∑¬å 欓∫“≈ ∫§ÿ ≈“°√Õπ◊Ë ∑‡’Ë °¬’Ë «¢Õâ ß Õ¬“à ßÕߧ√å «¡ √«¡‰ª∂ß÷ ºªŸâ «É ¬·≈–§√Õ∫§√«— ¡§’ «“¡  ”§—≠∑’Ë®–∑”„Àâ∑—Èߧÿ≥¿“æ™’«‘µ·≈–§ÿ≥¿“æ¢Õß°“√√—°…“¥’·≈–‰¥âª√–‚¬™πå ßŸ  ÿ¥ ‡Õ° “√Õ“â ßÕß‘ 1. Kerr PG. Renal anaemia: recent developments, innovative approaches and future directions for improved management. Nephrology 2006; 11: 542-48. 2. Muirhead N, Bargman J, Burgess E, Jindal KK, Levin A, Nokin L, et al. Evidence-based recommendations for the clinical use of recombinant human erythropoietin. Am J Kidney Dis 1995; 26: 1-24. 3. McClellan W, Aronoff SL, Bolton WK, Hood S, Lorber DL, Tang KL, Tse TF, Wasserman B, Leiserowitz M. The prevalence of anemia in patients with chronic kidney disease. Cur Med Res Opin 2004; 20: 1501-10. 4. HSU CY, Mcculloch CE, Curhan GC. Epidemiology of anemia associated with chronic renal insufficieney among adults in the United States: results from the third national health and nutrition examination survey. J Am Soc Nephrol 2002; 13: 504-10. 5. New JP, Aung T, Baker PG, Yongsheng G, Pylypczukt R, Houghtont J, et al.The high prevalence of unrecognized anaemia in patients with diabetes and chronic kidney disease: a population based study. Diabet Med 2008; 25: 564- 9. 6. Kohagura K, Iseki K. Anemia as a risk factor for chronic kidney disease. Kidney Int 2007; 72: s4-9. 7. National Kidney Foundation; KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Anemia in Chronic Kidney Disease. Am J Kidney Dis 2006; 47s3: s17-27. 8. Locatelli F, Vecchio LD, Pozzoni P, Andrulli S. Dialysis adequacy and response to erythropoiesis-stimulation agents: what is the evidence base? Semin Nephrol 2006; 26: s269-74. 9. Cohen JJ, Harrington JT, Kassirer JP, Madias NE, Zusman CJ. The anemia of chronic renal failure: Pathophysiology and the effects of recombinant erythropoietin. Kidney Int 1989; 35: 134-48. 10. Locatelli F, Vecchio LD. Dialysis adequacy and response to erythropoietic agents: what is the evidence base? Nephrol Dial Transplant 2003; 18: viii29-35. 11. National Kidney Foundation; KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Anemia in Chronic Kidney Disease. Am J Kidney Dis 2006; 47s3: s28-32. 12. Locatelli F, Aljama P, Barany P, Canaud B, Carrera F, Eckardt KU, et al. Revised European best practice guidelines for the management of anemia in patients with chronic renal failure. Nephrol Dial Transplant 2004;19s2: ii2-5. 13. Basile JN, MD. Clinical considerations and practical recommendations for the primary care practitioner in the management of anemia of chronic kidney disease. South Med J 2007; 100: 1200-7. 192

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Current Management of Anemia in Dialysis Patients 50. Johnson DW, Pollock CA, Macdougall IC. Erythropoiesis-stimulating agent hyporesponsiveness. Nephrology 2007; 12: 321-30. 51. Navarro JF, Mora C, Macia M, Garcia J. Randomized prospective comparison between erythropoietin and androgens in CAPD patients. Kidney Int 2002; 61: 1537-44. 52. US Renal Data System: Clinical indicators and preventive care, in USRDS 2003 Annual Data Report. The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2003: 87-102. 53. Kausz AT, Solid C, Pereira BJG, Collins AJ, Peter WST. Intractable anemia among hemodialysis patients: a sign of suboptimal management or a marker of disease? Am J Kidney Dis 2005; 45: 136-47. 54. Locatelli F, Aljama P, Barany P, Canaud B, Carrera F, Eckardt KU, et al. Revised European best practice guidelines for the management of anemia in patients with chronic renal failure. Nephrol Dial Transplant 2004;19s2: ii 32-6. 55. National Kidney Foundation; KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Anemia in Chronic Kidney Disease. Am J Kidney Dis 2006; 47s3: s81-5. 56. Movilli E, Cancarini GC, Zani R, Camerini C, Sandrini M, Maiorca R, et al. Adequacy of dialysis reduces the doses of recombinant erythropoietin independently from the use of biocompatible membranes in haemodialysis patients. Nephrol Dial Transplant 2001; 16: 111-4. 57. Johnson DW. Intravenous versus oral iron supplementation in peritoneal dialysis patients. Perit Dialysis Int 2007; 27s2: s255-60. 58. National Kidney Foundation; KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Anemia in Chronic Kidney Disease. Am J Kidney Dis 2006; 47s3: s58-70. 59. Locatelli F, Aljama P, Barany P, Canaud B, Carrera F, Eckardt KU, et al. Revised European best practice guidelines for the management of anemia in patients with chronic renal failure. Nephrol Dial Transplant 2004;19s2: ii 39-41. 60. Gilmartin C. Pharmacistûs role in managing anemia in patients with chronic kidney disease: potential clinical and economic benefits. Am J Health Pharm 2007; 64s8:s15-22. 61. Pizzi LT. Economic considerations in a changing anemia environment. Am J Kidney Dis 2008; 52: s29-33. 62. Schiffl H, Lang SM. Folic acid deficiency modifies the haematopoietic response to recombinant human crythropoietin in maintenance dialysis patients. Nephrol Dial Transplant 2006; 21: 133-7. 63. Nassar GM, Fishbane S, Ayus JC. Occult infection of old nonfunctioning arteriovenous grafts: a novel cause of erythropoietin resistance and chronic inflammation in hemodialysis patients. Kidney Int 2002; 61: s49-54. 64. Locatelli F, Andrulli S, Pecchini F, Pedrini L, Agliata S, Lucchi L, et al. Effect of high- flux dialysis on the anaemia of haemodialysis patients. Nephrol Dial Transplant 2000; 15: 1399-409. 65. Schiffl H, Lang SM, Bergner A. Ultrapure dialysate reduces dose of recombinant human erythropoietin. Nephron 1999; 83: 278-9. 195



Fundamental Basis of Pediatric Hemodialysis 10 Fundamental Basis of Pediatric Hemodialysis °“≠®π“ µÈß— π√“√™— ™°®‘ 1. ∫∑π” 2. §«“¡·µ°µ“à ß∑“ß √’√–«∑‘ ¬“¢Õ߇¥Á°·≈–ºâŸ„À≠à 3.  “‡Àµ¢ÿ Õ߉µ«“¬„π‡¥Á° 4. ‡¡Õ◊Ë „¥®–‡≈◊Õ°∑” hemodialysis „π‡¥Á°‰µ«“¬ 5. Hemodialysis component 6. Pediatric hemodialysis prescription and monitoring 7. ‡ªÑ“À¡“¬°“√øÕ°‡≈Õ◊ ¥∑‡’Ë À¡“– ¡ 8.  √ÿª 197

Practical Dialysis in the Year 2009 1. ∫∑π” Hemodialysis ‡ªìπ°“√√—°…“‚¥¬°“√øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉µ‡∑’¬¡ ‚¥¬‡ªìπ°“√√—°…“∑¥·∑𠉵∑„Ë’ ™„â π‡«™ªØ∫‘ µ— ¡‘ “π“π·≈–·æ√Àà ≈“¬ ”À√∫— º„⟠À≠∑à ¡Ë’ ª’ ≠í À“‰µ«“¬ ‡§√ÕË◊ ß hemodialysis „πª®í ®∫ÿ π— ‰¥â√—∫°“√æ—≤π“„Àâ„™âß“π‰¥âßà“¬ ¡’§«“¡≈–‡Õ’¬¥∂Ÿ°µâÕß ¡’√–∫∫°“√µ√«® Õ∫·≈–‡µ◊Õπ¿—¬∑’Ë¡’ ª√– ‘∑∏‘¿“æ Ÿß ªí®®ÿ∫—π “¡“√∂π”¡“„™â°—∫ºâŸªÉ«¬‡¥Á°‰¥â¥’·≈–¡’ª√– ‘∑∏‘¿“懙àπ‡¥’¬«°—∫ºâŸ„À≠à „π°¡ÿ “√‡«™»“ µ√‚å √§‰µ hemodialysis ‰¥√â ∫— °“√æ≤— π“¡“‚¥¬µ≈Õ¥ ‡πÕ◊Ë ß®“°¡°’ “√ª√∫— ª√ßÿ ·≈–æ—≤π“„π¥â“πÕÿª°√≥åµà“ßÊ ∑—Èß blood line ·≈– dialyzer „Àâ¡’À≈“¬¢π“¥‡æ◊ËÕ„Àâ‡À¡“– ¡°—∫¢π“¥ ¢Õßµ—«‡¥Á° ·≈–°“√ —Ëß°“√√—°…“‚¥¬«‘∏’ hemodialysis „π‡¥Á°¡’‡ªÑ“À¡“¬‰ª àŸ optimal dialysis prescription ‡æÕË◊ „À‡â ¥°Á ∑®Ë’ ”‡ªπì µÕâ ß„™â long term dialysis ¡°’ “√‡®√≠‘ ‡µ∫‘ ‚µ∑¥Ë’ ’ ·≈–¡ª’ ≠í À“∑“ßÀ«— „®·≈–À≈Õ¥‡≈Õ◊ ¥ πâÕ¬∑’Ë ÿ¥1 æß÷ √–≈°÷ ‡ ¡Õ«“à °“√∑” dialysis ‡ªπì ‡æ¬’ ß «à πÀπßË÷ ¢Õß√ªŸ ·∫∫°“√¥·Ÿ ≈ºªŸâ «É ¬·∫∫∫√Ÿ ≥“°“√ ·≈–·æ∑¬åºŸâ¥Ÿ·≈ºŸâªÉ«¬‡¥Á°‰µ«“¬‡√◊ÈÕ√—ß√–¬– ÿ¥∑⓬§«√«“ß·ºπ°“√¥Ÿ·≈‚¥¬¡’‡ªÑ“À¡“¬„ÀâºâŸªÉ«¬‡¥Á° ‰¥â√—∫°“√ª≈°Ÿ ∂à“¬‰µ„π∑’Ë ÿ¥ 2. §«“¡·µ°µà“ß∑“ß √√’ –«∑‘ ¬“¢Õ߇¥Á°·≈–ºâ„Ÿ À≠à «¬— ‡¥°Á ¡°’ “√‡ª≈¬Ë’ π·ª≈ß∑“ß√“à ß°“¬Õ¬“à ß√«¥‡√«Á ‡¡ÕË◊ Õ“¬ÿ 1 ªï ®–¡π’ È”Àπ°— ‡æ¡Ë‘ ¢πÈ÷ ∂ß÷ 3 ‡∑“à ¢ÕßπÈ”Àπ—°·√°‡°‘¥ §◊Õª√–¡“≥ 9-10 °‘‚≈°√—¡ §«“¡¬“«‡æ‘Ë¡¢÷Èπ®“° 50 ‡´πµ‘‡¡µ√‡¡◊ËÕ·√°‡°‘¥ ‡ªìπ 75 ‡´πµ‘‡¡µ√‡¡◊ËÕÕ“¬ÿ 1 ªï ‡¡◊ËÕÕ“¬ÿ 4 ªï ®–¡’πÈ”Àπ—° 16-18 °‘‚≈°√—¡ ·≈–§«“¡ Ÿßª√–¡“≥ 100 ‡´πµ‘‡¡µ√ ®“°π—ÈππÈ”Àπ—°®–‡æ‘Ë¡ªï≈– 2 °‘‚≈°√—¡ §«“¡ Ÿß‡æ‘Ë¡¢÷Èπªï≈– 4-6 ‡´πµ‘‡¡µ√ πÈ”Àπ—°·≈– à«π ßŸ ®–‡æ‘Ë¡ ¢÷ÈπÕ¬à“ß√«¥‡√Á«Õ’°§√—È߇¡◊ËÕ‡¢â“ àŸ«—¬√ÿàπ πÕ°®“°°“√‡ª≈’ˬπ·ª≈ß∑“ߥâ“π√à“ß°“¬·≈â« ‡¥Á°¬—ß¡’ ¡¥ÿ≈¢ÕßπÈ”·≈–‡°≈◊Õ·√àµà“ß®“° ºâŸ„À≠à ºâŸ„À≠à¡’πÈ”„π√à“ß°“¬‡æ’¬ß√âÕ¬≈– 50-60 ¢ÕßπÈ”Àπ—°µ—« ·µà‡¥Á°·√°‡°‘¥¡’πÈ”„π√à“ß°“¬¡“°∂÷ß √Õâ ¬≈– 80 ¢ÕßπÈ”Àπ°— µ«— ·≈–§Õà ¬Ê ≈¥≈߇¡Õ◊Ë ‡¥°Á ‚µ¢π÷È §√ß÷Ë Àπß÷Ë ¢ÕßπÈ”®–Õ¬„àŸ π extracellular compartment (ECF) ´ßË÷ ‡ªπì  «à π∑¡Ë’ °’ “√À¡πÿ ‡«¬’ π‡¢“â ÕÕ°®“°√“à ß°“¬ „π‡¥°Á µÕâ ß°“√ª√¡‘ “≥π”È ∑ÀË’ ¡πÿ ‡«¬’ π„™·â µ≈à –«π— ∂ß÷ √Õâ ¬≈– 25 ¢Õßπ”È  «à π ECF ´ßË÷ ¡“°°«“à º„⟠À≠∑à „Ë’ ™πâ ”È À¡πÿ ‡«¬’ π‡æ¬’ ß√Õâ ¬≈– 16 ≈°— …≥–¥ß— °≈“à «∑”„Àâ ‡¥Á°ª√—∫µ—«µàÕ°“√‡ª≈’ˬπ·ª≈ߢÕß “√πÈ”·≈–‡°≈◊Õ·√à‰¥â‰¡à¥’‡∑à“ºâŸ„À≠à ‡¥Á°∑’ˉ¥â√—∫°“√√—°…“‚¥¬ hemodialysis ®ß÷ Õ“®æ∫¿“«–·∑√°´Õâ π∑“ß hemodialysis ‰¥∫â Õà ¬·≈–√πÿ ·√ß°«“à ´ßË÷ ®”‡ªπì µÕâ ߇Ω“Ñ √–«ß— Õ¬à“ß„°≈♑¥‚¥¬‡©æ“–‡¥Á°‡≈Á° ‡¥Á°¡’§à“√–¥—∫ BUN ·≈– ´’√—¡§√’Õ–µ‘π’πµË”°«à“„πºŸâ„À≠à ‡π◊ËÕß®“°¡’°≈â“¡‡π◊ÈÕπâÕ¬°«à“·≈– ¡’°“√„™â‚ª√µ’π„π°√–∫«π°“√‡®√‘≠‡µ‘∫‚µ¡“°°«à“°“√∑”≈“¬·≈–¬àÕ¬ ≈“¬ °“√·ª≈º≈√–¥—∫´’√—¡ §√’Õ–µ‘π’π ´÷ËßµâÕ߇∑’¬∫°—∫§à“ª°µ‘„π·µà≈–Õ“¬2ÿ (µ“√“ß∑’Ë 1) ‡¥Á°∑’Ë¡’¿“«–‰µ«“¬‡°‘¥¢÷ÈπÕ“®‡°‘¥Õ“°“√ ·≈–Õ“°“√· ¥ß¢Õß¿“«–¬√Ÿ ’‡¡’¬‰¥â‚¥¬¡’§à“√–¥—∫ BUN µË”°«à“„πºâŸ„À≠à 198

Fundamental Basis of Pediatric Hemodialysis µ“√“ß∑Ë’ 1 §à“ª°µ‘¢Õß√–¥—∫´’√—¡§√’Õ–µ‘π’π„π‡¥Á°µ“¡Õ“¬2ÿ Õ“¬ÿ Serum creatinine (mg/dL) Range (mg/dL) Õ“¬ÿ§√√¿å <34  —ª¥“Àå 0.7-1.4 0.7-0.9 <2  —ª¥“Àå 0.9 0.4-0.6 ≥2  —ª¥“Àå 0.8 0.3-0.5 Õ“¬ÿ§√√¿å >34  —ª¥“Àå 0.2-0.5 0.3-1.0 <2  —ª¥“Àå 0.5 0.6-1.4 ≥2  —ª¥“Àå 0.4 2  —ª¥“Àå - 5 ªï 0.4 5 ªï - 10 ªï 0.6 >10 ªï 0.9 3.  “‡Àµÿ¢Õ߉µ«“¬„π‡¥Á° 3.1 ‰µ«“¬‡©¬’ ∫æ≈—π  “‡Àµÿ¢Õ߉µ«“¬‡©’¬∫æ≈—π (acute renal failure) ∑’Ëæ∫∫àÕ¬ ¢÷Èπ°—∫™à«ßÕ“¬ÿ¢Õ߇¥Á° ∑“√°¡—° ‡°‘¥®“° acute tubular necrosis ∑’Ë¡’ “‡Àµÿ®“° birth asphyxia °“√‡ ’¬‡≈◊Õ¥√–À«à“߇°‘¥ °“√‰¥â√—∫¬“∑’Ë¡’ º≈µàÕ‰µ ‡™àπ ∑“√°‡°‘¥°àÕπ°”À𥉥â indomethacin ‡æ◊ËÕªî¥ patent ductus arteriosus À√◊Õ‰¥â√—∫ aminoglycoside √—°…“°“√µ‘¥‡™◊ÈÕ ºâŸªÉ«¬™à«ß 2 ¢«∫ªï·√° ¡—°¡’¿“«–‰µ«“¬‡©’¬∫æ≈—π®“° diarrheal dehydration „π‡¥Á°‚µ¡—°æ∫«à“‡°‘¥®“° prolong shock ®“°‚√§‰¢â‡≈◊Õ¥ÕÕ°, ¿“«– sepsis, post-cardiac surgery ´÷Ëß¿“«– acute tubular necrosis æ∫‰¥â‡ªìπ à«πÀπ÷ËߢÕß multiple organ failure πÕ°®“°π’ÈÕ“®æ∫  “‡Àµÿ¡“®“°¿“«–‰µÕ—°‡ ∫√ÿπ·√ß®“°‚√§ systemic lupus erythematosus, acute poststreptococcal glomerulonephritis, rapidly progressive glomerulonephritis ·≈– hemolytic uremic syndrome ‰¥3â ,4 ¢âÕ¡≈Ÿ ∑“ß√–∫“¥«‘∑¬“æ∫«à“ “‡Àµÿ¢Õ߉µ«“¬‡©’¬∫æ≈—π„π‡¥Á°¡’§«“¡·µ°µà“ß°—π¢÷Èπ°—∫‡»√…∞ ∂“π– (socioeconomic status) ·≈– ªí®®—¬·«¥≈âÕ¡¢Õߪ√–‡∑»µà“ßÊ5 (µ“√“ß∑’Ë 2) ¢âÕ∫àß™’È¢Õß°“√∫”∫—¥∑¥·∑π‰µ„π¿“«–‰µ«“¬‡©’¬∫æ≈—π ‰¥â·°à °√≥’∑’Ë¡’‰µ«“¬‡©’¬∫æ≈—π √ÿπ·√ß√à«¡°—∫ multi-organ system failure À√◊Õ‰µÕ—°‡ ∫√ÿπ·√ß (severe glomerular disease) ∑’Ë¡’¿“«–πÈ” ‡°‘π ¿“«–‚æ·∑ ‡´’¬¡„π‡≈◊Õ¥ Ÿß ‡≈◊Õ¥‡ªìπ°√¥√ÿπ·√ß ¡’Õ“°“√¢Õ߬Ÿ√’‡¡’¬ ´÷Ëß°“√√—°…“‚¥¬°“√„™â¬“ ‰¡à “¡“√∂·°â‰¢‰¥â 3.2 ‰µ«“¬‡√Õ◊È √ß— ¿“«–‰µ«“¬‡√Õ◊È √ß— „π‡¥°Á æ∫‰¥‰â ¡∫à Õà ¬·µ‡à ¡Õ◊Ë ‡°¥‘ ¢π÷È ·≈«â ®–‡ªπì ¿“√–µÕà §√Õ∫§√«— ·≈–√–∫∫  “∏“√≥ ÿ¢¢Õߪ√–‡∑»Õ¬à“ß¡“° ¬‘Ë߇¡◊ËÕ‚√§¥”‡π‘π‡¢â“ Ÿà¿“«–‰µ«“¬√–¬– ÿ¥∑⓬ (end stage renal 199

Practical Dialysis in the Year 2009 µ“√“ß∑’Ë 2 Developing country/ industrialized country/  “‡Àµÿ¢Õß acute renal failure „π‡¥Á°5 Referral center Tertiary center n (%) n (%)  “‡Àµÿ 25 (31) 5 (3) 18 (23) - Hemolytic-uremic syndrome - 64 (44) Glomerulonephritis 7 (9) - Intrinsic renal disease 14 (18) 49 (34) Urinary obstruction 14 (18) - Postoperative sepsis - 19 (13) Ischemic and prerenal 2 (3) 9 (6) Organ and bone marrow transplant 80 146 Miscellaneous Total disease; ESRD) ‡¥°Á ®”‡ªπì µÕâ ߉¥√â ∫— °“√√°— …“∑¥·∑π‰µ√«à ¡°∫— °“√µ¥‘ µ“¡°“√√°— …“Õ¬“à ß„°≈™â ¥‘ ∑”„Àâ ¡§’ “à „™®â “à ¬ ßŸ ¡“° ¬ßË‘ ¡º’ ≈°√–∑∫¡“°¢πÈ÷ µßÈ— ·µà æ.». 2550 √–∫∫À≈°— ª√–°π—  ¢ÿ ¿“æ∂«â πÀπ“â ‰¥Õâ π¡ÿ µ— ‘ „Àâ°“√√—°…“∑¥·∑π‰µ™π‘¥≈â“ߺà“π™àÕß∑âÕßÕ¬à“ßµàÕ‡π◊ËÕß (peritoneal dialysis, PD) ·≈–øÕ°‡≈◊Õ¥ (hemodialysis) ‡©æ“–√“¬∑‰Ë’ ¡ à “¡“√∂∑” PD ‰¥â √«¡∂ß÷ °“√ª≈°Ÿ ∂“à ¬‰µ·°ºà ªâŸ «É ¬‰µ«“¬√–¬– ¥ÿ ∑“â ¬ ‚¥¬ ºâŸªÉ«¬‰¡àµâÕß®à“¬√à«¡∑”„Àâ≈¥¿“√–¢ÕߺŸâª°§√Õ߉ª‰¥â¡“° ·≈–ºŸâªÉ«¬‡¥Á°‰µ«“¬√–¬– ÿ¥∑⓬¡’‚Õ°“  ‰¥â√—∫°“√√—°…“∑¥·∑π‰µ¡“°¢÷Èπ ¡’§ÿ≥¿“æ™’«‘µ∑’Ë¥’¢÷Èπ √“¬ß“π¢Õß United Stage Renal Data System (USRDS) ª√–‡∑» À√—∞Õ‡¡√‘°“ªï 25516 æ∫ «“à Õ∫ÿ µ— °‘ “√≥·å ≈–§«“¡™°ÿ ¢Õß ESRD ∑µË’ Õâ ߉¥√â ∫— °“√∫”∫¥— ∑¥·∑π‰µ„π‡¥°Á Õ“¬πÿ Õâ ¬°«“à 19 ªï ¡®’ ”π«π 15 ·≈– 86.1 √“¬µàÕª√–™“°√ 1 ≈â“π§π µ“¡≈”¥—∫ æ∫«à“Õÿ∫—µ‘°“√≥å®– ßŸ „π‡¥Á°‡≈Á°·≈–«—¬√ÿàπ ‚¥¬æ∫ «à“§«“¡™ÿ° Ÿß¢÷ÈπÕ¬à“ßµàÕ‡π◊ËÕß„π√–¬–‡«≈“∑’˺à“π¡“ πÕ°®“°π’Ȭ—ßæ∫«à“ºâŸªÉ«¬‡¥Á°¡’·π«‚πâ¡®–µâÕß√Õ °“√ª≈°Ÿ ∂“à ¬‰µπ“π¢π÷È ¥«â ¬ ”À√∫— ª√–‡∑»‰∑¬¬ß— ‰¡¡à √’ “¬ß“πÕ∫ÿ µ— °‘ “√≥·å ≈–§«“¡™°ÿ ¢Õß ESRD „π‡¥°Á  “‡Àµÿ¢Õ߉µ«“¬‡√◊ÈÕ√—ß„π‡¥Á°‰∑¬Õ“¬ÿπâÕ¬°«à“ 15 ªï √“¬ß“π‚¥¬Õ—®©√“  —¡∫ÿ≠≥“ππ∑å ·≈–§≥– æ∫«à“ “‡Àµÿ à«π„À≠à‡°‘¥®“° structural ·≈– anatomical defect ‰¥â·°à obstructive uropathy ·≈– hypoplastic/dysplastic kidney √Õß≈ß¡“‰¥â·°à °≈ÿà¡ glomerulonephritis7 (µ“√“ß∑’Ë 3) ´÷Ëߺ≈§≈⓬§≈÷ß ∞“π¢âÕ¡Ÿ≈¢Õß NAPRTCS ªï 25518 (µ“√“ß∑’Ë 4) ·≈–®“° Ital Kid Project9 ∑’Ë√«∫√«¡®“°ºâŸªÉ«¬‡¥Á°‰µ«“¬ ‡√◊ÈÕ√—ß√–¬–‡«≈“ 10 ªï µ—Èß·µàªïæ.». 2530-2543 ‚¥¬æ∫«à“‡¥Á°Õ“¬ÿπâÕ¬°«à“ 2 ªï ‡°◊Õ∫∑—ÈßÀ¡¥®–‡ªìπ structural ·≈– anatomical defect ∑’ˇªìπ¡“·µà°”‡π‘¥  à«π‚√§„π°≈ÿà¡ glomerulonephritis æ∫‡ªì𠓇Àµÿ ¢Õß‚√§‰µ«“¬‡√◊ÈÕ√—ß„π‡¥Á°‚µ·≈–«—¬√ÿàπ 200

Fundamental Basis of Pediatric Hemodialysis µ“√“ß∑’Ë 3 √âÕ¬≈–  “‡Àµÿ¢Õß‚√§‰µ‡√◊ÈÕ√—ß„π‡¥Á°‰∑¬ (®”π«π 238 §π, 100%)7 20.6 8.4  “‡Àµÿ 5.0 Obstructive uropathy 1.8 Chronic glomerulonephritis 1.7 Hypoplastic/dysplastic kidney 0.8 SLE nephritis Familial nephritis Polycystic kidney disease µ“√“ß∑’Ë 4  “‡Àµ¢ÿ Õß‚√§‰µ‡√Õ◊È √ß— √–¬– ¥ÿ ∑“â ¬„π‡¥°Á ·≈–«¬— √πÿà Õ“¬ÿ 0-19 ªï ™«à ß√–À«“à ߪï 2545-2549 (NAPRTCS annual report 2008)  “‡Àµÿ √âÕ¬≈– Cystic/hereditary/congenital disease 32.7 Glomerulonephritis 25 Vasculitis 11.4 Interstitial nephritis/pyelonephritis 6.7 Others 24.2 4. ‡¡ËÕ◊ „¥®–‡≈Õ◊ °∑” hemodialysis „π‡¥Á°‰µ«“¬ °“√‡≈Õ◊ °°“√√°— …“∑¥·∑π‰µ„π‡¥°Á ¢π÷È °∫— ª®í ®¬— À≈“¬Õ¬“à ß ‰¥·â °à ª®í ®¬— ¢Õßµ«— ‡¥°Á ‡Õß ‰¥·â °à Õ“¬ÿ¢Õ߇¥Á° ‚√§∑’ˇªì𠓇Àµÿ¢Õ߉µ«“¬ §«“¡º‘¥ª°µ‘¢ÕßÕ«—¬«–Õ◊ËπÊ ‚¥¬‡©æ“–ªí≠À“°“√∑”ß“π ¢ÕßÀ—«„®·≈–√–∫∫‰À≈‡«’¬π‚≈À‘µ §«“¡º‘¥ª°µ‘¢ÕßÕ«—¬«–¿“¬„π™àÕß∑âÕß·≈–ºπ—ß™àÕß∑âÕß ·≈– ªí®®—¬¿“¬πÕ° ‰¥â·°à §«“¡æ√âÕ¡¢Õß ∂“π∑’Ë·≈–∫ÿ§≈“°√∑“ß°“√·æ∑¬å√«¡∂÷ßÕÿª°√≥åµà“ßÊ ∑’Ë ‡À¡“– ¡°—∫‡¥Á° °“√√—°…“∑¥·∑π‰µ∑’Ë„™â°—π¡“°„π‡¥Á°‰µ«“¬∑—Èß™π‘¥‡©’¬∫æ≈—π·≈–‡√◊ÈÕ√—ß §◊Õ peritoneal dialysis ‡π◊ËÕß®“°¢âÕ®”°—¥¢Õß vascular access „π‡¥Á° ¥—ßπ—Èπ„π°√≥’∑’ˉ¡à¡’¢âÕÀâ“¡„¥Ê „π°“√‡≈◊Õ°∑” peritoneal dialysis À√◊Õ hemodialysis ·≈â« NKF-K/DOQI guideline10 ·π–π”«à“„π°“√√—°…“¥â«¬ chronic dialysis ππÈ— ‡¥°Á ∑¡Ë’ π’ ”È Àπ°— µ«— πÕâ ¬°«“à 20 °‚‘ ≈°√¡— §«√‡≈Õ◊ °∑” peritoneal dialysis ¡“°°«“à hemodialysis Hemodialysis‡ªπì °“√√°— …“∑¥·∑π‰µ∑‡’Ë À¡“–°∫— ‡¥°Á ‚µ·≈–‡¥°Á ‡≈°Á ∑¡’Ë ¢’ Õâ À“â ¡ ”§≠— ¢Õß°“√ ∑” peritoneal dialysis‰¥â·°à abdominal wall defect, diaphragmatic hernia, post-abdominal surgery À√◊Õ extensive abdominal adhesion ºâŸªÉ«¬·º≈§«“¡√âÕπ≈«°∫√‘‡«≥Àπâ“∑âÕß ´÷ËßÕ“®¡’º≈„À⇰‘¥°“√µ‘¥‡™◊ÈÕ 201

Practical Dialysis in the Year 2009 ‰¥âßà“¬ À√◊ÕºŸâªÉ«¬∑’Ë∑” peritoneal dialysis ·≈â«¡’¿“«–·∑√°´âÕ𠇙àπ πÈ”¬“√—Ë«∫√‘‡«≥·º≈∑’Ë„ à “¬ peritoneal catheter À√Õ◊  “¬Õ¥ÿ µπ— ·°‰â ¢·≈«â ‰¡¥à ¢’ πÈ÷ ·≈–ºŸâªÉ«¬∑’Ë¡’°“√µ‘¥‡™◊ÈÕ∑’˺π—ßÀπâ“∑âÕß·≈–¿“¬„π ™àÕß∑âÕß∫àÕ¬Ê °“√µ¥—  π‘ „®∑” hemodialysis¬ß— ¢π÷È °∫— §«“¡æ√Õâ ¡¢Õß∑¡’ ∫§ÿ ≈“°√∑“ß°“√·æ∑¬·å ≈–Õªÿ °√≥å ∑’Ë„™â∑” hemodialysis „π‡¥Á°  ‘∑∏‘°“√√—°…“∑’˺⟪ɫ¬æ÷߉¥â√—∫ §«“¡‡ÀÁπ™Õ∫®“°ºŸâªÉ«¬‡¥Á° ·≈–/À√◊Õ ®“° ºŸâª°§√Õß Õ¬à“߉√°Áµ“¡ªí®®—¬∑’˵âÕߧ”π÷ß∂÷ß√à«¡¥â«¬ §◊Õ √–¬–∑“ß√–À«à“ß∑’ËÕ¬Ÿà ·≈– ∂“π欓∫“≈/ ‚√ß欓∫“≈∑’Ë¡’»Ÿπ¬å‰µ‡∑’¬¡ „πªí®®ÿ∫—π¡’»Ÿπ¬å‰µ‡∑’¬¡∑’Ë„Àâ∫√‘°“√√—°…“∑¥·∑π‰µ ”À√—∫ºâŸ„À≠à®”π«π ¡“°¢÷Èπ Õ¬àŸ„π®—ßÀ«—¥µà“ßÊ ∑—Ë«ª√–‡∑»‰∑¬ ∂â“ “¡“√∂ª√–¬ÿ°µå„™âÕÿª°√≥å∑’Ë¡’Õ¬Ÿà√à«¡°—∫¡’°“√®—¥À“ Õÿª°√≥å∑’ˇÀ¡“– ¡°—∫ºŸâªÉ«¬‡¥Á°‰«â„πÀπ૬‰µ‡∑’¬¡¢Õߺ⟄À≠à °Á®–™à«¬„Àâ°“√„™â‡§√◊ËÕ߉µ‡∑’¬¡∑’Ë¡’Õ¬àŸ π—Èπ‡°‘¥ª√–‚¬™πå‡æ‘Ë¡¢÷Èπ „πª√–‡∑» À√—∞Õ‡¡√‘°“ æ∫«à“¡’‡¥Á°®”π«π‰¡àπâÕ¬∑’ˉ¥â√—∫°“√øÕ°‡≈◊Õ¥Õ¬àŸ„π adult hemodialysis unit æ∫«à“∑’¡·æ∑¬å ·≈–欓∫“≈‰µ‡∑’¬¡∑’Ë¥Ÿ·≈ºâŸ„À≠à “¡“√∂¥Ÿ·≈‡¥Á°‰¥â§àÕπ¢â“ß ¥’‚¥¬‡©æ“–‡¥Á°‚µ11 5. Hemodialysis component  à«πª√–°Õ∫À≈—°¢Õß hemodialysis „π‡¥Á°‡À¡◊Õπ°—∫„πºâŸ„À≠à ‰¥â·°à √–∫∫√—∫- à߇≈◊Õ¥ (vascular access ·≈– blood line) √–∫∫√—∫- àßπÈ”¬“ dialysate (dialysis delivery) µ—«°√Õ߇≈◊Õ¥ (dialyzer) ·≈–µ—«‡§√◊ËÕß hemodialysis  «à πª√–°Õ∫µ“à ßÊ¡°— ‡ππâ Õªÿ °√≥∑å ‡’Ë À¡“– ¡°∫— ¢π“¥¢Õßµ«— ‡¥°Á ´ß÷Ë ¡§’ «“¡·µ°µ“à ß°π— §Õà π ¢â“ß¡“° ‚¥¬¡’À≈—° ”§—≠∑—Ë«‰ª ¥—ßπ’È 5.1 Dialyzer Pediatric dialysis ∑’Ë¥’§«√¡’ internal blood volume µË” ·≈– dialysis membrane ‡ªìπ™π‘¥∑’Ë¡’ biocompatibility π”¡“„™â√—°…“ºâŸªÉ«¬·≈â«¡’º≈µàÕ hemodynamic ¢Õ߇¥Á°πâÕ¬·≈–‰¡à°√–µÿâπªØ‘°‘√‘¬“∑“ß Õ‘¡¡Ÿπ 12,13 Dialyzer  ”À√—∫‡¥Á°„πª√–‡∑»‰∑¬ à«π„À≠à‡ªìπ™π‘¥ low flux (KUF πâÕ¬°«à“ 10 ¡≈./™¡./ ¡¡.ª√Õ∑) ¢π“¥µ—Èß·µà 0.4-1.3 µ“√“߇¡µ√ (µ“√“ß∑’Ë 5) „π‡¥Á°‚µ∑’Ë¡’æ◊Èπ∑’˺‘«°“¬¡“°°«à“ 1.3 µ“√“ß ‡¡µ√ Õ“®„™â™π‘¥ high performance dialyzer (KUF µ—Èß·µà 10-20 ¡≈./™¡./¡¡.ª√Õ∑)  à«π high flux dialyzer (KUF >20 ¡≈./™¡./¡¡.ª√Õ∑) ‰¡§à Õà ¬π¬‘ ¡„™„â π‡¥°Á ‡πÕË◊ ß®“°¡§’ «“¡‡ ¬Ë’ ßµÕà °“√‰À≈°≈∫— (backleak) ¢Õß πÈ”¬“ dialysate ‡¢â“ Ÿà blood compartment ®“°°“√∑’˧«“¡¥—πµË”≈ß„π blood compartment À≈—ß®“°∂°Ÿ ¥÷ßπÈ”ÕÕ°‰ªÕ¬à“ß√«¥‡√Á« §«√‡≈◊Õ°„™â dialyzer membrane ∑’Ë¡’ biocompatibility ‰¥â·°à polysulfone À√◊Õ polyamine ´÷Ë߇ªìπ “√ —߇§√“–Àå À√◊Õ hemophane ´÷Ë߇ªìπ cellulosynthetic °“√‡≈◊Õ° pediatric dialyzer §«√‡≈◊Õ°„™â dialyzer ∑’Ë¡’ surface area ‰¡à‡°‘π¢π“¥¢Õßæ◊Èπ∑’˺‘« °“¬ (body surface area) ¢Õ߇¥Á° Õ—µ√“ à«π∑’ˇÀ¡“– ¡∑’Ë ÿ¥ (optimal) ¢Õß¢π“¥ dialyzer °—∫¢π“¥¢Õß æ◊Èπ∑’˺‘«°“¬§«√Õ¬Ÿà∑’Ë 0.7-1 14 °“√À“§à“¢π“¥¢Õßæ◊Èπ∑’˺‘«°“¬ “¡“√∂§”π«≥‰¥â®“° Ÿµ√ 202

Fundamental Basis of Pediatric Hemodialysis µ“√“ß∑Ë’ 5 · ¥ßµ—«Õ¬à“ß pediatric dialyzer ∑’Ë¡’„™â„πª√–‡∑»‰∑¬ Dialyzer Membrane Surface Priming Kuf Urea clearance at type area (m2) volume (mL) (mL/h/mmHg) BFR 200 mL/min F3 Polysulfone 0.4 28 17 125 F4 Polysulfone 0.7 42 2.8 155 F5 Polysulfone 1.0 63 4.0 170 F6 Polysulfone 1.3 82 5.5 180 Asahi AM 650 Cellulosynthetic 1.3 78 7.8 184 Asahi AM 750 Cellulosynthetic 1.5 94 8.8 188 Surflex 110E Cellulosynthetic 1.1 65 15 184 Surflex 130E Cellulosynthetic 1.3 75 17.8 188 Surflex 150E Cellulosynthetic 1.5 90 20.5 191 Body surface area (m2) = Ht × Wt / 3600 Ht = height (cm) Wt = body weight (kg) 5.2 Blood delivery system √–∫∫∑’Ëπ”‡≈◊Õ¥ÕÕ°¡“ Ÿà dialyzer ª√–°Õ∫¥â«¬ vascular access ·≈– blood line §«√‡≈◊Õ°„™â µ“¡¢π“¥µ—«‡¥Á°12-14 „π°“√∑” acute hemodialysis  “¡“√∂‡≈◊Õ°„™â temporary catheter ‚¥¬¢π“¥¢Õß acute hemodialysis catheter ∑’Ë¡’®”Àπà“¬„πª√–‡∑»‰∑¬‡ªìπ double lumen ¡’¢π“¥µ—Èß·µà 7-12 Fr ´÷Ëß  “¡“√∂„™‰â ¥¥â „’ π‡¥°Á ∑¡’Ë π’ È”Àπ°— 8-10°‚‘ ≈°√¡— ¢π÷È ‰ªµ«— Õ¬“à ß·≈–¢Õâ ·π–π”„π°“√‡≈Õ◊ °„™·â  ¥ß„𠵓√“ß ∑’Ë 6 ·≈– 7 µ“¡≈”¥—∫ Chronic vascular access  ”À√—∫‡¥Á°„πªí®®ÿ∫—π¡’∑—Èß AV fistula, AV graft ·≈– permanent catheter ´ßË÷ ‡ªπì  “¬ «π∑πË’ ¡Ë‘ ·≈–¡’ cuff ´ßË÷ ™«à ¬≈¥°“√µ¥‘ ‡™ÕÈ◊ º“à π∑“ߺ«‘ Àπß— ·≈–™«à ¬µ√ß÷  “¬ «π‰«°â ∫— º«‘ Àπß— „πª√–‡∑»‰∑¬¬ß— ‰¡¡à ’ catheter  ”À√∫— ‡¥°Á ‡≈°Á ®”Àπ“à ¬ ‡¥°Á ‡≈°Á ®ß÷ §«√‡≈Õ◊ °∑” chronic peritoneal dialysis ∂“â ‡¥°Á ¡π’ È”Àπ°— ¡“°°«“à 20-30 °‚‘ ≈°√¡— 殑 “√≥“∑” AV fistula °Õà πÕ¬“à ßÕπ◊Ë 15 °√≥∑’ ‰Ë’ ¡ à “¡“√∂ „™â AV fistula ‰¥â Õ“®‡ª≈’ˬπ‡ªìπ AV graft ·∑π ·µà‚Õ°“ ‡°‘¥°“√Õÿ¥µ—π®– ßŸ °«à“ AV fistula Õ¬à“߉√ °µÁ “¡„π‡¥°Á ‚µÀ√Õ◊ «¬— √πàÿ ∑¡Ë’ ·’ ºπ°“√ª≈°Ÿ ∂“à ¬‰µ¿“¬„π‡«≈“ πÈ— ‡æ¬’ ß 1-2 ªï À≈ß— ‡√¡Ë‘ ∑” hemodialysis Õ“® æ‘®“√≥“„ à permanent cuffed central venous catheter·µà‚Õ°“ ‡°‘¥°“√µ‘¥‡™◊ÈÕ∑“ß “¬ catheter ®–¡’ ¡“°°«à“ AV fistula ·≈– AV graft16 Pediatric blood line §«√¡’ internal volume µË” µ—«Õ¬à“ß·≈–¢π“¥¢Õß blood line ∑’Ë¡’„™â· ¥ß „πµ“√“ß∑’Ë 8 203

Practical Dialysis in the Year 2009 µ“√“ß∑’Ë 6 ¢âÕ·π–π”°“√‡≈◊Õ°„™â acute hemodialysis catheter Patient size Access size Site of insertion Femoral vein Neonate 2 separate 5 Fr single Internal jugular, subclavian or femoral vein Internal jugular, subclavian or femoral vein lumen or 6.5 Fr dual lumen Internal jugular, subclavian or femoral vein Internal jugular, subclavian or femoral vein 3-6 kg 6.5 Fr dual lumen Internal jugular, subclavian or femoral vein Internal jugular, subclavian or femoral vein 6-15 kg 7 Fr dual lumen 10-20 kg 8 Fr dual lumen 20-30 kg 9 Fr dual lumen >30 kg 11.5 or 12 Fr dual lumen µ“√“ß∑’Ë 7 · ¥ß¢âÕ¥’¢âÕ‡ ’¬¢Õß°“√„ à “¬ «π„πµ”·Àπà߇ âπ‡≈◊Õ¥„À≠àµà“ßÊ Location Advantage Disadvantage Internal jugular vein Long duration More difficult to access Easy for mobility Complication: pneumothorax Less complication with infection and venous stenosis Subclavian vein Long duration More difficult to access Easy to mobility Complication: pneumothorax High incidence of venous stenosis Femoral vein Easy to access for emergency High incidence of infection placement Difficult to mobility µ“√“ß∑Ë’ 8 · ¥ßµ—«Õ¬à“ß blood line ∑’Ë¡’„™â„πª√–‡∑»‰∑¬ (Kawasumi) Type of blood line Priming volume Body weight of patient < 20 °°. Pediatric 48 ¡≈. ≥ 20 °°. Adult 88 ¡≈. 204

Fundamental Basis of Pediatric Hemodialysis °“√‡≈◊Õ° dialyzer ·≈– blood line §«√§”π÷ß∂÷ß priming volume ‡¡◊ËÕ√«¡°—π‰¡à§«√‡°‘π√âÕ¬≈– 10 ¢Õߪ√‘¡“µ√‡≈◊Õ¥ (total blood volume) ¢Õ߇¥Á° ª√‘¡“µ√‡≈◊Õ¥„π‡¥Á°14 §”π«≥‰¥â®“° ª√‘¡“µ√‡≈◊Õ¥ (¡≈.) = πÈ”Àπ—° (°°.) × 60 „π«—¬√ÿàπ = πÈ”Àπ—° (°°.) × 80 „π‡¥Á°Õ“¬ÿ¡“°°«à“ 1 ‡¥◊Õπ = πÈ”Àπ—° (°°.) × 100 „π∑“√°·√°‡°‘¥ ‡¥°Á ∑πË’ ”È Àπ°— πÕâ ¬°«“à 20 °‚‘ ≈°√¡— À√Õ◊ priming volume √«¡¡“°°«“à √Õâ ¬≈– 10 ¢Õߪ√¡‘ “µ√ ‡≈◊Õ¥ §«√ prime blood line ·≈– dialyzer ¥â«¬‡≈◊Õ¥ À√◊Õ 5% albumin °àÕπ∑”°“√øÕ°‡≈◊Õ¥ 5.3 Hemodialysis machine1,17,18 ‡§√Õ◊Ë ß‰µ‡∑¬’ ¡ ”À√∫— ‡¥°Á ππ—È §«√‡ªπì ‡§√Õ◊Ë ß∑¡’Ë §’ ≥ÿ  ¡∫µ— ¥‘ ß— π’È ‡ªπì √–∫∫ bicarbonate  “¡“√∂ §«∫§¡ÿ §“à ultrafiltration (UF) ‰¥·â ¡πà ¬”‚¥¬√–∫∫ volumetric control ¡√’ –∫∫§«“¡ª≈Õ¥¿¬— ∑ ’Ë ”§≠— ‰¥·â °à monitor · ¥ß venous pressure, transmembrane pressure ·≈–√–∫∫§«∫§¡ÿ Õ≥ÿ À¿¡Ÿ ¢‘ Õßπ”È ¬“ dialysate ¡’ blood pump ∑ªË’ √∫— „™°â ∫— blood line ‰¥∑â ßÈ— º„Ÿâ À≠·à ≈–‡¥°Á  “¡“√∂ª√∫— blood flow rate µ”Ë Ê ‰¥â ‡πÕË◊ ß®“° ‡¥Á°‡≈Á°Õ“®µâÕß°“√ blood flow rate ‡æ’¬ß 25-50 ¡≈./π“∑’ ªí®®ÿ∫—π‡§√◊ËÕß√ÿàπ„À¡à®–¡’ monitor  ”À√—∫ blood volume ·≈– “¡“√∂‡≈Õ◊ °„™‚â ª√·°√¡ sodium modeling ‰¥¥â «â ¬ ∑”„À™â «à ¬≈¥ª≠í À“§«“¡¥π— ‚≈Àµ‘ µË”„π¢≥–øÕ°‡≈◊Õ¥‰¥â 5.4 Dialysate πÈ”¬“ dialysate §«√‡ªìπ™π‘¥∑’Ë¡’ bicarbonate ‡ªìπ “√∫—ø‡øÕ√å·≈– “¡“√∂ª√—∫§«“¡‡¢â¡¢âπ ¢Õß solutes ‰¥âµ“¡µâÕß°“√14 (µ“√“ß∑’Ë 9) Õ—µ√“°“√‰À≈¢Õß dialysate ‰¡à§«√πâÕ¬°«à“ 1.5-2 ‡∑à“ ¢Õß blood flow rate ‚¥¬ à«π„À≠à¡—°ª√—∫‰«â∑’Ë 500 ¡≈./π“∑’ „π‡¥Á°‡≈Á°πÈ”Àπ—°πâÕ¬°«à“ 10-15 °‘‚≈°√—¡ ¡—°¡’ ¿“«– hypothermia ‰¥â∫àÕ¬ ®÷ߧ«√µ—ÈßÕÿ≥À¿¡Ÿ ¢‘ Õßπ”È ¬“ dialysate ‰« â ߟ ∂÷ß 38-39 Õß»“‡´≈‡´’¬ 17,18 ·≈– ∫“ß√“¬Õ“®µâÕß„™â radiant warmer √à«¡¥â«¬ µ“√“ß∑Ë’ 9 ª√‘¡“≥ (mmol/L) 132-155  à«πª√–°Õ∫¢ÕßÕ‘‡≈Á°‚∑√‰≈µå„π dialysate 0-4 Õ‡‘ ≈°Á ‚∑√‰≈µå 1.25-2 Sodium 0.25-1 Potassium 90-120 Calcium 30-38 Magnesium 0-5.5 Chloride 7.1-7.3 Bicarbonate Dextrose pH 205

Practical Dialysis in the Year 2009 °“√µ—ÈßπÈ”¬“ dialysate ‚¥¬„™â sodium modeling §◊Õ°“√µ—Èß√–¥—∫‚´‡¥’¬¡‰«â Ÿß (hyperosmolar dialysate sodium concentration) „π™—Ë«‚¡ß·√° ·≈â«≈¥≈ß„π™—Ë«‚¡ßÀ≈—ß æ∫«à“ “¡“√∂¥÷ß ultrafiltration ÕÕ°‰¥¥â ’ ‚¥¬ºªŸâ «É ¬¡ ’ ≠— ≠“≥™æ’ §ß∑Ë’ ·≈–Õ“°“√·∑√°´Õâ π√–À«“à ß∑” hemodialysis ‡™πà °“√‡°¥‘ µ–§√«‘ ≈¥≈ß19 5.5 Anticoagulant „π°“√∑” hemodialysis µâÕßÕ“»—¬ anticoagulant ‡æ◊ËÕªÑÕß°—π°“√·¢Áßµ—«¢Õ߇≈◊Õ¥„π blood line ·≈–„π dialyzer ‚¥¬‡©æ“–ºâŸªÉ«¬‡¥Á°‡≈Á°∑’Ë¡—°„™â blood flow rate µË”Ê ´÷Ëß®–¡’§«“¡‡ ’ˬߵàÕ°“√·¢Áß µ—«¢Õ߇≈◊Õ¥‰¥âßà“¬ Anticoagulant ∑’Ë„™â∫àÕ¬„π‡¥Á°§◊Õ heparin „π¢π“¥ loading dose 10-30 ¬πŸ ‘µ/°°. ·≈–À¬¥ µàÕ‡π◊ËÕß„π¢π“¥ 10-20 ¬Ÿπ‘µ/°°./™¡. ‡æ◊ËÕ„Àâ§à“ activated clotting time (ACT) π“π 150-200 «‘π“∑’ À√◊Õ activated partial thromboplastin time (aPTT) π“π 1.5-3 ‡∑à“¢Õß§à“ control À√◊ÕÕ“®‡≈◊Õ°„™â low molecular weight heparin ‡™àπ enoxaparin 0.5-1 ¡°./°°. §√—È߇¥’¬«‡¡◊ËÕ‡√‘Ë¡∑” hemodialysis13,20 „π√“¬∑’Ë®”‡ªìπµâÕß„Àâ°“√√—°…“·∫∫ anticoagulant-free dialysis ¡—°‡°‘¥≈‘Ë¡‡≈◊Õ¥Õÿ¥µ—π„π dialyzer ·≈– blood line ‰¥â∫àÕ¬ ´÷ËߪÑÕß°—π‰¥â¥â«¬°“√ prime blood line ·≈– dialyzer ¥â«¬ heparin-saline solution ¥â«¬§«“¡‡¢â¡¢âπ 500-1,000 ¬πŸ ‘µ/≈‘µ√ ·≈⫵—Èß∑‘È߉«â 1-2 ™—Ë«‚¡ß°àÕπ flush ¥â«¬ NSS ∑‘Èß √à«¡°—∫ °“√„Àâ NSS flush 100-200 ¡≈. „π√–À«à“ß°“√∑” hemodialysis ∑ÿ° 15-30 π“∑’ 6. Pediatric hemodialysis prescription and monitoring12,13,18,20 ‡≈◊Õ° dialyzer ∑’Ë¡’¢π“¥„°≈⇧’¬ß body surface area ¢Õ߇¥Á° ·≈– blood line ‰¥â·≈â« §«√ §”π«≥ priming volume ∑’Ë®–µâÕß„™â„π blood line ·≈– dialyzer √«¡°—π‰¡à§«√‡°‘π√âÕ¬≈– 10 ¢Õߪ√‘¡“µ√ ‡≈◊Õ¥¢Õ߇¥Á° (80 ¡≈./°°.) ‡æ◊ËÕªÑÕß°—π¿“«– hypovolemia, hypotension ·≈– anemia ®“°°“√ Ÿ≠‡ ’¬ ‡≈◊Õ¥ °√≥’∑’Ë priming volume ¡“°°«à“√âÕ¬≈– 10 ¢Õߪ√‘¡“µ√‡≈◊Õ¥À√◊Õ‡¥Á°πÈ”Àπ—°πâÕ¬°«à“ 10 °‘‚≈°√—¡ „Àâ„™â packed red blood cells º ¡°—∫ NSS „πÕ—µ√“ à«π 1:1  ”À√—∫‡¥Á°∑’ËπÈ”Àπ—° 10-20 °‘‚≈°√—¡ Õ“® æ‘®“√≥“„™â 5% albumin À≈àÕ„π dialyzer ·≈– blood line ·∑π NSS °àÕπ∑”°“√øÕ°‡≈◊Õ¥ ·≈â«„Àâ packed red blood cells „π™«Ë— ‚¡ß·√°¢Õß°“√øÕ°‡≈Õ◊ ¥ „π°√≥‡’ ¥°Á ‚µ (π”È Àπ°— ¡“°°«“à 20-30 °‚‘ ≈°√¡— )  “¡“√∂ „™â NSS ‡™àπ‡¥’¬«°—∫ºâŸ„À≠à‰¥â µ—«Õ¬à“ß°“√§”π«≥ 1. °√≥’‡¥°Á ‡≈Á° ‡¥Á°Õ“¬ÿ 2 ªï πÈ”Àπ—° 9 °‘‚≈°√—¡  ßŸ 80 ‡´πµ‘‡¡µ√ ª√‘¡“µ√‡≈◊Õ¥„π√à“ß°“¬ (TBV) = 80 ¡≈./°°. × 9 °°. = 720 ¡≈. 10% ¢Õß TBV = 72 ¡≈. Body surface area = 80 × 9 / 3600 = 0.45 m2 206

Fundamental Basis of Pediatric Hemodialysis ‡≈◊Õ° dialyzer F3 (0.4 m2) ·≈– pediatric blood line §”π«≥ extracorporeal blood volume ¢Õß dialyzer ·≈– blood line √«¡ (28 + 48) ‡∑à“°—∫ 76 ¡≈. (®“°µ“√“ß∑’Ë 5 ·≈– 8) æ∫«à“ extracorporeal blood volume ¡“°°«à“√âÕ¬≈– 10 ¢Õߪ√‘¡“µ√‡≈◊Õ¥„π√à“ß°“¬‡¥Á° °√≥’π’ȧ«√À≈àÕ dialyzer ·≈– blood line ¥â«¬ packed red blood cells º ¡ NSS 1:1 ¢âÕ‡ ’¬¢Õß°“√„™â packed red blood cells ¡“À≈àÕ blood line ·≈– dialyzer §◊Õ ‡≈◊Õ¥„π blood line ¡’§«“¡Àπ◊¥ (Hct Õ“®¡“°°«à“ 40%) ∑”„ÀâµâÕß°“√¢π“¥ heparin  Ÿß°«à“ª°µ‘ ·≈–∑’Ë ”§—≠‡≈◊Õ¥¡’‚æ·∑ ‡´’¬¡ ßŸ ¡’ pH ‡ªìπ°√¥®“° lactate  Ÿß ∑”„Àâ¡’ metabolic derangement „π√–¬–∑’ˇ√‘Ë¡∑” hemodialysis ‰¥â ·π–π”„ÀâªÑÕß°—π‚¥¬∑” dialysis „Àâ‡≈◊Õ¥¥—ß°≈à“«‚¥¬ µàÕ blood line 2 ¢â“߇¢â“¥â«¬°—π ·≈â« recirculate ‡≈◊Õ¥¥—ß°≈à“« æ√âÕ¡„Àâ anticoagulant ·≈–‡ªî¥πÈ”¬“ dialysate ºà“π‡¢â“ Ÿà dialyzer π“π 30 π“∑’ °àÕπ‡√‘Ë¡°“√√—°…“ æ∫«à“∑”„Àâ‡≈◊Õ¥¡’√–¥—∫‚æ·∑ ‡´’¬¡·≈– lactate „π‡≈◊Õ¥≈¥≈ß ·≈–¬—ߙ૬ªÑÕß°—πªí≠À“°“√ clot ‰¥â¥â«¬21 ‡¡◊ËÕ‡√‘Ë¡√—°…“§√—Èß·√°§«√µ—Èß blood flow rate µË”Ê ‡æ◊ËÕ„À≥â urea clearance ª√–¡“≥ 3 ¡≈./ °°./π“∑’ ·≈–„™â‡«≈“ —Èπ‰¡à‡°‘π 2 ™—Ë«‚¡ß ‡¡◊ËÕ‡√‘Ë¡∑” hemodialysis §√—Èß·√° À√◊Õ√–¥—∫ BUN °àÕπ∑” hemodialysis ¡“°°«à“ 100 ¡°./¥≈. §«√„Àâ 20% mannital 0.5 °√—¡/°°. À¬¥„ÀâµàÕ‡π◊ËÕß„π√–À«à“ß°“√ √—°…“ æ∫«à“™à«¬ªÑÕß°—π ¡Õß∫«¡®“° disequilibrium syndrome ‰¥â „π°“√√—°…“§√—ÈßµàÕÊ ‰ª §àÕ¬Ê ‡æ‘Ë¡®π‰¥â urea clearance 5 ¡≈./°°./π“∑’ ·≈–‡æ‘Ë¡‡«≈“‡ªìπ 4 ™—Ë«‚¡ß °“√§”π«≥ blood flow rate (BFR) Urea clearance 3 ¡≈./°°./π“∑’ = 3 ¡≈./°°./π“∑’ × 9 °°. = 27 ¡≈./π“∑’ ®“°µ“√“ß∑’Ë 4 F3 dialyzer „™â BFR 200 ¡≈./π“∑’ ®–‰¥â urea clearance 125 ¡≈./π“∑’ 200 QB = BFR ∑’˵âÕß°“√ 125 urea clearance 27 urea clearance BFR ∑’˵âÕß°“√ = 200 × 27 125 = 43 ¡≈./π“∑’ ‡æÕË◊ „À‰â ¥â urea clearance 3 ¡≈./°°./π“∑’ µÕâ ßµßÈ— BFR ª√–¡“≥ 40 ¡≈./π“∑’‚¥¬°“√§”π«≥ ¢â“ßµâπæ∫«à“ °“√µ—Èß BFR ª√–¡“≥ 75 ¡≈./π“∑’ ®–‰¥â urea clearance 5 ¡≈./°°./π“∑’ °”Àπ¥ dialysate flow rate Õ¬à“ßπâÕ¬ 1.5-2 ‡∑à“¢Õß blood flow rate ‡æ◊ËÕ„Àâ¡’ª√– ‘∑∏‘¿“æ „π°“√°”®—¥¢Õ߇ ’¬ÕÕ°®“°√à“ß°“¬ §«√µ—Èß dialysate blood flow ‰«â 300 ¡≈./π“∑’ À√◊Õ 500 ¡≈./π“∑’ ‡À¡◊Õπ„πºâŸ„À≠à ª√‘¡“≥πÈ”∑’Ë®–¥÷ßÕÕ° À√◊Õ ultrafiltrate ‰¡à§«√‡°‘π√âÕ¬≈– 5 ¢ÕßπÈ”Àπ—°µ—« ´÷Ë߇∑à“°—∫ 50 ¡≈./°°.  ”À√—∫°“√øÕ°‡≈◊Õ¥·µà≈–§√—Èß Ultrafiltrate = 50 ¡≈. × 9 °°. = 450 ¡≈. 207

Practical Dialysis in the Year 2009 2. °√≥‡’ ¥°Á ‚µ ‡¥Á°Õ“¬ÿ 8 ªï πÈ”Àπ—° 25 °‘‚≈°√—¡  Ÿß 125 ‡´πµ‘‡¡µ√ ª√‘¡“µ√‡≈◊Õ¥„π√à“ß°“¬ (TBV) = 80 ¡≈./°°. × 25 °°. = 2000 ¡≈. 10% ¢Õß TBV = 200 ¡≈. Body surface area = 25 × 125 / 3600 = 0.86 m2 ‡≈◊Õ° dialyzer F4 (0.7 m2) ·≈– adult blood line Extracorporeal volume = 42 + 88 = 130 ¡≈. °√≥’π’Èæ∫«à“ extracorporeal volume πâÕ¬°«à“ 10% ¢Õß TBV °àÕπ‡√‘Ë¡ hemodialysis §«√ À≈àÕ dialyzer ·≈– blood line ¥â«¬ normal saline °”Àπ¥ target urea clearance §√—Èß·√°∑’Ë 3 ¡≈./°°./π“∑’ ‡∑à“°—∫ 75 ¡≈./π“∑’ §”π«≥ blood flow rate ‚¥¬ dialyzer F4 ¡’ urea clearance 155 ¡≈./π“∑’ ‡¡◊ËÕ blood flow rate 200 ¡≈./π“∑’ ∂â“ µâÕß°“√ target urea clearance 45 ¡≈./π“∑’ §”π«≥ blood flow rate ‰¥â 200 x 75/155 = 97 ¡≈./π“∑’ µ—Èß dialysate blood flow 500 ¡≈./π“∑’ ª√‘¡“≥πÈ”∑’Ë¥÷ßÕÕ° (ultrafiltrate) µ“¡∑’˵âÕß°“√·µà‰¡à‡°‘π√âÕ¬≈– 5 ¢ÕßπÈ”Àπ—°µ—« ‡«≈“„π°“√∑” dialysis §√—Èß·√°π‘¬¡‰¡à‡°‘π 2 ™—Ë«‚¡ß ∂⓺⟪ɫ¬√—∫°“√√—°…“‰¥â¥’ „π°“√∑” §√—ÈßµàÕÊ ‰ª §àÕ¬Ê ‡æ‘Ë¡ blood flow rate √–¬–‡«≈“µàÕ§√—Èß ·≈–®”π«π§√—ÈßµàÕ —ª¥“Àå ®π‰¥â blood flow rate 150-200 ¡≈./π“∑’ √–¬–‡«≈“ 3-4 ™—Ë«‚¡ßµàÕ°“√∑”·µà≈–§√—Èß ·≈–‰¥â 3 §√—ÈßµàÕ —ª¥“Àå ®– “¡“√∂‰¥â Kt/V 1.2-1.4 µ“¡∑’˵âÕß°“√1 °“√ ßË— °“√√°— …“ hemodialysis µÕâ ß®”‡æ“– ”À√∫— ‡¥°Á ·µ≈à –§π §«√∑”°“√ª√–‡¡π‘ ·≈–ª√∫— °“√√—°…“Õ¬à“ß ¡Ë”‡ ¡Õ„π‡¥Á°‡≈Á°·≈–‡¥Á°∑’Ë‚µ‡√Á« («—¬√ÿàπ) °“√„Àâ°“√ª√–§—∫ª√–§Õߥâ“𮑵„®¡’§«“¡  ”§—≠·≈–®”‡ªìπ ”À√—∫‡¥Á°·≈–§√Õ∫§√—« πÕ°®“°π’È°“√„Àâ°“√ªÑÕß°—𧫓¡‡®Á∫ª«¥∂◊Õ‡ªìπ ‘Ëß ®”‡ªìπ ”À√—∫‡¥Á°1 °Õà π∑”°“√øÕ°‡≈Õ◊ ¥„Àªâ √–‡¡π‘  ¿“«–π”È „π√“à ß°“¬ µ√«®«¥— §«“¡¥π— ‚≈Àµ‘ µ√«®∑“ßÀÕâ ß ªØ‘∫—µ‘°“√∑’Ë®”‡ªì𠇙àπ BUN, creatinine, electrolytes, calcium, phosphate, parathyroid hormone·≈– Õ◊ËπÊ µ“¡§«“¡®”‡ªìπ ™—ËßπÈ”Àπ—°µ—«°àÕπ·≈–À≈—ß°“√øÕ°‡≈◊Õ¥ ‡¥Á°∑’ËπÈ”Àπ—°µ—«‡æ‘Ë¡¢÷Èπ¡“°°«à“√âÕ¬≈– 10 ¢Õß dry weight „π°“√øÕ°‡≈◊Õ¥§√—ÈßµàÕ‰ª · ¥ß«à“‰¡à‰¥â§«∫§ÿ¡πÈ”Àπ—°·≈–Õ“À“√ À√◊Õ‰¡à‰¥âªØ‘∫—µ‘ µ“¡·π«∑“ß°“√√—°…“ √–À«à“ß°“√øÕ°‡≈◊Õ¥§«√«—¥§«“¡¥—π‚≈À‘µ∑ÿ° 15-30 π“∑’  —߇°µÕ“°“√∑—Ë«‰ª ‡ΩÑ“√–«—ß¿“«–·∑√°´âÕπ ·æ∑¬å·≈–欓∫“≈‰µ‡∑’¬¡§«√∑√“∫™π‘¥¢Õ߬“∑ÿ°µ—«∑’˺⟪ɫ¬‰¥â√—∫ ¬“À≈“¬ ™π‘¥®”‡ªìπµâÕ߉¥â√—∫°“√ª√—∫¢π“¥„Àâ‡À¡“– ¡ 7. ‡ª“Ñ À¡“¬°“√øÕ°‡≈Õ◊ ¥∑‡Ë’ À¡“– ¡ ª®í ®∫ÿ π— ¬ß— ‰¡¡à °’ “√»°÷ …“ √ªÿ ‡ª“Ñ À¡“¬¢Õß°“√∑” chronic hemodialysis „π‡¥°Á Õ¬“à ߉√°µÁ “¡ ¡’¢âÕ·π–π”«à“‡ªÑ“À¡“¬°“√øÕ°‡≈◊Õ¥„π‡¥Á°§«√ Ÿß°«à“‡ªÑ“À¡“¬∑’Ë°”Àπ¥„πºâŸ„À≠1à ´÷Ëß°“√øÕ°‡≈◊Õ¥ 3 §√—Èß/ —ª¥“Àå §à“ Kt/V §«√¡“°°«à“ 1.2-1.4 ‡π◊ËÕß®“°°“√øÕ°‡≈◊Õ¥∑’ˇ撬ßæÕ®–™à«¬„À⇥Á°¡’°“√‡®√‘≠ 208

Fundamental Basis of Pediatric Hemodialysis ‡µ‘∫‚µ∑’ˇÀ¡“– ¡·≈–¡’‚¿™π“°“√∑’Ë¥’ ‚¥¬°“√»÷°…“„π‡¥Á°æ∫«à“ºâŸªÉ«¬∑’ˉ¥â√—∫°“√øÕ°‡≈◊Õ¥∑’Ë¡’√–¬– ‡«≈“‡æ‘Ë¡¢÷Èπ®–™à«¬≈¥ left ventricular hypertrophy ‰¥2â 2 πÕ°®“°π’Ȭ—ßæ∫«à“ºâŸªÉ«¬‡¥Á° 5 §π ∑’ˉ¥â√—∫°“√ øÕ°‡≈◊Õ¥∑ÿ°«—πÕ¬à“߇¢â¡¢âπ (intensified and daily hemodialysis) ¡’Õ—µ√“°“√‡®√‘≠‡µ‘∫‚µ‡æ‘Ë¡¢÷ÈπÕ¬à“ß ™—¥‡®π23 ‚¥¬∑—Ë«‰ª°“√øÕ°‡≈◊Õ¥ —ª¥“Àå≈– 3 §√—Èß §√—Èß≈– 4 ™—Ë«‚¡ß °Á‡æ’¬ßæÕ ”À√—∫‡¥Á° „π°√≥’‡¥Á° ‡≈°Á π”È Àπ°— πÕâ ¬°«“à 10 °‚‘ ≈°√¡— Õ“®®”‡ªπì µÕâ ßøÕ°‡≈Õ◊ ¥ 4-5 §√ßÈ— / ª— ¥“Àå ‡πÕË◊ ß®“°¥¡Ë◊ π¡∑”„À®â ”π«π πÈ”∑’Ë¥◊Ë¡·µà≈–«—π¡“° ·≈–°“√‡Õ“ ultrafiltration ÕÕ°§√—Èß≈–¡“°Ê Õ“®¡’¿“«–·∑√°´âÕπ‰¥â ®÷ßÕ“®µâÕß ª√—∫‡æ‘Ë¡®”π«π§√—ÈßµàÕ —ª¥“Àå 8.  √ªÿ °“√∑” hemodialysis „π‡¥°Á ¡°’ “√æ≤— π“Õ¬“à ßµÕà ‡πÕ◊Ë ß∑ß—È Õªÿ °√≥∑å ¡’Ë §’ «“¡‡À¡“– ¡µ“¡¢π“¥ ¢Õ߇¥Á°·µà≈–«—¬ ·≈–°“√ —Ëß°“√√—°…“‡æ◊ËÕ„À≥Ⱃ√¢®—¥¢Õ߇ ’¬∑’ˇ撬ßæÕ æ—≤𓉪 Ÿà°“√¢®—¥¢Õ߇ ’¬ „À‰â ¥Õâ ¬“à ߇µ¡Á ∑Ë’ (optimal dialysis) ‡æÕË◊ ¡ßàÿ À«ß— „À‡â ¥°Á ¡°’ “√‡®√≠‘ ‡µ∫‘ ‚µ∑¥Ë’ ¢’ πÈ÷ ¡¿’ “«–·∑√°´Õâ πµ“à ßÊ πÕâ ¬ ∑’Ë ÿ¥ °“√„Àâ°“√ª√–§—∫ª√–§Õߥâ“𮑵„®¡’§«“¡®”‡ªìπµàÕ‡¥Á°·≈–§√Õ∫§√—« ºâŸªÉ«¬‡¥Á°‰µ«“¬√–¬–  ÿ¥∑⓬®÷ߧ«√‰¥â√—∫°“√¥Ÿ·≈·∫∫∫Ÿ√≥“°“√1 (integrated care model) ·≈–¡’‡ªÑ“À¡“¬§◊Õ°“√‰¥â√—∫°“√ ‡µ√’¬¡æ√âÕ¡∑—Èß∑“ß√à“ß°“¬·≈–®‘µ„®‡æ◊ËÕ°“√ª≈Ÿ°∂à“¬‰µ24 (kidney transplantation) ´÷Ë߇ªìπ°“√√—°…“ ∑¥·∑π‰µ∑’Ë¥’∑’Ë ÿ¥„πªí®®ÿ∫—π ‡Õ° “√Õ“â ßÕß‘ 1. Fischbach M, Edefonti A, Schröder C, Watson A. The European Pediatric Dialysis Working Group. Hemodialysis in children: general practical guidelines. Pediatr Nephrol 2005;20:1054-66. 2. Way AF, Bolonger AM, Gambertogh JG. Pharmacokinetics and drug dosing in children with decreased renal function. In: Holiday Ma. Barratt TM, Avner ED, editors. Pediatric Nephrology. 3rd ed. Baltimore: Williams & Wilkins; 1994. p.1306. 3. Barletta GM, Bunchman TE. Acute renal failure in children and infants. Curr Opin Crit Care 2004;10:499-504. 4. Quan A, Quigley R. Renal replacement therapy and acute renal failure. Curr Opin Pediatr 2005;17:205-9. 5. Flynn JT. Causes, management approaches, and outcome of acute renal failure in children. Curr Opin Pediatr 1998;10:184-9. 6. US Renal Data System. USRDS 2008 Annual Data Report. Atlas of End-stage Renal Disease in the United Stage. Bethesda: MD; 2008 7. Sumboonnanonda A, Thirakhupt P, Kingwatanakul P, Vongjirad A. Chronic renal failure in Thai children: etiology, cost, and outcome. J Med Assoc Thai 2000;83:894-901. 8. North American Pediatric Trial and collaborative Studies (NAPRTCS). NAPRTCS 2008 Annual Report. The EMMES Corporation 2008 9. Ardissino G, Dacco V, Testa S, Bonaudo R, Claris-Appiani A, Taioli E, et al. Epidemiology of chronic renal failure in children: data from the ItalKid project. Pediatrics 2003;111:e382-7. 10. NKF-DOQI clinical practice guidelines. Am J Kid Dis 1997;50(suppl 2). 209

Practical Dialysis in the Year 2009 11. Fadrowski JJ, Frankenfield DL, Friedman AL, Warady BA, Neu AM, Fivush BA. Impact of specialization of primary nephrologist on the care of pediatric hemodialysis patients. Am J Kidney Dis 2006;47:115-21. 12. Main AN, Mendley SR. Acute dialysis in children. In: Hernrich WL, editor. Principles and practice of dialysis. 3rd ed. Philadelphia: Williams & Wilkins; 2004. p. 617-28. 13. Warady BA, Jabs KL, Goldstein SL. Chronic dialysis in children. In: Henrich WL, editor. Principle and practice of dialysis. 3rd ed. Philadelphia: Williams & Wilkins; 2004. p. 592-616. 14. Lau SC. Hemodialysis. In: Chiu MC, Yap HK, editors. Practical pediatric nephrology: An update of current practices. Hong Kong: Medcom limited; 2005. p. 280-6. 15. Chand DH, Valentini RP. International pediatric fistula first initiative: a call to action. Am J Kidney Dis 2008;51:1016- 24. 16. Fadel FI, Abdel Mooty HN, Bazaraa HM, Sabry SM. Central venous catheters as a vascular access modality for pediatric hemodialysis. Int Urol Nephrol 2008;40:489-96. 17. Cochat P, Lioux C. Maintenance dialysis during infancy. In: Warady BA, Schaefer FS, Fine RN, Alexander SR, editors. Pediatric dialysis. Dordechit: Kluwer Academic Publishers; 2006. p. 91-112. 18. Donckerwolcke RA, Bunchman TE. Hemodialysis in infants and small children. Pediatr Nephrol 1994;8:103-6. 19. Sadowski RH, Allred EN, Jabs K. Sodium modeling ameliorates intradialytic and interdialytic symptoms in young hemodialysis patients. J Am Soc Nephrol 1993 ;4:1192-8 20. Goldstein SL. Perscribing and monitoring hemodialysis. In: Warady BA, Schaefer FS, Fine RN, Alexander SR, editors. Pediatric dialysis. Dordechit: Kluwer Academic Publishers; 2004. p. 135-410. 21. Hackbarth RM, Eding D, Gianoli Smith C, Koch A, Sanfilippo DJ, Bunchman TE. Zero balance ultrafiltration (Z-BUF) in blood-primed CRRT circuits achieves electrolyte and acid-base homeostasis prior to patient connection. Pediatr Nephrol 2005;20:1328-33. 22. Ulinski T, Genty J, Viau C, Tillous-Borde I, Deschênes G. Reduction of left ventricular hypertrophy in children undergoing hemodialysis. Pediatr Nephrol 2006;21:1171-8. 23. Fischbach M, Terzic J, Menouer S, Dheu C, Soskin S, Helmstetter A, et al. Intensified and daily hemodialysis in children might improve statural growth. Pediatr Nephrol 2006;21:1746-52. 24. Goldstein SL. Advances in renal replacement therapy as a bridge to renal transplantation. Pediatr Transplant 2007;11:463- 70. 210

Pediatric Care in Adult Hemodialysis Units: Pediatric Maintenance Hemodialysis Pediatric Care in Adult 11 Hemodialysis Units: Pediatric Maintenance Hemodialysis π—π∑«—π ªî¬–¿“≥’ 1. ∫∑π” 2. Vascular access 3. Prescribing and monitoring hemodialysis 4. Hemodialysis adequacy 5. Nutrition 6. Growth 7. Anemia 8. Renal bone disease 9. Hypertension 10. Cardiovascular disease 11.  √ªÿ 211

Practical Dialysis in the Year 2009 1. ∫∑π” °“√≈â“߉μ„π‡¥Á°‰μ«“¬‡√◊ÈÕ√—ß ‡ªìπ°“√√—°…“∑¥·∑π‰μ‡æ◊ËÕ√Õ§«“¡æ√âÕ¡„π¥â“πμà“ßÊ °àÕπ ∑”°“√ª≈°Ÿ ∂à“¬‰μ (kidney transplantation) „πºŸâªÉ«¬«—¬∑“√°·≈–‡¥Á°‡≈Á°π‘¬¡∑”°“√≈â“߉μ∑“ß™àÕß∑âÕß (peritoneal dialysis) ‡πÕË◊ ß®“° “¡“√∂§«∫§¡ÿ ª√¡‘ “≥ “√π”È ‰¥¥â ’ ·≈–¡°— ¡§’ «“¡®”°¥— „π°“√∑” vascular access  «à π„π‡¥°Á ‚μÕ“®æ®‘ “√≥“°“√≈“â ߉μ∑“ß™Õà ß∑Õâ ßÀ√Õ◊ øÕ°‡≈Õ◊ ¥¥«â ¬‡§√Õ◊Ë ß‰μ‡∑¬’ ¡ (hemodialysis) °Á‰¥â ‚¥¬æ‘®“√≥“μ“¡§«“¡‡À¡“– ¡¢Õß ¿“溟âªÉ«¬ §«“¡æ√âÕ¡¢Õߧ√Õ∫§√—« √«¡∑—Èß ∂“π∑’Ë „Àâ°“√∫√‘°“√ ªí®®ÿ∫—π¡’°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‰μ«“¬‡√◊ÈÕ√—ß‚¥¬°“√øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡°—πÕ¬à“ß ·æ√àÀ≈“¬„πºŸâªÉ«¬ºŸâ„À≠à  à«π°“√øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡„πºŸâªÉ«¬‡¥Á°°Á¡’·π«‚πâ¡∑’Ë¡“°¢÷Èπ1 °“√ ¥·Ÿ ≈ºªâŸ «É ¬‡¥°Á ‰μ«“¬‡√ÕÈ◊ √ß— ·∫∫ maintenance hemodialysis §«√‰¥√â ∫— °“√¥·Ÿ ≈·∫∫ multidisciplinary team ª√–°Õ∫¥â«¬°ÿ¡“√·æ∑¬å 欓∫“≈‚√§‰μ‡¥Á° π—°‚¿™π“°“√ π—° —ߧ¡ ß‡§√“–Àå ‡ªìπμâπ ·μà‡π◊ËÕß®“° ®”π«π∫ÿ§≈“°√¥—ß°≈à“«¡’®”π«π®”°—¥ Õ’°∑—Èß hemodialysis unit  ”À√—∫ºŸâªÉ«¬‡¥Á°¬—ß¡’πâÕ¬¡“° ·≈– μ—ÈßÕ¬Ÿà‡©æ“–∫√‘‡«≥‡¡◊Õß„À≠à ¢≥–‡¥’¬«°—π¡’ºŸâªÉ«¬‡¥Á°∑’ˬ—ߧßμâÕß°“√¥Ÿ·≈√—°…“¥â«¬°“√øÕ°‡≈◊Õ¥ ¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡Õ’°®”π«πÀπ÷Ëß∑’ˉ¡à “¡“√∂‡¢â“∂÷ß°“√√—°…“‰¥â ºâŸªÉ«¬‡¥Á°‡À≈à“π—Èπ®÷ß®”‡ªìπμâÕ߉¥â √—∫°“√√—°…“„π adult hemodialysis unit ‡ªìπ∑’Ë∑√“∫°—π¥’«à“ °“√¥·Ÿ ≈ºŸâªÉ«¬‡¥Á°¡’§«“¡·μ°μà“ß®“°°“√¥·Ÿ ≈ºŸâ„À≠à¡“°æÕ ¡§«√ ºâŸ ªÉ«¬‡¥Á°·μà≈–«—¬¡’§«“¡·μ°μà“ߢÕßπÈ”Àπ—°  à«π Ÿß ·≈– æ◊Èπ∑’˺‘«°“¬ ®÷ßμâÕß°“√§«“¡‡À¡“– ¡¢Õß Õÿª°√≥å∑’Ë„™â„π°“√øÕ°‡≈◊Õ¥ ·≈–°“√√–¡—¥√–«—ߢâÕ·∑√°´âÕπ∑’ËÕ“®®–‡°‘¥¢÷Èπμà“ßÊ ‡¥Á°μâÕß°“√°“√ ‡®√‘≠‡μ‘∫‚μ·≈–æ—≤π“°“√¥â“πμà“ßÊ ∑’ˇÀ¡“– ¡μ“¡«—¬ ‚¥¬ºâŸª°§√Õß §√Õ∫§√—« ·≈–‚√߇√’¬π ≈â«π¡’  «à π√«à ¡„π°“√¥·Ÿ ≈ºªŸâ «É ¬¥«â ¬ ¥ß— ππ—È °“√¥·Ÿ ≈ºªŸâ «É ¬‡¥°Á ‰μ«“¬‡√Õ◊È √ß— ®ß÷ μÕâ ß°“√°“√¥·Ÿ ≈∑ß—È ∑“ߥ“â π√“à ß°“¬ ®‘μ„®·≈–∑“ß —ߧ¡ ∫∑§«“¡π’È®–‰¡à°≈à“«∂÷ß°“√√—°…“ºŸâªÉ«¬‰μ«“¬‡√◊ÈÕ√—ß∑’Ë√—∫°“√√—°…“¥â«¬°“√øÕ°‡≈◊Õ¥¥â«¬ ‡§√◊ËÕ߉μ‡∑’¬¡„π«—¬∑“√° ·μà®–‡πâπ°“√¥Ÿ·≈ºâŸªÉ«¬∑’ˇªìπ‡¥Á°‚μ ∑’Ë “¡“√∂„Àâ°“√¥Ÿ·≈√—°…“„π adult hemodialysis unit 2. Vascular access Vascular access ¢Õߺ⟪ɫ¬‡¥Á°∑’ËøÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡ „π√–¬– maintenance hemodialysis ·π–π”„À∑â ” arterio-venous fistula (AVF) À√Õ◊ ∑” arterio-venous graft ¡“°°«“à °“√„™â central venous catheter (CVC) ‡π◊ËÕß®“°¡’Õ“¬ÿ„™âß“π‰¥âπ“π ·≈–¡’Õ—μ√“°“√‰À≈¢Õ߇≈◊Õ¥‡æ’¬ßæÕ ”À√—∫ prescription dose πÕ°®“°π—Èπ°“√„™â CVC ®–¡’Õ—μ√“°“√μ‘¥‡™◊ÈÕ‰¥â¡“° ·μà°“√∑” permanent vascular access Õ“®¡’ªí≠À“„π¥â“π°“√À“∫ÿ§≈“°√∑’Ë¡’∑—°…– §«“¡¬“°„π°“√À“‡ âπ‡≈◊Õ¥∑’ˇÀ¡“– ¡„πºŸâªÉ«¬ μ—«‡≈Á° À√◊Õªí≠À“°“√„™âß“π‰¥â¢Õß vascular access π—Èπ ∑”„Àâ¡’°“√‡≈◊Õ°„™â CVC ·∑π ‚¥¬∑—Ë«‰ª·π–π” „Àâ„™â CVC „π‡©æ“–°√≥’∑” hemodialysis „π√–À«à“ß°“√∑” peritoneal dialysis training À√◊Õ°√≥’μâÕß∑” 212

Pediatric Care in Adult Hemodialysis Units: Pediatric Maintenance Hemodialysis hemodialysis √–À«“à ß®”‡ªπì μÕâ ß remove PD catheter ‡πÕ◊Ë ß®“°ª≠í À“ peritonitis À√Õ◊ °√≥ ’ “¡“√∂ª√–‡¡π‘ ‰¥â«à“ ºŸâªÉ«¬®–‰¥â√—∫°“√ª≈Ÿ°∂à“¬‰μ„π√–¬–‡«≈“Õ—π —Èπ ‚¥¬∑—Ë«‰ª¢π“¥ “¬¢Õß catheter ∑’Ë„™â„π°“√øÕ°‡≈◊Õ¥§«√¡’¢π“¥ 8 Fr ¢÷Èπ‰ª ‚¥¬ “¡“√∂ „Àâ blood flow Õ¬à“ßπâÕ¬ 3-5 mL/kg/min ·π–π”„Àâ„ à∫√‘‡«≥ internal jugular vein ‚¥¬„Àâª≈“¬ “¬Õ¬àŸ∑’Ë ∫√‘‡«≥ right atrium ¡’°“√·π–π”°“√‡≈◊Õ°„™â vascular access ‚¥¬æ‘®“√≥“μ“¡πÈ”Àπ—°¢π“¥ºŸâªÉ«¬ ·≈–√–¬– ‡«≈“°“√√Õª≈°Ÿ ∂“à ¬‰μ ‚¥¬À“°ª√–¡“≥‰¥«â “à ºªŸâ «É ¬¡‚’ Õ°“ ‰¥√â ∫— °“√ª≈°Ÿ ∂“à ¬‰μ¿“¬„π 1 ªï 殑 “√≥“„™â cuffed CVC À“°√Õπ“π°«à“ 1 ªï æ‘®“√≥“∑’ËπÈ”Àπ—°μ—«¢Õߺ⟪ɫ¬ À“°¡’πÈ”Àπ—°μ—«πâÕ¬°«à“À√◊Õ‡∑à“°—∫ 20 °‘‚≈°√—¡ æ‘®“√≥“„™â cuffed CVC À“°πÈ”Àπ—°μ—«¡“°°«à“ 20 °‘‚≈°√—¡ æ‘®“√≥“∑” AVF À√◊Õ AVG2 ¢âÕ¡≈Ÿ ®“° ESRD clinical performance measurement (CPM) project æ∫«à“ºŸâªÉ«¬‡¥Á°øÕ° ‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡„π À√—∞Õ‡¡√‘°“ à«π„À≠à¡’°“√„™â vascular catheter (√âÕ¬≈– 59) ¡“°°«à“ permanent vascular access (AVF/AVG) (√âÕ¬≈– 41) ª√–¡“≥§√÷ËßÀπ÷ËߢÕߺ⟪ɫ¬∑’Ë„™â CVC ∑’Ë¡’πÈ”Àπ—° ¡“°°«à“ 20 °‘‚≈°√—¡ ·≈–¡’‡æ’¬ßÀπ÷Ëß„π “¡¢Õߺ⟪ɫ¬∑’Ë„™â CVC ‰¥â√—∫°“√ª≈°Ÿ ∂à“¬‰μ¿“¬„π 1 ª3ï 3. Prescribing and monitoring hemodialysis ‚¥¬∑«Ë— ‰ªÀ≈°— °“√°“√ ßË— °“√√°— …“°“√øÕ°‡≈Õ◊ ¥¥«â ¬‡§√ÕË◊ ߉μ‡∑¬’ ¡„πºªâŸ «É ¬‡¥°Á ‰¡·à μ°μ“à ß ®“°ºâŸ„À≠àπ—° ¡’®ÿ¥‡πâπ §◊Õ μâÕߧ”π÷ß∂÷ß¢π“¥¢Õߺ⟪ɫ¬ ·≈–ª√‘¡“≥‡≈◊Õ¥„π√à“ß°“¬ (total blood volume ,TBV) ‚¥¬μâÕ߇≈◊Õ°„™âÕÿª°√≥å à«π extracorporeal blood circuit ∑’Ë¡’ª√‘¡“μ√√«¡πâÕ¬°«à“√âÕ¬≈– 10 ¢Õß TBV ‡æ◊ËÕªíÕß°—πªí≠À“¥â“π hemodynamic ·≈–§”π÷ß∂÷ߧ«“¡‡æ’¬ßæÕ„π°“√¢®—¥¢Õ߇ ’¬ (hemodialysis adequacy) ´ßË÷ ‡ªπì º≈®“°°“√‡≈Õ◊ °„™â μ«— °√Õß (dialyzer) Õμ— √“°“√‰À≈¢Õ߇≈Õ◊ ¥ (blood flow rate) ·≈–√–¬–‡«≈“¢Õß°“√√°— …“ ·≈–∑Ë’ ”§≠— ®”‡ªìπμâÕߪ√–‡¡π‘ ·≈–·°â‰¢ª≠í À“¿“«–∑“ß‚¿™π“°“√ „πºâŸªÉ«¬‡¥Á°Õ¬Ÿà‡ ¡Õ 3.1 Extracorporeal blood circuit ª√–°Õ∫¥â«¬ needles, blood tubing ·≈– dialyzer ª√‘¡“μ√√«¡¢Õß needle, central venous catheter, blood tubing ·≈– priming volume ¢Õß dializer ‰¡à§«√‡°‘π√âÕ¬≈– 10 ¢Õß TBV ‚¥¬„π‡¥Á°·≈– «—¬√ÿàπ TBV ¡’§à“ª√–¡“≥ 60-70 mL/kg  ”À√—∫ blood tubing ∑’Ë¡’„Àâ‡≈◊Õ°„™â §◊Õ adult blood line ·≈– pediatric blood line ‚¥¬∑—Ë«‰ª ‡¥Á°∑’Ë¡’πÈ”Àπ—° 30 °‘‚≈°√—¡ ¢÷Èπ‰ª “¡“√∂„™â “¬π”‡≈◊Õ¥ ”À√—∫ºâŸ„À≠à ´÷Ëß¡’¢π“¥ª√‘¡“μ√ª√–¡“≥ 88-130 mL  à«π‡¥Á°∑’Ë¡’πÈ”Àπ—°πâÕ¬°«à“ 30 °‘‚≈°√—¡ §«√§”π«≥ extracorporeal blood volume ∑’ˬա√—∫ ‰¥â ·≈–≈∫ª√¡‘ “μ√μ«— °√Õß (dialyzer) ∑‡’Ë ≈Õ◊ °‰«‡â æÕ◊Ë æ®‘ “√≥“¢π“¥blood line ∑‡’Ë À¡“– ¡ ‚¥¬∑«—Ë ‰ª internal volume ¢Õß pediatric line ¡’ª√‘¡“μ√ª√–¡“≥ 48-73 mL 213

Practical Dialysis in the Year 2009 3.2 Dialyzer °“√‡≈◊Õ°μ—«°√Õß∑’Ë„™â„πºâŸªÉ«¬‡¥Á°§«√‡≈◊Õ°™π‘¥∑’Ë¡’ priming volume μË” ¡’ surface area „°≈â ‡§’¬ß°—∫ BSA ¢Õߺ⟪ɫ¬ ¡’ biocompatibility ∑’Ë¥’ §◊Õ‡ªìπ synthetic membrane ·≈–π‘¬¡‡≈◊Õ°μ—«°√Õß ™π‘¥ low-flux ∑’Ë¡’ Kuf πâÕ¬°«à“ 10 mL/hr/mmHg ´÷Ë߇撬ßæÕ„π°“√¢®—¥ “√∑’ˇªìπ small molecule „π °√≥’ºŸâªÉ«¬∑’Ë®”‡ªìπμâÕß„Àâ°“√√—°…“·∫∫ long term ‡ªìπ‡«≈“À≈“¬ªï °àÕπ∑” kidney transplant §«√ æ‘®“√≥“μ—«°√Õß™π‘¥ high-flux ‡æ◊ËÕ¢®—¥ “√∑’ˇªìπ middle molecule °“√„™âμ—«°√Õß∑’Ë¡’ Kuf  ßŸ ¡’Õ—μ√“ ‡ ¬’Ë ß¢Õß°“√‡°¥‘ backfiltration ¡“°¢π÷È ®”‡ªπì μÕâ ß¡√’ –∫∫¢Õß dialysate system ∑¥’Ë ’ ‡™πà ultrapure dialysate À√Õ◊ „À°â “√√°— …“·∫∫ online hemodiafiltration ‡æÕ◊Ë ªÕÑ ß°π— °“√ªπ‡ªÕóô π¢Õß “√„πdialysis fluid ‡¢“â  √Ÿà “à ß°“¬ ‰¥â √«¡∑—ÈßμâÕß¡’°“√§«∫§ÿ¡ ultrafiltration ∑’Ë¥’¥â«¬ 3.3 Blood urea clearance ·≈– Blood flow rate °“√¢®—¥ “√ urea ÕÕ°®“°‡≈◊Õ¥ (blood urea clearance) ‡ª√’¬∫‡ ¡◊Õπμ—«·∑π¢Õß°“√¢®—¥ uremic toxin ÕÕ°®“°‡≈◊Õ¥ °“√¢®—¥ urea „π maintenance hemodialysis „ÀâÕ¬àŸ∑’˪√–¡“≥ 3-5 ml/min/kg ‚¥¬°“√¢®—¥ urea ¢÷Èπ°—∫ª√– ‘∑∏‘¿“æ¢Õßμ—«°√Õß∑’ËÕ—μ√“°“√‰À≈¢Õ߇≈◊Õ¥Àπ÷ËßÊ ·≈–√–¬–‡«≈“„π°“√ ∑” hemodialysis ‚¥¬∑—Ë«‰ª§à“¢Õß urea clearance ¡’§à“„°≈⇧’¬ß°—∫ blood flow rate °≈à“«§◊Õ §à“ urea clearance ®–Õ¬àŸ√–À«à“ß 150-190 mL/min ∑’Ë blood flow rate 200 mL/min °”Àπ¥„Àâ blood flow rate „𠇥Á°Õ¬Ÿà∑’˪√–¡“≥ 150-200 mL/min/m2 À√◊Õ 5-7 mL/min/kg  ”À√—∫‡¥Á°‡≈Á° Õ“®§”π«≥‚¥¬„™â μŸ √μ“¡ πÈ”Àπ—°μ—«¢Õߺ⟪ɫ¬ Õ—μ√“°“√‰À≈¢Õ߇≈◊Õ¥(Qb, mL/min) = (BW (kg) + 10) × 2.5 3.4 Dialysate flow Õ—μ√“°“√‰À≈¢ÕßπÈ”¬“ dialysate „π‡¥Á°¡’°”Àπ¥„Àâ¡“°°«à“ 1.5 ‡∑à“¢Õß BFR ‚¥¬¡’Õ—μ√“ ª√–¡“≥ 300-800 ml/min ‚¥¬∑—Ë«‰ª¡—°„™â∑’ËÕ—μ√“ 500 mL/min ¬°‡«âπ„π‡¥Á°μ—«‡≈Á°Õ“®„™âÕ—μ√“‡æ’¬ß 300 ml/min  à«πª√–°Õ∫¢ÕßπÈ”¬“ °“√‡μ√’¬¡πÈ”¬“ ·≈–°“√ª√—∫§«“¡‡¢â¡¢âπ‰¡à·μ°μà“ß®“°ºŸâ„À≠à Õ“® μâÕߪ√—∫Õÿ≥À¿¡Ÿ ‘¢ÕßπÈ”¬“À“°æ∫«à“‡¥Á°∑’Ë¡’ªí≠À“ hypothermia 3.5 Anticoagulant °“√ ¡— º — ∑“߇≈Õ◊ ¥°∫— ∑Õà π”‡≈Õ◊ ¥ À√Õ◊ ºπß— μ«— °√Õß ≈«â π°√–μπÿâ intrinsic coagulation pathway ∑”„À⇰‘¥‡≈◊Õ¥·¢Áßμ—« °“√„Àâ anticoagulant ®÷ß¡’§«“¡®”‡ªìπÕ¬à“ß¡“° heparin ‡ªìπμ—«∑’Ëπ‘¬¡„™â„π°“√ øÕ°‡≈Õ◊ ¥ ‚¥¬º ¡„π flushing solution ¢π“¥§«“¡‡¢¡â ¢πâ 5,000 IU/L ‡¡ÕË◊ ‡√¡Ë‘ ∑”°“√øÕ°‡≈Õ◊ ¥„Àâ heparin bolus ¢π“¥ 10-20 IU/kg ®“°π—Èπ„Àâ·∫∫ continuous infusion ¢π“¥ 10-20 IU/kg/hr ‚¥¬„Àâ§à“ optimal whole blood activated clotting time (ACT) Õ¬àŸ∑’Ë 1.25-1.5 ‡∑à“¢Õß§à“ª°μ‘ (§à“ª°μ‘‡∑à“°—∫ 90-140 «‘π“∑’) ·≈–§à“ activated partial thromboplastin time (aPTT) ‡∑à“°—∫ 120-160 «‘π“∑’ 4 À√◊ÕÕ“®„™â low molecular weight heparin ‡™πà enoxaparin 0.5-1 mg/kg §√ß—È ‡¥¬’ «‡¡Õ◊Ë ‡√¡‘Ë ∑”°“√øÕ°‡≈Õ◊ ¥æ∫«“à °“√„™âLMWH  “¡“√∂ ≈¥Õ—μ√“‡ ’ˬߢÕß¿“«–‡≈◊Õ¥ÕÕ°‰¥â 214

Pediatric Care in Adult Hemodialysis Units: Pediatric Maintenance Hemodialysis 3.6 Ultrafiltration ‡æ◊ËÕ≈¥Õ—μ√“°“√‡°‘¥¿“«–§«“¡¥—π‚≈À‘μμË” (hypotension) ®“°°“√∑” hemodialysis §«√ °”Àπ¥ net ultrafiltration rate ‰¡à‡°‘π√âÕ¬≈– 2 ¢ÕßπÈ”Àπ—°μ—«μàÕ™—Ë«‚¡ß (ml/kg/hr)4 À√◊Õ‰¡à‡°‘π√âÕ¬≈– 5 ¢ÕßπÈ”Àπ—°μ—«„π°“√∑” hemodialysis ·μà≈–§√—Èß (mL/kg/session)5 °√≥’μâÕß°“√¥÷ßπÈ”„πª√‘¡“≥∑’Ë¡“° °«à“∑’Ë°≈à“«¢â“ßμâπ Õ“®„™â«‘∏’ sequential ultrafiltration À√◊Õ«‘∏’ sodium modeling ‰¥â ·μ৫√√–¡—¥√–«—ß ¿“«–§«“¡¥—π‚≈À‘μμË”√à«¡¥â«¬‡ ¡Õ 3.7 Dialysis session °“√∑” maintenance hemodialysis ‡¥Á° ‚¥¬∑—Ë«‰ª·π–π”„Àâ∑”Õ¬à“ßπâÕ¬ 3 §√—ÈßμàÕ —ª¥“Àå √–¬–‡«≈“π“π 4-6 ™—Ë«‚¡ß 3.8 Dry weight assessment °“√ª√–‡¡‘π·≈–°”Àπ¥ dry weight ¢Õߺ⟪ɫ¬¡’§«“¡ ”§—≠ „π‡¥Á°¡’ª√‘¡“≥πÈ”„π√à“ß°“¬ ·μ°μà“ß°—πμ“¡Õ“¬ÿ πÈ”Àπ—°μ—«Õ“®¡’°“√‡ª≈’ˬπ·ª≈߉¥âßà“¬®“°√—∫ª√–∑“πÕ“À“√À√◊Õ°“√Õ¥Õ“À“√ Õ’°∑—È߬—ß¡’ªí®®—¬¥â“π°“√‡®√‘≠‡μ‘∫‚μ ∑”„Àâª√–‡¡‘π dry weight ∑’ˇÀ¡“– ¡‰¥â¬“° ·μàÕ¬à“߉√°Áμ“¡°“√ ™—ËßπÈ”Àπ—°μ—« ‡ª√’¬∫‡∑’¬∫°“√‡ª≈’ˬπ·ª≈ߢÕßπÈ”Àπ—°μ—«·≈–μ‘¥μ“¡‡ªìπ√–¬– √à«¡°—∫°“√ª√–‡¡‘π ¿“«–‚¿™π“°“√ ®–™à«¬°”Àπ¥ dry weight ∑’ˇÀ¡“– ¡‰¥â À√◊ÕÕ“®„™â noninvasive monitoring ¢Õß§à“ hematocrit ‡æÕË◊ ‡ªπì ·π«∑“ß„π°“√ª√∫— ª√¡‘ “≥ ultrafiltration °“√μ√«®‡æÕË◊ „À‰â ¥§â «“¡·¡πà ¬”ÕπË◊ Ê ®”‡ªπì μâÕßÕ“»—¬‡§√◊ËÕß¡◊Õ摇»… ‡™àπ °“√μ√«® bioelectrical impedance analysis °“√μ√«®«—¥ à«πª√–°Õ∫¢Õß √à“ß°“¬‚¥¬„™â dual energy x-ray absorptiometry °“√„™â‡§√◊ËÕß ultrasound μ√«®«—¥‡ âπºà“π»Ÿπ¬å°≈“ß ¢Õß inferior vena cava (IVCD) ‡ªìπμâπ 4. Hemodialysis adequacy ºŸâªÉ«¬‡¥Á°‰μ«“¬‡√◊ÈÕ√—ß„π™à«ß·√°°àÕπ‰¥â√—∫°“√∑”°“√øÕ°‡≈◊Õ¥ ¡—°ª√– ∫ªí≠À“¿“«– ∑ÿæ‚¿™π“°“√  “√πÈ”„π√à“ß°“¬‡°‘π ·≈–¡’¿“«–§«“¡¥—π‚≈À‘μ Ÿß ¥—ßπ—Èπ„π™à«ß‡¥◊Õπ·√°®÷ߧ«√ ∑”°“√øÕ°‡≈◊Õ¥‡æ◊ËÕÀ«—ߺ≈„À⺟âªÉ«¬ª≈Õ¥¿—¬®“°¿“«–¥—ß°≈à“«°àÕπ ‚¥¬„À⧫“¡ ”§—≠°—∫ target dry weight °“√§«∫§ÿ¡§«“¡¥—π‚≈À‘μ ·≈–°“√¢®—¥ urea Õ¬à“߇À¡“– ¡ ·≈â«®÷ß„Àâ chronic hemodialysis prescription ·≈–ª√–‡¡π‘ §«“¡‡æ¬’ ßæÕ„π°“√øÕ°‡≈Õ◊ ¥ (hemodialysis adequacy) °“√ª√–‡¡π‘ §«“¡‡æ¬’ ß æÕ¢Õß°“√øÕ°‡≈◊Õ¥„π‡¥Á° ¡—°ª√–‡¡‘π∑—Èߥâ“π urea clearance ‚¥¬Õ“»—¬ formal urea kinetic modeling À√◊Õ natural logarithm formula of Daugirdas 6,7,8 ·≈–°“√ª√–‡¡‘π¿“«–‚¿™π“°“√ ‚¥¬°“√§”π«≥ normalized protein catabolic rate (nPCR) §«∫§àŸ°—π‰ª‡ ¡Õ Daugirdas natural logarithm formula (Daugirdas II) sp Kt/V = -ln (C1/C0 - 0.008t) + (4 - 3.5C1/C0) × UF/W 215

Practical Dialysis in the Year 2009 C0 = pre-dialysis blood urea nitrogen (BUN; mg/dL) C1 = post-dialysis blood urea nitrogen (BUN; mg/dL) t = session duration (hours) UF = ultrafiltration volume (kg) W = post-dialysis weight (kg) °“√§”π«≥ equilibrated double-pool Kt/V ®”‡ªìπμâÕß„™â§à“ equilibrated BUN (eqBUN) ‚¥¬  “¡“√∂§”π«≥ estimated eqBUN ‚¥¬Õ“»—¬¢âÕ¡≈Ÿ «à“ ª°μ‘ urea rebound ®–‡°‘¥¢÷Èπª√–¡“≥√âÕ¬≈– 69 ∑’ˇ«≈“ 15 π“∑’ ¿“¬À≈—ß dialysis treatment ¥—ßπ—Èπ “¡“√∂§”π«≥ estimated eqBUN ·≈â«π”¡“„™â ·∑π§à“ C1 „π Ÿμ√ Daugirdas II spKt/V approximation formula ‡æ◊ËÕÀ“§à“ equilibrated double-pool Kt/V ‰¥â ‚¥¬§”π«≥§à“ estimated eqBUN ¥—ßπ’È est eqBUN = [(BUN15min - BUN30s) / 0.69] + BUN30S À√◊ÕÕ“®§”π«≥§à“ estimated equilibrate Kt/V ®“°„™â§à“ cofactor μàÕ spKt/V ¥—ßπ’È estimated eqKt/V = spKt/V × (1 - 0.6/t) + 0.03 Normalized protein catabolic rate (nPCR) est G (Urea generation rate, mg/min) = [C2V2 - C1V1] / t C1 = post-dialysis BUN (mg/dL) C2 = pre-dialysis BUN (mg/dL) V1 = post-dialysis total body water (dL) V2 = pre-dialysis total body water (dL) t = time (min) from the end of the dialysis treatment to the beginning of the following treatment est nPCR (g/kg/day) = 5.43 × est G/V1 + 0.17 V1 = post-dialysis total body water (L) ¬—߉¡à¡’°“√»÷°…“¢π“¥„À≠àæÕ∑’Ë®–À“ optimal Kt/V ∑’ˇÀ¡“– ¡®√‘ßÊ  ”À√—∫ºŸâªÉ«¬‡¥Á° ·μà °Á‡ªìπ∑’ˬա√—∫μ“¡§”·π–π”¢Õß K/DOQI «à“‡¥Á°§«√‰¥â√—∫ dialysis dose Õ¬à“ßπâÕ¬‡∑à“°—∫ºŸâ„À≠à ‚¥¬ §«√¡’§à“ sp Kt/V Õ¬à“ßπâÕ¬‡∑à“°—∫ 1.2 9 „πºâŸªÉ«¬∑’Ë∑”°“√øÕ°‡≈◊Õ¥ 3 §√—Èß °“√‡æ‘Ë¡¢÷Èπ¢Õß dialysis dose √«à ¡°∫— °“√„À‚â ¿™π“°“√∑‡Ë’ 欒 ßæÕ π“à ®–∑”„Àºâ ªâŸ «É ¬‡¥°Á ¡Õ’ “°“√¥’ ¡°’ “√‡®√≠‘ ‡μ∫‘ ‚μ∑¥Ë’ ¢’ πÈ÷ 10,11,12 ·≈– ¡’ cardiac function ∑’Ë¥’¢÷Èπ‰¥â13 216

Pediatric Care in Adult Hemodialysis Units: Pediatric Maintenance Hemodialysis ªí®®ÿ∫—π¡’°“√„™â√ªŸ ·∫∫¢Õß intensified dialysis ‡™àπ intermittent long nocturnal hemodialysis (3-6 §√ß—È μÕà  ª— ¥“À)å À√Õ◊ short daily hemodialysis ´ß÷Ë ¡À’ ≈°— ∞“π«“à ∑”„À¡â °’ “√‡æ¡‘Ë ¢π÷È ¢Õßmiddle molecular clearance ¡’º≈≈—æ∏å∑“ߧ≈‘π‘°∑“ß√–∫∫ CVS ¥’¢÷Èπ ≈¥Õ“°“√∑“ß dialysis-related syndrome ·≈–™à«¬ ‡æ‘Ë¡§ÿ≥¿“æ™’«‘μ„Àâ·°àºâŸªÉ«¬14,15 ·≈–‡√‘Ë¡¡’°“√„™â«‘∏’¥—ß°≈à“«„πºâŸªÉ«¬‡¥Á° ´÷Ë߉¥âº≈≈—æ∏å∑’Ë¥1’ 6 5. Nutrition §«√§”πß÷ ∂ß÷ ∏√√¡™“μ¢‘ Õ߇¥°Á «“à ¡§’ «“¡μÕâ ß°“√æ≈ß— ß“π·≈– “√Õ“À“√‡æÕ◊Ë °“√‡®√≠‘ ‡μ∫‘ ‚μ ¢Õß√“à ß°“¬·≈– ¡Õß ‚¥¬‡©æ“–«¬— ‡¥°Á ‡≈°Á ·≈–«¬— √πàÿ ·≈–‡¥°Á ¬ß— ¡’ nutritional store πÕâ ¬°«“à º„Ÿâ À≠¥à «â ¬ ºŸâªÉ«¬‡¥Á°‰μ«“¬‡√◊ÈÕ√—ß∑’ˉ¥â√—∫°“√øÕ°‡≈◊Õ¥¡—°ª√– ∫ªí≠À“¿“«–∑ÿæ‚¿™π“°“√ ´÷Ëß¡—°‡°‘¥ ®“°°“√√—∫ª√–∑“πÕ“À“√‰¥âπâÕ¬ ‡∫◊ËÕÕ“À“√ ¡’Õ“°“√§≈◊Ëπ‰ âÕ“‡®’¬π ∫“ß√“¬∂Ÿ°®”°—¥Õ“À“√¡“°àÕπ À√◊ÕÕ“®¡’°“√ Ÿ≠‡ ’¬ “√Õ“À“√®“°¿“«– proteinuria ·≈–°“√‡ª≈’ˬπ·ª≈ß∑“߇¡μ“∫Õ≈‘°μà“ßÊ ¿“«– ∑æÿ ‚¿™π“°“√ ßà º≈μÕà °“√‡®√≠‘ ‡μ∫‘ ‚μ·≈–æ≤— π“°“√∑“ß√–∫∫ª√– “∑‡¥°Á ∑¡’Ë ¿’ “«–∑æÿ ‚¿™π“°“√‡√Õ◊È √ß— Õ“®· ¥ßÕ“°“√æƒμ‘°√√¡∑’ˇª≈’ˬπ·ª≈߉ª ‡™àπ irritability, apathy, decreased social responsiveness ·≈– attention deficits ‡¥Á°∑’Ë¡’ growth delay ·≈– BMI ∑’ËμË”¡“° ¡’§«“¡ —¡æ—π∏å°—∫°“√‡æ‘Ë¡¢÷Èπ¢ÕßÕ—μ√“ °“√æ°‘ “√·≈–°“√쓬„π‡¥°Á ∑‰Ë’ ¥√â ∫— maintenance dialysis ‰¥1â 7,18 ¥ß— ππÈ— °“√ª√–‡¡π‘ ¿“«–‚¿™π“°“√·≈– °“√„Àâ°“√√—°…“¥â«¬‚¿™π“°“√ ®÷ß¡’§«“¡ ”§—≠§«∫§àŸ‰ª°—∫°“√øÕ°‡≈◊Õ¥‡ ¡Õ 5.1 °“√ª√–‡¡π‘  ¿“«–‚¿™π“°“√„πºªŸâ «É ¬‡¥°Á °“√ª√–‡¡π‘  ¿“«–‚¿™π“°“√„π‡¥°Á §«√ª√–‡¡π‘ ‚¥¬„™¢â Õâ ¡≈Ÿ „πÀ≈“¬ «à πª√–°Õ∫°π— §«√ ´°— ª√–«μ— °‘ “√√∫— ª√–∑“πÕ“À“√ À√Õ◊ „À∫â π— ∑°÷ √“¬°“√·≈–ª√¡‘ “≥Õ“À“√∑√Ë’ ∫— ª√–∑“π (food record) ‡æÕË◊ ª√–‡¡π‘ æ≈ß— ß“π·≈–ª√¡‘ “≥‚ª√μπ’ ∑º’Ë ªâŸ «É ¬‰¥√â ∫— ®√ß‘ °“√ª√–‡¡π‘ °“√‡®√≠‘ ‡μ∫‘ ‚μ‚¥¬°“√™ß—Ë πÈ”Àπ°— (dry weight) §«“¡ Ÿß ·≈– plot ≈ß„π reference growth charts μ“¡‡æ» ·≈–Õ“¬ÿ ª√–‡¡‘π —¥ à«π∑“ßπÈ”Àπ—° μ“¡§«“¡ ßŸ ·≈–μ‘¥μ“¡§«“¡‡ª≈’ˬπ·ª≈ß∑“ß°“√‡®√‘≠‡μ‘∫‚μ∑ÿ° 3-4 ‡¥◊Õπ ª√–‡¡‘π muscle mass ·≈– subcutaneous fat store ‚¥¬°“√«—¥ mid-arm muscle circumference ·≈– triceps skin fold thickness μ“¡≈”¥∫— serum albumin ‡ªπì marker ∑ Ë’ ”§≠— ¢Õß ¿“«–‚¿™π“°“√ ·μÕà “®‡ª≈¬Ë’ π·ª≈߉¥μâ “¡ª®í ®¬— Õ◊ËπÊ ‡™àπ infection, inflammation, acidosis, nephrotic syndrome, hydration ·≈– liver disease ‰¥â §«√ μ√«®μ‘¥μ“¡ ¿“«–‚¿™π“°“√μ“¡μ“√“ß∑’Ë 1 5.2 °“√ª√–‡¡π‘ nPCR °“√ª√–‡¡‘π nPCR §«√°√–∑”‰ªæ√âÕ¡°—∫°“√ª√–‡¡‘π hemodialysis adequacy §à“ nPCR ∑’Ë ‡À¡“– ¡μ“¡ average recommended daily allowance „π‡¥Á°«—¬√ÿàπ§◊Õ 1 g/kg/day æ∫«à“„π‡¥Á°‡≈Á°®–¡’ §“à nPCR  ßŸ °«“à ‡¥°Á ‚μ Õ“®‡ªπì ‡æ√“–§«“¡·μ°μ“à ߢÕß protein catabolism ·≈–§«“¡·μ°μ“à ߢÕß growth rate „π‡¥Á°·μà≈–™à«ßÕ“¬ÿ 217

Practical Dialysis in the Year 2009 μ“√“ß∑’Ë 1 · ¥ß°“√μ√«®μ‘¥μ“¡ ¿“«–‚¿™π“°“√∑’Ë·π–π”„π‡¥Á°Õ“¬ÿ¡“°°«à“ 2 ªï 19 Parameter Minimum interval Dietary interview 3-4 months Standing height 3-4 months SDS length/height for chronological age 3-4 months Estimated dry weight 3-4 months Weight/height index 3-4 months Serum albumin monthly Serum bicarbonate monthly Skinfold thickness 3-4 months Mid-arm muscle circumference or area 3-4 months Urea kinetic modeling 3-4 months ‚¥¬∑—Ë«‰ªºâŸªÉ«¬‡¥Á°∑’Ë¡’ nPCR < 1 g/kg/day ®–¡’§«“¡‡ ’ˬߢÕß°“√¡’πÈ”Àπ—°≈¥≈ß æ∫«à“ nPCR ∑’ËμË”≈ß —¡æ—π∏å°—∫ weight loss ∑’Ë™—¥‡®π„π‡¥Á°«—¬√ÿàπ 20 5.3 °“√√—°…“¥â“π‚¿™π“°“√ ®ÿ¥¡ÿàßÀ¡“¬‡πâπ„À⇥Á°¡’°“√‡®√‘≠‡μ‘∫‚μ·≈–¿“«–‚¿™π“°“√∑’Ë¥’ ¥—ßπ—Èπ‡¥Á°®÷ߧ«√‰¥â√—∫ æ≈—ßß“π∑’ˇ撬ßæÕ ‚¥¬§«√‰¥â√—∫æ≈—ßß“πÕ¬à“ßπâÕ¬‡∑à“°—∫æ≈—ßß“π∑’ˇ¥Á°ª°μ‘„π·μà≈–«—¬ §«√‰¥â√—∫μàÕ «—π (recommended daily allowance; RDA) ·≈–§«√‰¥â√—∫‚ª√μ’π‡æ‘Ë¡‡μ‘¡®“°‡¥Á°∑—Ë«‰ªμ“¡Õ“¬ÿ «—π≈– ª√–¡“≥ 0.4 g/kg/day  “√Õ“À“√∑·’Ë π–π”„π·μ≈à –«π— ·°‡à ¥°Á ∑‰’Ë ¥√â ∫— °“√∑”≈“â ß‰μ§«√‰¥√â ∫— ¥ß— μ“√“ß∑’Ë 2 §”·π–π”πÕÈ’ “®ª√∫— „À‡â À¡“– ¡„πºªŸâ «É ¬∑¡Ë’ π’ ”È Àπ°— ¡“°‡°π‘ À√Õ◊ πÕâ ¬°«“à Ideal BW ‰¥â §«√ À≈’°‡≈’ˬ߰“√®”°—¥Õ“À“√ ‡æ◊ËÕ„ÀâºâŸªÉ«¬‰¥â√—∫æ≈—ßß“π‡æ’¬ßæÕ §«√„Àâ∫‘¥“¡“√¥“ À√◊ÕºŸâ¥Ÿ·≈ºâŸªÉ«¬¡’  à«π√à«¡„π°“√‡≈◊Õ°Õ“À“√∑’ˇÀ¡“– ¡ „À⧫“¡√⟷≈–μ‘¥μ“¡´—°∂“¡ªí≠À“‡ªìπ√–¬– ‡¥Á°∑’Ë¡’¿“«–∑ÿæ‚¿™π“°“√ ∑’ËÕ“¬ÿ¡“°°«à“ 4 ªï À“°√—∫ª√–∑“πÕ“À“√‰¥â Õ“®‡ √‘¡ commercial enteral supplements ∑‡’Ë ªπì ¢Õߺ„Ÿâ À≠‰à ¥â‚¥¬„À√â ∫— ª√–∑“π∑“ߪ“°À√Õ◊ feed ∑“ß nasogastric tube À√◊Õ∑” gastrostomy ‡æ◊ËÕ„À≥â√—∫Õ“À“√∑’ˇ撬ßæÕ „π√“¬∑’Ë¡’ severe protein energy malnutrition (BW < 90% of ideal body weight) §«√‰¥â√—∫ intradialytic pasenteral nutrition (IDPN) 6. Growth ºâŸªÉ«¬‰μ«“¬‡√◊ÈÕ√—ß¡—°‡º™‘≠ªí≠À“°“√‡®√‘≠‡μ‘∫‚μ≈à“™â“ §«“¡√ÿπ·√ߢÕß°“√‡®√‘≠‡μ‘∫‚μ ≈à“™â“ ¢÷ÈπÕ¬Ÿà°—∫ªí®®—¬∑“ߥâ“π‚¿™π“°“√ Õ“¬ÿ∑’ˇ¢â“ Ÿà¿“«–‰μ«“¬  “‡Àμÿ¢Õß‚√§‰μ«“¬‡√◊ÈÕ√—ß ¿“«–¥ÿ≈ 218

Pediatric Care in Adult Hemodialysis Units: Pediatric Maintenance Hemodialysis μ“√“ß∑’Ë 2 Daily nutrient recommendations for children on dialysis 19 Nutrient Toddler Child Adolescent (1-3 yr) (4-10 yr) (11-14 yr) (15-18 yr) Energy (kcal/kg/d) 102 4-6 yr: 90 Girls: 47 Girls: 40 1.6 7-10 yrs: 70 Boys: 55 Boys: 45 Protein (g/kg/d): 1-3 mmol/kg/d 4-6 yr: 1.6 Girls: 1.4 Girls: 1.7-1.8 7-10 yrs: 1.4 Boys: 1.4 Boys: 1.7-1.8 Potassium 1-3 mmol/kg/d 1-3 mmol/kg/d 1-3 mmol/kg/d -If hyperkalemic, restrict to: 500 4-8 yrs: 800 1300 1300 Calcium (mg/d) 8-10 yrs: 1300 Phosphorus (mg/d) -If hyperphosphatemic, ≤ 460 4-8 yrs: ≤ 500 ≤ 1250 ≤ 1250 restrict to: Vitamins 8-10 yrs: ≤ 1250 Trace Minerals 100% of the DRI for copper, thiamin, riboflavin, pyridoxine, folic acid and vitamin B12 and 100% of the RDA for vitamin A, C, E, K Fluids 100% of the RDA for copper and zinc; iron supplementation is usually needed with rHuEPO Total fluid intake (TFI) = insensibles + urine output + ultrafiltration capacity + other losses - amount to deficit  “√πÈ” ·√à∏“μÿ·≈–¥ÿ≈°√¥¥à“ß ¿“«– renal osteodystrophy ¿“«–´’¥ √«¡∑—Èß¿“«–§«“¡º‘¥ª°μ‘¢ÕßμàÕ¡ ‰√â∑àÕ·≈–ŒÕ√å‚¡π ¥—ßμ“√“ß∑’Ë 3 ºŸâªÉ«¬‡¥Á°∑’ˇ¢â“ àŸ√–¬–‰μ«“¬‡√◊ÈÕ√—ßμ—Èß·μà√–¬–∑“√° À“°‰¡à‰¥â√—∫°“√¥Ÿ·≈∑’ˇÀ¡“– ¡ ®–¡’ Õμ— √“°“√‡®√≠‘ ‡μ∫‘ ‚μ≈“à ™“â ¡“° „π‡¥°Á «¬— √πÿà ¡°— æ∫ª≠í À“°“√‡¢“â  «àŸ ¬— ‡®√≠‘ æπ— ∏‰ÿå ¥™â “â °«“à ‡¥°Á ∑«—Ë ‰ª (delay puberty) ·≈–¡’ªí≠À“μ—«‡μ’Ȭ (short statue) ´÷Ë߇ªìπ®“°ªí®®—¬¢Õß gonadotropic hormone „π à«π¢Õß growth hormone æ∫«à“ºŸâªÉ«¬‰μ«“¬‡√◊ÈÕ√—ß®–¡’√–¥—∫¢Õß growth hormone ∑’Ë Ÿß ·μà¡’°“√ √â“ß IGF-I ≈¥≈ß ·≈–¡’ªí≠À“ growth hormone insensitivity §◊Õ¡’ IGFBPs ∑’ˠߟ ∑”„Àâ¡’°“√≈¥ ≈ߢÕß IGF bioactivity ∑”„À⬗∫¬—Èß°“√∑”ß“π¢Õß IGF °“√„Àâ GH therapy Õ“®™à«¬°√–μÿâπ hepatic IGF synthesis ‡ªìπº≈„ÀâÕ—μ√“ à«π¢Õß growth-stimulatory IGFs μàÕ Inhibitory IGFBPs ‡æ‘Ë¡¢÷Èπ ∑”„Àâ GH (IGF) ÕÕ°ƒ∑∏‘ω¥â¥’¢÷Èπ °“√√—°…“∑’Ë ”§—≠§◊Õ °“√„Àâ‚¿™π“°“√∑’ˇ撬ßæÕ √à«¡°—∫°“√·°â‰¢¿“«– metabolic acidosis ·≈–¥ÿ≈ “√πÈ” °“√„Àâ Vitamin D supplement ‡æ◊ËÕªÑÕß°—π¿“«– renal osteodystrophy  à«π°“√„Àâ growth hormone æ∫«à“ “¡“√∂‡æ‘Ë¡§«“¡ Ÿß‰¥â¥’ „πºâŸªÉ«¬‰μ«“¬‡√◊ÈÕ√—ß°àÕπ‡¢â“ Ÿà√–¬– end stage renal disease 219

Practical Dialysis in the Year 2009 μ“√“ß∑Ë’ 3 Etiology of growth impairment in chronic renal failure Genetic factors - parent height - gender - syndromal disorder (with kidney disorder as a part) Age at start of CRF Duration of CRF Residual renal function Treatment modalities for CRF Energy malnutrition Water and electrolyte disturbances Metabolic acidosis Hormonal disorders - disturbance of PTH and vitamin D (renal osteodystrophy) - disturbance of the somatotropic hormone axis - disturbance of the gonadotropic hormonal axis - disturbance of insulin/glucose metabolism - disturbance of other hormones (ESRD) §«√æ‘®“√≥“„Àâ growth hormone À≈—ß®“° à߇ √‘¡„ÀâºâŸªÉ«¬‰¥â√—∫Õ“À“√∑’ˇ撬ßæÕ·≈â« ·≈–°“√ „Àâ∑’ˉ¥âº≈¥’ §◊Õ§«√„Àâ„π™à«ß°àÕπ‡¢â“«—¬‡®√‘≠æ—π∏ÿå (prepubertal stage) °“√„Àâ growth hormone „π√–¬– ESRD ∑’ˉ¥â°“√≈â“߉μ·≈â« ¡—°¡’°“√μÕ∫ πÕ߉¥â‰¡à¥’π—° æ∫«à“Õ—μ√“°“√‡æ‘Ë¡§«“¡ ßŸ ®“°°“√„™â growth hormone ¡§’ “à √Õâ ¬≈– 27, 11 ·≈– 25 „π°≈¡àÿ ºªŸâ «É ¬ chronic renal insufficiency, dialysis ·≈– transplantation μ“¡≈”¥∫— 21 ¡°’ “√√“¬ß“π«“à °“√„Àâ Intensified and daily hemodialysis ∑”„Àºâ ªâŸ «É ¬¡Õ’ μ— √“°“√‡®√≠‘ ‡μ∫‘ ‚μ ∑’Ë¥’¢÷Èπ22 7. Anemia ºªâŸ «É ¬‰μ«“¬‡√Õ◊È √ß— √–¬– ¥ÿ ∑“â ¬ ESRD ¡¿’ “«–´¥’ ®“°°“√ √“â ß erythropoietin (EPO) ∑‰’Ë ¡‡à 欒 ß æÕ ®”‡ªìπμâÕ߉¥â√—∫ recombinant human erythropoietin (rHuEPO) πÕ°®“°π—Èπ¡—°¡’ªí≠À“ nutritional deficiency anemia ‚¥¬‡©æ“–°“√¢“¥∏“μÿ‡À≈Á° ®”‡ªìπμâÕ߉¥â√—∫°“√∑¥·∑π„Àâ‡æ’¬ßæÕ ‡¥Á°∑’Ë¡’¿“«–´’¥ ®–¡’°“√‡ª≈’ˬπ·ª≈ß §◊Õ ™’æ®√·≈–À“¬„®‡√Á«, ¡’§«“¡®”‰¡à¥’, ÕàÕπ‡æ≈’¬, ‡∫◊ËÕÕ“À“√ ·≈–¡’ left ventricular hypertrophy ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫‡¥Á°∑’ˉ¡à¡’¿“«–´’¥ ¿“«–´’¥‡ªìπªí®®—¬ 220

Pediatric Care in Adult Hemodialysis Units: Pediatric Maintenance Hemodialysis ‡ ¬’Ë ß∑ ’Ë ”§≠— μÕà Õμ— √“°“√쓬∑ ’Ë ßŸ ¢π÷È ¢ÕߺªŸâ «É ¬‡¥°Á 23 ‡™πà ‡¥¬’ «ºªâŸ «É ¬º„⟠À≠à ·≈–¬ß—  ¡— æπ— ∏°å ∫— √–¬–‡«≈“ °“√πÕπ‚√ß欓∫“≈∑’Ë¡“°¢÷Èπ¥â«¬ À≈ß— ®“°„À°â “√«π‘ ®‘ ©¬— anemia §«√«π‘ ®‘ ©¬— ·¬°‚√§‡æÕË◊ À“ “‡ÀμÕÿ πË◊ Ê ¢Õß¿“«–´¥’ ¥«â ¬ §«√ μ√«® CBC, MCH, MCV, MCHC, absolute reticulocyte count, red blood cell distribution width (RDW) §«√ μ√«®«—¥ serum ferritin ·≈– serum TSAT ‡æ◊ËÕª√–‡¡‘𧫓¡‡æ’¬ßæÕ¢Õß∏“μÿ‡À≈Á° ‡æ◊ËÕ𔉪„™â„π°“√  √â“߇¡Á¥‡≈◊Õ¥·¥ß ¢π“¥¬“‡√‘Ë¡μâπ∑’Ë·π–π”„πºâŸªÉ«¬ hemodialysis §◊Õ ‡¥Á°Õ“¬ÿ < 5 ªï rHuEPO ¢π“¥ 250-300 u/kg/week ‡¥Á°Õ“¬ÿ > 5 ªï rHuEPO ¢π“¥ 150-200 u/kg/week §«√√—°…“√–¥—∫ Hemoglobin (Hb) „ÀâÕ¬àŸ√–À«à“ß 11-12 g/dL ·≈–‰¡à§«√ ßŸ °«à“ 13 g/dL24 μ“¡°“√·π–π”·∫∫ºŸâ„À≠à „π 2-6  —ª¥“Àå·√° §«√μ√«® Hb Õ¬à“ßπâÕ¬ —ª¥“Àå≈–§√—Èß À≈’°‡≈’ˬ߰“√ À¬ÿ¥¬“°√≥’ Hb  Ÿß ·μ৫√≈¥¢π“¥≈ߧ√—Èß≈–ª√–¡“≥√âÕ¬≈– 25 °√≥’ Hb ‡æ‘Ë¡πâÕ¬°«à“ 1.6-2 g/dL „π 8  —ª¥“Àå „Àâª√—∫¬“§√—Èß≈–√âÕ¬≈– 10-25 √—°…“√–¥—∫ serum ferritin ¡“°°«à“ 100 ng/mL ·≈– TSAT ¡“°°«à“√âÕ¬≈– 20 ‚¥¬ª√–‡¡‘π∑ÿ°‡¥◊Õπ‡¡◊ËÕ‡√‘Ë¡„À⬓ rHuEPO ·≈–∑ÿ° 3 ‡¥◊Õπ ‡¡◊ËÕÕ“°“√ºŸâªÉ«¬§ß∑’Ë ºªâŸ «É ¬∑‰Ë’ ¥√â ∫— °“√ª√∫— ‡æ¡Ë‘ ¬“„π¢π“¥ ßŸ (>500 u/kg/week) ·≈«â ¬“‰¡ à “¡“√∂√°— …“√–¥∫— Hb „π‡≈◊Õ¥ Õ“®¡’ “‡Àμÿ®“°°“√¡’ iron depletion, immunologic activation, secondary hyperparathyroidism, chronic blood loss, vitamin depletion, medications, inadequate dialysis, ·≈– malnutrition ®÷ߧ«√À“  “‡Àμÿ‡æ‘Ë¡‡μ‘¡‡æ◊ËÕ·°â‰¢μàÕ‰ª ¡’°“√»÷°…“°“√√—°…“√–¥—∫ Hb „π‡¥Á°μ“¡ adult target hemoglobin value æ∫«à“Õ—μ√“°“√ 쓬≈¥≈ß ·μà‰¡à≈¥√–¬–‡«≈“°“√πÕπ„π‚√ß欓∫“≈25 °“√„™â Darbepoetin alfa ´÷Ë߇ªìπ novel erythropoiesis stimulating protein (NESP) ∑’ËÕÕ°ƒ∑∏‘Ï ‰¥âπ“π æ∫«à“¬—ß¡’°“√„™â„π‡¥Á°‰¡à¡“°π—° ªí≠À“∑’Ëæ∫§◊Õ °“√ª√—∫¢π“¥¬“®“° rHuEPO ‡ªìπ¢π“¥¬“ NESP (conversion index) ∑’ˇÀ¡“– ¡ ·≈–æ∫«à“ºâŸªÉ«¬∑’Ë¡’ Hb ‡æ‘Ë¡¢÷Èπ¡“°®–¡’§«“¡¥—π‚≈À‘μ Ÿß26 8. Renal bone disease Renal osteodystrophy ‡ªì𧫓¡º‘¥ª°μ‘¢Õß°√–¥Ÿ°·≈–‡¡μ“∫Õ≈‘´÷¡¢Õß·§≈‡´’¬¡·≈– øÕ øÕ√—  ‚¥¬‡ªìπº≈®“°°“√∫°æ√àÕß„π°“√∑”ß“π¢Õ߉μ ≈¥°“√ √â“ß 1, 25-dihydroxy vitamin D3 ¡’ °“√‡æ‘Ë¡¢÷Èπ¢Õß parathyroid hormone (PTH) ‡°‘¥§«“¡º‘¥ª°μ‘¢Õß°√–¥Ÿ°·∫∫ high-turnover disorders (osteitis fibrosa and mild lesions of secondary hyperparathyroidism) À√◊Õ low-turnover bone diseases (osteomalacia and adynamic lesion) °“√¥·Ÿ ≈ºªŸâ «É ¬‡¥°Á ‰μ«“¬‡√ÕÈ◊ √ß— ®ß÷ ®”‡ªπì μÕâ ߧ«∫§¡ÿ ¿“«– secondary hyperparathyroidism ·≈–°“√ªÑÕß°—π¿“«–¢Õß low bone turnover ∑’Ë ”§—≠ ‡æ◊ËÕªÑÕß°—πªí≠À“ bone deformity ·≈– growth retardation Õ’°∑—Èߪí≠À“¢Õß vascular calcification §«√§«∫§ÿ¡¥ÿ≈¢Õß·§≈‡´’¬¡·≈–øÕ øÕ√—  ‚¥¬º≈§Ÿ≥‰¡à‡°‘π 65 mg2/dL2 „π‡¥Á°Õ“¬ÿ 1-12 ªï ·≈– ‰¡à‡°‘π 55 mg2/dL2 „π‡¥Á°Õ“¬ÿ >12 ªï, √—°…“√–¥—∫øÕ øÕ√— √–À«à“ß 4-6 mg2/dL2 „π‡¥Á°Õ“¬ÿ 221

Practical Dialysis in the Year 2009 1-12 ªï ·≈– √–À«à“ß 3.5-5.5 mg2/dL2 „π‡¥Á°Õ“¬ÿ >12 ªï (μ“√“ß∑’Ë 4) ‰¡à§«√‡ª≈’ˬπ„À⇥Á°¡’√–¥—∫ øÕ øÕ√ — μË”°«“à §“à ∑°’Ë ”Àπ¥ ‡πÕ◊Ë ß®“°øÕ øÕ√ — ¡ ’ «à π„π°“√‡®√≠‘ ‡μ∫‘ ‚μ¢Õ߇¥°Á ·≈–√°— …“√–¥∫— PTH √–À«à“ß 200-300 pg/mL °“√√°— …“¿“«–øÕ øÕ√ — „π‡≈Õ◊ ¥ ßŸ §«√∑”‚¥¬°“√§«∫§¡ÿ Õ“À“√∑¡Ë’ ø’ Õ øÕ√ —  ßŸ ·≈–„Àâ phosphate binder ‚¥¬§«√‡≈◊Õ°„™â calcium-based phosphate binder „π‡¥Á°‡≈Á° „π‡¥Á°‚μ·≈–«—¬√ÿàπÕ“® ‡≈◊Õ°„™â‰¥â∑—Èß calcium based ·≈– non-calcium, non metal-containing phosphate binder ‡™àπ Sevelamer calcium ∑’˺ŸâªÉ«¬‰¥â√—∫ (√«¡ calcium ®“°Õ“À“√·≈–¬“) §«√¡’ elemental calcium ‰¡à‡°‘π«—π≈– 2,500 mg °“√„™â aluminum based phosphate binder „À„â ™‰â ¥„â π‡©æ“–°√≥º’ ªâŸ «É ¬«¬— √πÿà ∑¡’Ë ª’ ≠í À“hyperphosphatemia (serum P > 7 mg/dL) ‚¥¬„Àâ„π™à«ß‡«≈“‰¡à‡°‘π 4-6  —ª¥“Àå ·≈⫇ª≈’Ë¬π‰ª„™â¬“°≈ÿà¡Õ◊Ëπ °“√„À«â μ‘ “¡π‘ ¥’ calcitriol §«√„À‡â ¡Õ◊Ë √–¥∫— PTH ¡“°°«“à 300 pg/mL ·π–π”„À·â ∫∫ intermittent administration ¡“°°«à“„Àâ·∫∫√—∫ª√–∑“π∑ÿ°«—π „À⬓¢π“¥ 0.25-1 mg  —ª¥“Àå≈– 3 §√—Èß (0.0075-0.25 mg/kg/dose) À≈—߇√‘Ë¡¬“À√◊Õ¡’°“√ª√—∫‡æ‘Ë¡¢π“¥¬“ §«√μ‘¥μ“¡√–¥—∫·§≈‡´’¬¡·≈–øÕ øÕ√— „π‡≈◊Õ¥ ∑ÿ° 2  —ª¥“Àå π“π 1 ‡¥◊Õπ ®“°π—Èπμ‘¥μ“¡∑ÿ°‡¥◊Õπ ·≈–μ√«®√–¥—∫ PTH ∑ÿ°‡¥◊Õπ π“π 3 ‡¥◊Õπ ®“°π—Èπ μ√«®∑ÿ° 3 ‡¥◊Õπ 9. Hypertension §”®”°—¥§«“¡¢Õß §«“¡¥—π‚≈À‘μ Ÿß„π‡¥Á° §◊Õ §«“¡¥—π‚≈À‘μ∑’Ë¡’§à“¡“°°«à“À√◊Õ‡∑à“°—∫ percentile ∑’Ë 95 (P95) μ“¡‡æ» Õ“¬ÿ ·≈–§«“¡ Ÿß27 Chronic hypertension ‡ªìπªí≠À“∑’Ëæ∫‰¥â∫àÕ¬„πºâŸªÉ«¬‡¥Á°‰μ«“¬‡√◊ÈÕ√—ß∑’ˉ¥â√—∫°“√øÕ°‡≈◊Õ¥ ¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡ ·μàÕ—μ√“§«“¡™ÿ°¬—߉¡à∑√“∫·πàπÕπ ºâŸªÉ«¬∫“ß√“¬¬—ߧߡ’ªí≠À“·¡â‰¥â√—∫¬“≈¥ §«“¡¥—π‚≈À‘μ chronic hypertension ‡ªìπªí®®—¬∑’Ë∑”„À⇰‘¥ cardiovascular disease ´÷Ë߇ªì𠓇Àμÿ°“√쓬 ∑ ’Ë ”§≠— ¢ÕߺªŸâ «É ¬‡¥°Á ESRD ‡™πà left ventricular hypertrophy (LVH), left ventricular conduction abnormalities ·≈– coronary artery disease  “‡Àμ¢ÿ Õߧ«“¡¥π— ‚≈Àμ‘  ßŸ „πºªâŸ «É ¬‡¥°Á ¡°— ‡°¥‘ ®“°¡’ chronic fluid overload μ“√“ß∑Ë’ 4 Representative normal values for serum phosphorus, total calcium, blood ionized calcium and alkaline phosphatase concentrations (¥—¥·ª≈ß®“° K/DOQI Clinical Practice Guidelines for bone metabolism and disease in children with CKD, 2005) Age (years) Serum P (mg/dL) Serum Total Ca Blood Ionized ALP (IU) (mg/dL) Calcium (mM) 1-5 4.5-6.5 9.4-10.8 1.22-1.32 100-350 6-12 3.6-5.8 9.4-10.3 1.15-1.32 60-450 13-20 2.3-4.5 8.8-10.2 1.12-1.30 40-180 222

Pediatric Care in Adult Hemodialysis Units: Pediatric Maintenance Hemodialysis °“√∑”ß“π¢Õß√–∫∫ renin-angiotensin-aldosterone system °“√°√–μÿâπ√–∫∫ sympathetic ·≈–°“√‰¥â √—∫¬“ erythropoietin À≈—°°“√¥Ÿ·≈∑—Ë«‰ª‡™àπ‡¥’¬«°—∫ºâŸ„À≠à §◊Õ °“√°”Àπ¥ dry weight ∑’ˇÀ¡“– ¡„π°“√øÕ° ‡≈◊Õ¥∑’ˇ撬ßæÕ ·≈–°“√„À⬓≈¥§«“¡¥—π‚≈À‘μ ‚¥¬‡≈◊Õ°¬“∑’ËÕÕ°ƒ∑∏‘Ï vasodilation ¬“ amlodipine ‡ªì𠬓∑’Ë¡’°“√»÷°…“·∫∫ clinical trial ‡ªìπ∑’ˬա√—∫„π°“√≈¥§«“¡¥—π‚≈À‘μ„πºŸâªÉ«¬‡¥Á°  à«π¢âÕ¡Ÿ≈º≈°“√ „™â¬“ ACEIs „π‡¥Á°∑’ˉ¥â√—∫°“√√—°…“∑¥·∑π‰μ¬—ß¡’®”°—¥ 10. Cardiovascular disease Cardiovascular disease ‡ªì𠓇Àμÿ°“√쓬∑’Ë ”§—≠¢Õߺ⟪ɫ¬ ESRD ·≈–‡ªìπªí≠À“ ”§—≠ ∑’Ëæ∫‰¥â∫àÕ¬„πºâŸªÉ«¬‡¥Á° ¡’°“√»÷°…“æ∫«à“ª√–¡“≥√âÕ¬≈– 82 ¢ÕߺŸâªÉ«¬‡¥Á°‰μ«“¬‡√◊ÈÕ√—ß¡’ LVH μ—Èß·μà ‡¡ÕË◊ ‡√¡Ë‘ ∑”°“√√°— …“¥«â ¬ dialysis ·≈–§«“¡™°ÿ ¢Õß‚√§‰¡‡à ª≈¬Ë’ π·ª≈ß·¡‰â ¥√â ∫— °“√√°— …“¥«â ¬ dialysis ·≈«â π“πª√–¡“≥ 2 ªï28 ºâŸªÉ«¬‡¥Á°∑’ˉ¥â√—∫°“√√—°…“‚¥¬ dialysis ¡“‡ªìπ√–¬–‡«≈“π“π æ∫«à“¡’ coronary artery calcifications ‰¥2â 9 πÕ°®“°ππ—È ºªŸâ «É ¬º„Ÿâ À≠∑à ‡’Ë ªπì ESRD μß—È ·μ„à 𫬗 ‡¥°Á ®–¡°’ “√≈¥≈ߢÕß arterial elasticity ·≈– ¡’Õÿ∫—μ‘°“√≥å¢Õß coronary artery calcifications ‰¥â 30 11.  √ªÿ ºªâŸ «É ¬‡¥°Á ‰∑¬∑¡’Ë ¿’ “«–‰μ«“¬‡√Õ◊È √ß— ·≈–μÕâ ߉¥√â ∫— °“√øÕ°‡≈Õ◊ ¥¥«â ¬‡§√Õ◊Ë ß‰μ‡∑¬’ ¡Õ“®®”‡ªπì μâÕ߉¥â√—∫°“√√—°…“„π adult hemodialysis unit À≈—°°“√∑” hemodialysis „πºâŸªÉ«¬‡¥Á°‚¥¬∑—Ë«‰ª‰¡à·μ° μ“à ß®“°º„Ÿâ À≠πà °— ¡¢’ Õâ §«√§”πß÷ ∂ß÷ §Õ◊ °“√‡≈Õ◊ °Õªÿ °√≥∑å ¡Ë’ ¢’ 𓥇À¡“– ¡°∫— ºªâŸ «É ¬ „À§â «“¡ ”§≠— °∫— hemodialysis adequacy ·≈– nutritional status ª√–‡¡‘π¥â“π°“√‡®√‘≠‡μ‘∫‚μ·≈–æ—≤π“°“√μ“¡«—¬‡ªìπ √–¬– ‡ΩÑ“√–«—ß¿“«–·∑√°´âÕπ∑—Èß¿“«–´’¥ §«“¡º‘¥ª°μ‘¢Õß·§≈‡´’¬¡ øÕ øÕ√—  ·≈–°√–¥Ÿ° §«“¡ ¥—π‚≈À‘μ Ÿß ·≈–ªí≠À“∑“ß√–∫∫À—«„®·≈–À≈Õ¥‡≈◊Õ¥ ¡’°“√»÷°…“º≈≈—æ∑å¢Õß°“√√—°…“¢ÕߺŸâªÉ«¬ ‡¥Á°∑’ˉ¥â√—∫°“√¥Ÿ·≈®“° pediatric nephrologists ‡ª√’¬∫‡∑’¬∫°—∫ internal medicine nephrologists æ∫«à“ ‰¥ºâ ≈°“√√°— …“μ“¡‡ª“Ñ À¡“¬∑·’Ë π–π”Õ“â ßÕß‘ μ“¡§“à „πºªŸâ «É ¬º„Ÿâ À≠‰à ¡·à μ°μ“à ß°π— ‚¥¬‡©æ“–„π «à π¢Õß hemodialysis adequacy ·≈–√–¥—∫¢Õß hemoglobin31  à«π parameter Õ◊Ë𮔇ªìπμâÕß»÷°…“μàÕ‰ªπÕ°®“° „Àâ°“√¥Ÿ·≈ºŸâªÉ«¬‡¥Á°∑’ˉ¥â√—∫°“√øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕ߉μ‡∑’¬¡¢â“ßμâπ·≈â« §«√„Àâ°“√¥Ÿ·≈ºŸâªÉ«¬·∫∫ Õߧå√«¡ „ÀâºâŸª°§√Õß·≈–§√Õ∫§√—«¡’ à«π√à«¡„π°“√¥Ÿ·≈ºŸâªÉ«¬ Õ’°∑—È߇μ√’¬¡§«“¡æ√âÕ¡ºŸâªÉ«¬‡æ◊ËÕ√—∫ °“√ª≈°Ÿ ∂à“¬‰μ„πÕπ“§μ 223

Practical Dialysis in the Year 2009 ‡Õ° “√Õ“â ßÕß‘ 1. United States Renal Data Systems (USRDS). Treatment modalities. 2008 USRDS annual data report III.www.usrds.org/ 2008. 2. Clinical Practice Recommendation 8: vascular access in pediatric patients. Am J Kidney Dis. 2006; 48 Suppl 1:S274- 6. 3. Fadrowski JJ, Hwang W, Neu AM, Fivush BA, Furth SL. Patterns of use of vascular catheters for hemodialysis in children in the United States. Am J Kidney Dis. 2008 Oct 23. (Epub ahead of print) 4. Daschner M, Schaefer FS. Technical aspects of the hemodialysis procedure. In: Warady BA, Schaefer FS, Fine RN, Alexander SR, eds. Pediatric Dialysis. Dordrecht: Kluwer Academic Publishers, 2004;91-111. 5. Fischbach M, Edefonti A, Schröder C, Watson A. The European Pediatric Dialysis Working Group. Hemodialysis in children: general practical guidelines. Pediatr Nephrol 2005;20:1054-66. 6. Daugirdas JT. Second generation logarithmic estimates of single-pool variable volume Kt/V: an analysis of error. J Am Soc Nephrol. 1993;4:1205-13. 7. Goldstein SL, Sorof JM, Brewer ED. Natural logarithmic estimates of Kt/V in the pediatric hemodialysis population. Am J Kidney Dis. 1999;33:518-22. 8. Daugirdas JT, Schneditz D. Overestimation of hemodialysis dose depends on dialysis efficiency by regional blood flow but not by conventional two pool urea kinetic analysis. ASAIOJ. 1995;41:M719-24. 9. Hemodialysis Adequacy 2006 Work Group. Clinical practice guidelines for hemodialysis adequacy, update 2006. Am J Kidney Dis. 2006;48 Suppl 1: S2-90. 10. Tom A, McCauley L, Bell L, Rodd C, Espinosa P, Yu G, et al. Growth during maintenance hemodialysis: impact of enhanced nutrition and clearance. J Pediatr. 1999;134:464-71. 11. Sharma A. Reassessing haemodialysis adequacy in children: the case for more. Pediatr Nephrol. 2001;16:283-90. 12. Bell L, Eapinosa P. Intensive in center hemodialysis for children: a case for longer dialysis duration. Hemodia Int 2003;7:290-5. 13. Fischbach M, Terzic J, Laugel V, Dheu C, Menouer S, Helms P, Livolsi A. Daily online hemodiafiltration: a pilot experience in children. Nephrol Dial Transplant. 2004;19:2360-7. 14. Pierratos A. Daily nocturnal home hemodialysis. Kidney Int. 2004;65:1975-86. 15. Lindsay RM. Minutes to recovery after a hemodialysis session: a simple health-related quality of life question that is reliable, valid and sensitive to change. Clin J Am Soc Nephrol 2006;1:952-59. 16. Müller D, Zimmering M, Chan CT, McFarlane PA, Pierratos A, Querfeld U. Intensified hemodialysis regimens: neglected treatment options for children and adolescents. Pediatr Nephrol. 2008;23:1729-36. 17. Furth SL, Stablein D, Fine RN, Powe NR, Fivush BA. Adverse clinical outcomes associated with short stature at dialysis initiation: A report of the North American Pediatric Renal Transplant Cooperative Study. Pediatrics. 2002;109:909- 13. 18. Wong CS, Gipson DS, Gillen DL, et al. Anthropometric measures and risk of death in children with end-stage renal disease. Am J Kid Dis. 2002;36:811-9. 19. Secker D. Achieving nutritional goals for children on dialysis. In: Warady BA, Schaefer FS, Fine RN, Alexander SR, eds. Pediatric Dialysis. Dordrecht: Kluwer Academic Publishers, 2004;221-42. 20. Juarez-Congelosi M, Orellana P, Goldstein SL. Normalized protein catabolic rate versus serum albumin as a nutrition status marker in pediatric patients receiving hemodialysis. J Ren Nutr. 2007;17:269-74. 224

Pediatric Care in Adult Hemodialysis Units: Pediatric Maintenance Hemodialysis 21. Seikaly MG. Salhab N, Warady BA, Stablein D. Use of rhGH in children with chronic kidney disease: lessons from NAPRTCS. Pediatr Nephrol. 2007;22:1195-204. 22. Fischbach M, Terzic J, Menouer S, Dheu C, Soskin S, Helmstetter A, et al. Intensified and daily hemodialysis in children might improve statural growth. Pediatr Nephrol 2006;21:1746-52. 23. Warady BA, Ho M. Morbidity and mortality in children with anemia at initiation of dialysis. Pediatr Nephrol. 2003;18:1055- 62. 24. KDOQI. KDOQI Clinical Practice Guideline and Clinical Practice Recommendations for anemia in chronic kidney disease: 2007 update of hemoglobin target. Am J Kidney Dis 2007; 50:471-530. 25. Amaral S, Hwang W, Fivush B, Neu A, Frankenfield D, Forth S. Association of mortality and hospitalization with achievement of adult hemoglobin targets in adolescents maintained on hemodialysis. J Am Soc Nephrol 2006;17:2878- 85. 26. De Palo T, Giordano M, Palumbo F, Bellantuono R, Messina G, Colella V, et al. Clinical experience with darbepoietin alfa (NESP) in children undergoing hemodialysis. Pediatr Nephrol 2004;19:337-40. 27. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 2004;114:555-76. 28. Mitsnefes MM, Barletta GM, Dresner IG, Chand DH, Geary D, Lin JJ, et al. Severe cardiac hypertrophy and long- term dialysis: the Midwest Pediatric Nephrology Consortium Study. Pediatr Nephrol 2006;21:1167-70. 29. Civilibal M, Caliskan S, Adaletli I, Oflaz H, Sever L, Candan C, et al. Coronary artery calcifications in children with end- stage renal disease. Pediatr Nephrol 2006;21:1426-33. 30. Briese S, Wiesner S, Will JC, Lembeke A, Opgen-Rhein B, Nissel R, et al. Arterial and cardiac disease in young adults with childhood-onset end-stage renal disease-impact of Ca and vitamin D therapy. Nephrol Dial transplant 2006;21:1906-14. 31. Fadrowski JJ, Frankenfield DL, Friedman AL, Warady BA, Neu AM, Fivush BA. Impact of specialization of primary nephrologists on the care of pediatric hemodialysis patients. Am J Kidney Dis 2006;47:115-21. 225



Pediatric Care in Adult Hemodialysis Units: Nursing role 12 Pediatric Care in Adult Hemodialysis Units: Nursing role «≈—¬ æ≈– « — ¥‘Ï 1. ∫∑π” 2. Õ—μ√“°”≈—߇®â“Àπ“â ∑Ë’ 3. °“√¥Ÿ·≈ºªŸâ É«¬‡¥°Á ∑√’Ë —∫°“√√°— …“‚¥¬°“√øÕ°‡≈◊Õ¥¥â«¬‡§√◊ÕË ß‰μ‡∑’¬¡ 4. Vascular access 5. ‡ª“Ñ À¡“¬πÈ”Àπ—° 6. Hemodialysis prescription 7. Choice of dialyzer 8.  “√ªÑÕß°π— °“√·¢Áßμ«— ¢Õ߇≈◊Õ¥ 9. ‚¿™π“°“√ 10. °“√‡®√≠‘ ‡μ‘∫‚μ·≈–æ—≤π“°“√ 11. Anemia 12. Immunization 13. Emergency cart 14. °“√‡√’¬π 227

Practical Dialysis in the Year 2009 1. ∫∑π” ‡πÕË◊ ß¡“®“°°“√‡æ¡Ë‘ ¢πÈ÷ ¢ÕߺªâŸ «É ¬‡¥°Á ‰μ«“¬∑μË’ Õâ ߉¥√â ∫— °“√¥·Ÿ ≈¥«â ¬°“√øÕ°‡≈Õ◊ ¥¡®’ ”π«π ‡æ‘Ë¡¡“°¢÷Èπ ¡’ºŸâªÉ«¬‡¥Á°∫“ß√“¬∑’ËμâÕ߉¥â√—∫°“√¥·Ÿ ≈∑’ËÀâÕ߉μ‡∑’¬¡ºâŸ„À≠à ®“°¢âÕ¡Ÿ≈ United State Renal Data System (USRDS) ®π°√–∑—Ëß∂÷ߪï 2005 ¡’®”π«πºŸâªÉ«¬‡¥Á°‚√§‰μ‡√◊ÈÕ√—ß√–¬–∑’Ë 5 ®”π«π 7,288 √“¬ „π®”π«ππ’ȉ¥â√—∫°“√øÕ°‡≈◊Õ¥ 1,292 √“¬, ‰¥â√—∫°“√≈â“߉μ∑“ß™àÕß∑âÕß 892 √“¬ ·≈– ‰¥â√—∫°“√ª≈°Ÿ ∂à“¬‰μ 5,104 √“¬ „πªï 2008  À√—∞Õ‡¡√‘°“¡’»πŸ ¬å≈â“߉μ∑—È߇¥Á°·≈–ºâŸ„À≠à√«¡°—π∑—ÈßÀ¡¥ 354 ·Ààß1 °“√¥·Ÿ ≈ºŸâªÉ«¬‡¥Á°„πÀâÕ߉μ‡∑’¬¡ºâŸ„À≠à 欓∫“≈ºŸâ¥·Ÿ ≈®–μâÕß¡’∑—°…–∑’Ë·μ°μà“ßÕÕ°‰ª„π ‡√ÕË◊ ߢÕß°“√¥·Ÿ ≈ºªâŸ «É ¬‡¥°Á °“√‡®√≠‘ ‡μ∫‘ ‚μ∑ Ë’ ¡«¬— ·≈–°“√æ≤— π“°“√‡¥°Á ‡æÕË◊ ∑®Ë’ –¥·Ÿ ≈ºªâŸ «É ¬‡¥°Á °≈¡àÿ πÈ’ ‰¥â¥’¬‘Ëߢ÷Èπ 2 2. Õμ— √“°”≈ß— ‡®“â Àπâ“∑Ë’ °“√„Àâ∫√‘°“√øÕ°‡≈◊Õ¥„πºâŸªÉ«¬‡¥Á°¡’«‘∏’§‘¥Õ—μ√“°”≈—ß欓∫“≈∑’Ë·μ°μà“ß®“°ºâŸ„À≠à ¥—ß μ“√“ß∑’Ë 1 3. °“√¥·Ÿ ≈ºŸâªÉ«¬‡¥Á°∑Ë’√—∫°“√√°— …“‚¥¬°“√øÕ°‡≈◊Õ¥¥â«¬‡§√Õ◊Ë ß‰μ‡∑¬’ ¡ 3.1 °“√ª√–‡¡π‘ ºŸªâ É«¬ „π·ß°à “√ª√–‡¡π‘ ºªâŸ «É ¬°Õà π·≈–À≈ß— °“√øÕ°‡≈Õ◊ ¥ ‚¥¬∑«Ë— ‰ª§≈“â ¬§≈ß÷ °∫— º„⟠À≠à ·μ¡à ·’ ß¡à ¡ÿ ∑’Ë·μ°μà“ßÕÕ°‰ª °“√™—ËßπÈ”Àπ—°°àÕπ·≈–À≈—ßμâÕßÕ¬àŸ„π§«“¡§«∫§ÿ¡¥Ÿ·≈¢Õß欓∫“≈ ‚¥¬‰¡àª≈àÕ¬ „Àºâ ªŸâ «É ¬™ßË— π”È Àπ°— ‡Õß ∑ßÈ— π‡È’ æÕË◊ §«“¡∂°Ÿ μÕâ ß·¡πà ¬”¢ÕߢÕâ ¡≈Ÿ ·≈–¡°’ “√«¥—  «à π ßŸ Õ¬“à ßπÕâ ¬∑°ÿ 3 ‡¥Õ◊ π ∑”∫—π∑÷°‰«â„πμ“√“ß°“√‡®√‘≠‡μ‘∫‚μ §«√«—¥Õÿ≥À¿Ÿ¡‘√à“ß°“¬°àÕπ √–À«à“ß ·≈–À≈—ß°“√øÕ°‡≈◊Õ¥„π °√≥’∑’Ë ß —¬«à“¡’°“√μ‘¥‡™◊ÈÕ ºâŸªÉ«¬‡¥Á°πÈ”Àπ—°πâÕ¬°«à“ 20 °‘‚≈°√—¡ ®–μâÕ߉¥â√—∫°“√μ√«®§≈◊ËπÀ—«„® °àÕπ°“√øÕ°‡≈◊Õ¥3 Õ—μ√“°“√‡μâπ¢ÕßÀ—«„®·≈–™’æ®√§«√®–Õ¬Ÿà„π™à«ß ¥—ßμ“√“ß∑’Ë 2 4 μ“√“ß∑Ë’ 1 欓∫“≈:ºªŸâ «É ¬ Õ—μ√“°”≈—ß欓∫“≈μàÕºŸâªÉ«¬‡¥Á°øÕ°‡≈◊Õ¥ 3 1:1 1:2 π”È Àπ°— 1:3 < 10 kgs 10-20 kgs > 20 kgs 228

Pediatric Care in Adult Hemodialysis Units: Nursing role μ“√“ß∑Ë’ 2 Pediatric heart rate and respiratory rate - normal range varies with age Age Heart rate (beats/minute) Respiratory rate (breaths/minute) New born 120-170 30-80 1 year 80-160 20-40 3 years 80-120 20-40 6 years 75-115 16-22 10 years 70-110 16-20 17 years 70-110 12-20 §«“¡¥—π‚≈À‘짫√®–«—¥‚¥¬„™â cuff ∑’ˇÀ¡“– ¡ ¢π“¥¢Õß cuff bladder §«√®–‚Õ∫√Õ∫ 80-100% ¢Õß√Õ∫«ß·¢π ·≈–¢π“¥§«“¡¬“« 2 „π 3 ¢Õßμâπ·¢π3 §«“¡¥—π‚≈À‘μ„πºâŸªÉ«¬‡¥Á°¡’§«“¡ ·μ°μà“ßμ“¡‡æ»·≈–Õ“¬ÿ ¥—ßμ“√“ß∑’Ë 3 4 4. Vascular access 4.1 Acute hemodialysis catheter in children §«√‡≈Õ◊ °¢π“¥¢Õß catheter ∑‡’Ë À¡“– ¡°∫— ºªŸâ «É ¬ ‚¥¬¡¢’ 𓥇 πâ º“à »πŸ ¬°å ≈“߇≈°Á °«“à À≈Õ¥ ‡≈◊Õ¥¥”∑’Ë„™â ‡æ◊ËÕªÑÕß°—π°“√‡°‘¥°“√Õÿ¥μ—π¢Õß venous return ¥—ß· ¥ß„πμ“√“ß∑’Ë 4 4.2 Chronic hemodialysis access 1. Arteriovenous fistula (AVF) AVF ∑”„πºâŸªÉ«¬‡¥Á°∑’Ë¡’πÈ”Àπ—°¡“°°«à“ 30 °‘‚≈°√—¡ ‚¥¬‡≈◊Õ°μàÕ‡ âπ‡≈◊Õ¥∑’Ë·¢π (non dominant arm) ·≈– “¡“√∂‡√‘Ë¡„™â‡ âπ AVF ‰¥âÀ≈—ߺà“μ—¥ 4 ‡¥◊Õπ ‡π◊ËÕß®“°‡ âπºà“»πŸ ¬å°≈“ߢÕß AVF ¡’ ¢π“¥‡≈Á° 2. Arteriovenous graft (AVG) AVG ®–∑”„π°√≥’∑’˺ŸâªÉ«¬¡’ªí≠À“‰¡à “¡“√∂∑” AVF ‰¥â ·≈–‡≈◊Õ°∑”∑’Ë·¢π ∂⓺ŸâªÉ«¬μ—« ‡≈Á°¡’πÈ”Àπ—°πâÕ¬ Õ“®‡≈◊Õ°∑”∑’Ë¢“ (thigh)  “¡“√∂‡√‘Ë¡„™â‡ âπ AVG ‰¥âÀ≈—ߺà“μ—¥ ¿“¬„π 2-4  —ª¥“Àå 3. Semipermanent cuffed catheter „™â„πºŸâªÉ«¬∑’Ë¡’πÈ”Àπ—°πâÕ¬°«à“ 10 °°. À√◊Õ „πºâŸªÉ«¬‡¥Á°‚μ∑’ˉ¡à “¡“√∂∑” AVF ·≈–/À√◊Õ AVG ‰¥â ‚¥¬‡≈◊Õ°„™â pediatric size Õ“®‡≈◊Õ°„™â single-unit dual lumen catheters À√◊Õ two different single lumen catheters placed side-by-side in the same vein (Tessio®) 229

Practical Dialysis in the Year 2009 μ“√“ß∑Ë’ 3 Blood Pressure Standard for Age (Boys) Age group Significant BP* Severe BP** 95% All Height percentile 5% 95% >99% 106/59 >115/75 BP percentile 95% 113/67 >118/82 117/76 > 124/84 1 mo.-1 year 98/55 123/82 >130/86 130/84 >134/90 1-3 years 104/63 140/89 >144/92 No data >150/100 4-6 years 109/72 Severe BP** 7-10 years 114/77 All >99% 11-13 years 121/79 >115/75 >118/82 13-17 years 132/85 > 124/84 >130/86 > 17 years No data >134/90 >144/92 (Girls) Age group Significant BP* >150/100 Height percentile 5% 95% BP percentile 95% 95% 1 mo.-1 year 101/57 107/60 1-3 years 104/65 110/68 4-6 years 108/71 114/75 7-10 years 116/77 122/80 11-13 years 121/80 128/84 13-17 years 126/83 132/86 > 17 years No data No data *Adated from update on 1987 Task Force on HBP, 1996 **Adapted from Second Task Force on BP Controls in Children, 1987. μ“√“ß∑’Ë 4 ¢π“¥‡ âπºà“»Ÿπ¬å¢Õß catheter °—∫À≈Õ¥‡≈◊Õ¥¥”∑’Ë„™â 4 Patient Catheter diameter Site of insertion - New born Umbilical venous catheter Umbilical vein - Infants weight 2-4 kg Two single lumen catheter 4-6 Fr. Femoral or Internal Jugular vein - Older Infants and children Dual lumen catheter 6-8 Fr. Femoral or Internal Jugular vein weight 5-20 kg - Children weight 20-30 kg Dual lumen catheter 9-10 Fr. Femoral or Internal Jugular vein - Children and adolescents Dual lumen catheter 11-12.5 Fr. Femoral, Internal Jugular or weight 30-35 kg Subclavian vein 230

Pediatric Care in Adult Hemodialysis Units: Nursing role ¿“«–·∑√°´âÕπ¢Õß vascular access „πºâŸªÉ«¬‡¥Á°®–‰¡à·μ°μà“ß®“°ºâŸªÉ«¬ºâŸ„À≠à μ”·Àπàß À≈Õ¥‡≈◊Õ¥¥”∑’Ë«“ß “¬ à«π„À≠à∑’Ë„™â §◊Õ internal jugular vein ‡æ◊ËÕÀ≈’°‡≈’ˬߪí≠À“°“√‡°‘¥ subclavian vein stenosis ‚¥¬‡≈◊Õ° catheter ¢π“¥‡ âπºà“»Ÿπ¬å°≈“ßμ“¡πÈ”Àπ—° ¥—ßμ“√“ß∑’Ë 5 5. ‡ªÑ“À¡“¬πÈ”Àπ—° °“√ª√–‡¡‘π dry weight „πºâŸªÉ«¬‡¥Á°∑”‰¥â¬“°‡¡◊ËÕ‡∑’¬∫°—∫ºŸâ„À≠à ‡æ√“–°“√‡ª≈’ˬπ·ª≈ß ¢Õß “√πÈ”‡æ’¬ß‡≈Á°πâÕ¬√–À«à“ß ultrafiltration ¡’º≈∑”„À⇰‘¥μ–§√‘«·≈–Õ“°“√§≈◊Ëπ‰ â‰¥â °“√∫√√≈ÿ‡ªÑ“ À¡“¬ dry weight ¡’§«“¡ ”§—≠ ‡æ√“– “√πÈ”∑’ˇ°‘π‡√◊ÈÕ√—ß¡’º≈∑”„À⇰‘¥§«“¡¥—π‚≈À‘μ ßŸ ·≈–À—«„®ÀâÕß ≈à“ߴ⓬‚μ °“√ª√–‡¡‘πºâŸªÉ«¬§«√®–„™â°“√ª√–‡¡‘π∑“ߧ≈‘π‘°√à«¡¥â«¬°“√„™â‡§√◊ËÕß¡◊Õ摇»… °“√ ª√–‡¡‘ππÈ”Àπ—° dry weight §«“¡¥—π‚≈À‘μ°àÕπ ¢≥–·≈–À≈—ß ≈â“߉μ √«¡∂÷ß°“√„™â‡§√◊ËÕß¡◊Õ摇»…‡æ◊ËÕ «—¥ noninvasive volumetric measurement (NIVM) ·≈– bioimpedance NIVM ‡ªπì °“√μ√«®À“§“à hematocrit ª√¡‘ “μ√‡≈Õ◊ ¥∑‡’Ë ª≈¬’Ë π·ª≈ߧ«“¡‡¢¡â ¢πâ ¢ÕßÕÕ°´‡‘ ®π „π‡≈◊Õ¥√–À«à“ß°“√øÕ°‡≈◊Õ¥ °“√«—¥§à“‡À≈à“π’È®–™à«¬„Àâ·æ∑¬å·≈–欓∫“≈ “¡“√∂ —߇°μ°“√ ‡ª≈’ˬπ·ª≈ߢÕߪ√‘¡“μ√‡≈◊Õ¥„π¢≥–π—Èπ ·≈– “¡“√∂ªÑÕß°—π¿“«–·∑√°´âÕπ®“°°“√øÕ°‡≈◊Õ¥¥â«¬  “‡Àμÿ¢Õß°“√¥÷ßπÈ”‡°‘π  à«π°“√«—¥ bioimpedance ‡ªìπ°“√™à«¬¥ªŸ √‘¡“≥‰¢¡—π·≈–πÈ”„π°≈â“¡‡π◊ÈÕ3 6. Hemodialysis prescription §” ß—Ë °“√√°— …“„π°“√‡≈Õ◊ °„™μâ «— °√Õ߇≈Õ◊ ¥·≈– “¬ ßà ‡≈Õ◊ ¥¢π÷È Õ¬°Ÿà ∫— πÈ”Àπ°— ¢Õ߇¥°Á §«√®– πâÕ¬°«à“√âÕ¬≈– 10 ¢Õߪ√‘¡“μ√‡≈◊Õ¥„π√à“ß°“¬ ‚¥¬ “¡“√∂ª√–¡“≥ª√‘¡“μ√‡≈◊Õ¥„π‡¥Á°·≈–«—¬√ÿàπ4 ‚¥¬„™â EVB = Dry weight in kg × 70 ml ECV% = (Dialyzer volume + blood line volume) / EBV EVC = Extracorporeal volume EVB = Estimated blood volume μ“√“ß∑’Ë 5 ¢π“¥‡ âπºà“»πŸ ¬å°≈“ߢÕß catheter ∑’Ë„™âμàÕπÈ”Àπ—°μ—«¢ÕߺŸâªÉ«¬4 Diameter Body weight (kg) 7-8 Fr. 20 10 Fr. 20-30 11.5-12 Fr. 30-35 231

Practical Dialysis in the Year 2009 ∂â“ ECV ¡“°°«à“√âÕ¬≈– 10 ¢Õߪ√‘¡“≥‡≈◊Õ¥„π√à“ß°“¬ ¡’·π«∑“ߪؑ∫—μ‘¥—ßπ’È 1. ECV 10-12.5% ¢Õß EBV „Àâ prime μ—«°√Õ߇≈◊Õ¥·≈– “¬ à߇≈◊Õ¥¥â«¬ 5% albumin in saline 2. ECV 12.5-15% ¢Õß EBV À√◊Õ ¡“°°«à“ 15% ¢Õß EBV „Àâ prime μ—«°√Õ߇≈◊Õ¥·≈– “¬ àß ‡≈Õ◊ ¥¥«â ¬ whole blood ·≈–‡¡ÕË◊  πÈ‘  ¥ÿ °“√øÕ°‡≈Õ◊ ¥ ®–‰¡‰à ≈‡à ≈Õ◊ ¥„π√–∫∫§π◊ ‡¢“â  √Ÿà “à ß°“¬ºªŸâ «É ¬ ¬°‡«πâ ºŸâªÉ«¬¡’¿“«–´’¥·≈–·æ∑¬å¡’§” —Ëß°“√√—°…“„Àâ‡≈◊Õ¥ºŸâªÉ«¬ Õ—μ√“°“√‰À≈¢Õß blood flow rate §«√Õ¬Ÿà„π√–¥—∫ 200-350 ¡≈./π“∑’μàÕ 1.73 μ√¡.4 Õ—μ√“ °“√‰À≈¢ÕßπÈ”¬“øÕ°‡≈◊Õ¥§«√Õ¬àŸ∑’Ë 1.5-2 ‡∑à“ ¢ÕßÕ—μ√“°“√‰À≈¢Õß Blood pump μ«— °√Õ߇≈Õ◊ ¥∑π’Ë ”‡¢“â ¡“‡ πÕ‡æÕ◊Ë ®”Àπ“à ¬„πª√–‡∑»‰∑¬¡À’ ≈“¬∫√…‘ ∑— ·≈–À≈“°À≈“¬·∫∫ ¥—ßμ“√“ß∑’Ë 6 7. Choice of dialyzer °“√‡≈◊Õ°„™âμ—«°√Õ߇≈◊Õ¥∑’ˇÀ¡“– ¡°—∫ºŸâªÉ«¬æ‘®“√≥“®“° dialyzer surface area §«√„°≈â ‡§’¬ß°—∫ childûs surface area 4 °“√§”π«≥ Body surface area (BSA) ‚¥¬„™â μŸ √ BSA = (Wt × Ht) / 3,600 Wt = body weight (kg) Ht = height (cm) 8.  “√ªÑÕß°π— °“√·¢ßÁ μ«— ¢Õ߇≈Õ◊ ¥ °“√∫√‘À“√¬“ heparin „πºâŸªÉ«¬‡¥Á°¡’§«“¡·μ°μà“ß®“°ºâŸ„À≠à„π¢π“¥¢Õ߬“ (μ“√“ß∑’Ë 7) ·μà°“√¥·Ÿ ≈·≈–°“√ªÑÕß°—π¿“«–·∑√°´âÕπ®“°º≈¢â“߇§’¬ß¢Õ߬“‰¡à¡’§«“¡·μ°μà“ß®“°ºâŸ„À≠à ºŸâªÉ«¬ ‡¥Á°·≈–«—¬√ÿàπ∑’Ë¡’ arteriovenous fistula (AVF) À√◊Õ arteriovenous graft (AVG) §«√®–À¬ÿ¥„Àâ heparin 1/2-1 ™¡. °Õà π§√∫°“√øÕ°‡≈Õ◊ ¥ ‡æÕË◊ ≈¥°“√‡°¥‘ ª≠í À“‡≈Õ◊ ¥À¬¥ÿ ¬“°μ√ßμ”·Àπßà ‡¢¡Á  «à πºªâŸ «É ¬∑¡Ë’  ’ “¬ catheter §«√‰¥â√—∫ heparin ®π ‘Èπ ÿ¥°“√øÕ°‡≈◊Õ¥ 9. ‚¿™π“°“√ ºâŸªÉ«¬‡¥Á°∑’ˉ¥â√—∫°“√øÕ°‡≈◊Õ¥¡’‚Õ°“ ‡ ’ˬßμàÕ°“√‡°‘¥¿“«–∑ÿæ‚¿™π“°“√ ‡¥Á°§«√®–‰¥â √∫— ‚ª√μπ’ ·≈–æ≈ß— ß“π∑‡Ë’ 欒 ßæÕ π°— ‚¿™π“°“√·≈–·æ∑¬§å «√®–쥑 μ“¡§“à normalized protein catabolic rate (nPCR) ·≈–√–¥—∫Õ—≈∫¡Ÿ ‘π„π‡≈◊Õ¥ ºŸâªÉ«¬‡¥Á°∑’Ë¡’§à“ nPCR πâÕ¬°«à“ 1 g/kg/d ¡’§«“¡‡ ’ˬßμàÕπÈ”Àπ—° ≈¥ „π‡¥Á°°≈ÿà¡π’ÈÕ“®®–‰¥â√—∫Õ“À“√‡ √‘¡ ‡™àπ Nepro À√◊Õ Suplena ‚¥¬°“√√—∫ª√–∑“π „π°√≥’∑’Ë√—∫ ª√–∑“πÕ“À“√‡ √‘¡‰¡à‡æ’¬ßæÕ Õ“®®”‡ªìπμâÕ߉¥â√—∫Õ“À“√‡ √‘¡‚¥¬∑“ß nasogastric À√◊Õ gastrostomy 232

μ“√“ß∑’Ë 6 Dialyzer ∑’Ë„™â„πºâŸªÉ«¬‡¥Á° ∫√…‘ ∑— ASAHI BAXTER FRESENIUS F4 F5 F6 F4HPS F5HPS F6HPS Model SD-500H SD-650H SD-750U BIO-WET650 BIO-WET 750 CA110 CA150 F3 Polysulfone Membrane Regenerated cellulose Asahi-Biomembrane Cellulose Triacetate 0.4 ETO In-Line Steam 28 0.7 1.0 1.3 0.7 1.0 1.3 Sterilization Gamma ETO 1.7 42 63 82 42 63 82 1.5 1.1 1.5 2.8 4.0 5.5 4.3 6.2 8.5 SA (m2) 1.0 1.3 1.5 1.3 125 95 155 170 180 160 174 183 PV (ml) 63 78 94 78 94 70 95 50 128 149 164 131 152 167 20 78 103 123 95 120 140 Kuf 5.0 6.4 10.3 7.8 8.8 4.8 6.8 32 45 60 50 65 80 N/A Clearance at Qb = 200 ml/min, Qd = 500 ml/min N/A 183 206 222 190 217 237 N/A 145 175 194 155 182 206 N/A 88 115 145 115 145 170 34 47 62 56 74 92 Urea Pediatric Care in Adult Hemodialysis Units: Nursing role177 186 194 184188 172 183 233 Creatinine 155 167 178 166 172 145 162 Phosphate 131 145 161 142 150 100 120 B12 54 66 85 66 74 50 63 Clearance at Qb = 300 ml/min, Qd = 500 ml/min Urea 223 242 263 237 246 212 236 Creatinine 185 205 225 203 214 170 196 Phosphate 150 170 195 166 178 110 135 B12 57 70 92 70 79 52 67 ETO = Ethylene oxide gas Qb = Blood flow rate SA = Effective surface area Qd = Dialysate flow rate PV = Priming volume N/A = Not available Kuf = Ultrafiltration coefficient (ml/h-mmHg)

Practical Dialysis in the Year 2009μ“√“ß∑Ë’ 6 234 Dialyzer ∑’Ë„™â„πºâŸªÉ«¬‡¥Á° (μàÕ) ∫√…‘ ∑— KAWASUMI NIKKISO NIPRO SF SF FB FB Model ME-12H ME-12U ME-15H ME-15U SMCR10 SMCR13 BLF- BLF- BLF- SF 130E 150E 110U 130U FB 110E 150U 08GW 10GW 12GW Cellulose Triacetate 1.1 ETO 1.5 Membrane Hemophan SMC Hemophan 65 90 10.45 1.3 1.5 1.1 1.3 29.8 Sterilization ETO Gamma Gamma 75 90 65 75 190 12.35 14.25 21.8 25.8 196 SA (m2) 1.2 1.2 1.5 1.5 1.0 1.3 0.8 1.0 1.2 174 188 149 194 195 190 194 182 PV (ml) 63 63 82 82 60 76 40 50 60 100 181 185 179 184 133 158 166 171 177 Kuf 5.5 6.5 7.7 8.7 5.0 6.5 4.4 5.5 6.6 237 110 119 114 125 270 212 246 Clearance at Qb = 200 ml/min, Qd = 500 ml/min 188 249 254 N/A N/A 233 113 221 231 N/A N/A 153 Urea 177 180 185 188 169 181 161 175 179 200 208 N/A N/A 125 137 N/A N/A Creatinine 156 161 168 172 144 159 140 153 160 Phosphate 139 144 152 157 134 150 120 136 140 B12 52 61 61 72 50 62 45 54 60 Clearance at Qb = 300 ml/min, Qd = 500 ml/min Urea N/A 229 N/A 246 209 231 195 219 227 Creatinine N/A 195 N/A 214 168 192 163 182 193 Phosphate N/A 169 N/A 188 154 177 136 157 163 B12 N/A 64 N/A 77 52 65 47 57 63 SMC = Superior membrane concept Qb = Blood flow rate ETO = Ethylene oxide gas Qd = Dialysate flow rate SA = Effective surface area N/A = Not available PV = Priming volume Kuf = Ultrafiltration coefficient (ml/h-mmHg)

Pediatric Care in Adult Hemodialysis Units: Nursing role μ“√“ß∑’Ë 7 ‡ª√’¬∫‡∑’¬∫«‘∏’∫√‘À“√¬“ heparin √–À«à“ߺ⟪ɫ¬‡¥Á° - ºâŸ„À≠à „π¢π“¥ª°μ‘ μ“¡«‘∏’ Routine heparin, constant-infusion method 5, 6,7 Patient Initial bolus dose ( IU/kg ) Constant infusion (IU/kg/hr.) Pediatric 5 10-20 10-20 Adult 6,7 30-50 12-15 or 50 500-1500 (IU/hr.)  «à π„πºªâŸ «É ¬∑¡’Ë ¿’ “«–∑æÿ ‚¿™π“°“√√πÿ ·√ߧ«√®–‰¥√â ∫— Õ“À“√‡ √¡‘ ∑“߇ πâ ‡≈Õ◊ ¥√–À«“à ß°“√ øÕ°‡≈◊Õ¥ (intradialytic parenteral nutrition; IDPN)  “‡Àμÿ¢Õß¿“«–∑ÿæ‚¿™π“°“√ 4 1. Anorexia and alterations in taste 2. Catabolic uremic state - increased muscle protein breakdown - inhibition of protein synthesis 3. Comorbidities: chronic infection, vomiting or diarrhea 4. Loss of protein and aminoacid in dialysate during hemodialysis 5. Insulin resistance 6. Personal food preference 7. Limited financial resources 10. °“√‡®√‘≠‡μ∫‘ ‚μ·≈–æ—≤π“°“√ °“√‡®√‘≠‡μ‘∫‚쇪ìπªí≠À“ ”§—≠„πºŸâªÉ«¬‚√§‰μ‡√◊ÈÕ√—ß °“√·°â‰¢¿“«–∑ÿæ‚¿™π“°“√ ‡≈◊Õ¥ ‡ªìπ°√¥ ´’¥ ‚√§∑“ß°√–¥°Ÿ √à«¡°—∫°“√√—°…“¥â«¬ growth hormone ®–™à«¬‡æ‘Ë¡§«“¡ ßŸ „πºâŸªÉ«¬°≈ÿà¡π’È ¢âÕ¡Ÿ≈®“° USRDS æ∫«à“√âÕ¬≈– 65 ¢Õߺ⟪ɫ¬‡¥Á°‰μ‡√◊ÈÕ√—ß√–¬–∑’Ë 5 ®–¡’Õ—μ√“°“√‡®√‘≠‡μ‘∫‚μμË” ÿ¥ Õ¬„Ÿà π™«à ß percentile ∑Ë’ 0-20 ¢Õߪ√–™“°√∑«Ë— ‰ª ºªâŸ «É ¬‡¥°Á ‚√§‰μ‡√ÕÈ◊ √ß— ®–¡°’ “√‡®√≠‘ ‡μ∫‘ ‚μ‡¢“â  «àŸ ¬— ‡®√≠‘ æ—π∏剥â™â“°«à“ª°μ‘ §«√®–‰¥â¡’°“√μ√«®√à“ß°“¬ª√–‡¡‘π Tanner staging ªï≈– 2 §√—Èß „π‡¥Á°∑’ËÕ¬Ÿà„π™à«ß «—¬‡®√‘≠æ—π∏ÿå ¥—ßμ“√“ß∑’Ë 8 ªí®®—¬∑’Ë∑”„Àâ°“√‡®√‘≠‡μ‘∫‚μ‰¡à ¡«—¬ 1. Protein-calorie malnutrition 2. Acidosis 235

Practical Dialysis in the Year 2009 μ“√“ß∑’Ë 8 Tanner stages for males and females 3 Tanner stages 1 2 34 Female No breast tissue Enlargement of Enlargement of Projection of areola with breast and areola areola above breast bud as singer mound breast as double mound Male Prepubertal Testes enlarge Penis enlarge in Penis grows in length with length and width continued growth with pigmented of testes and growth of testes scrotum and scrotum Male and Non Few darker hair Curly pigmented Small adult female public along hair labia / base of hair across pubis pattern of hair development penis 3. Renal sodium wasting 4. Renal bone disease 5. Hypertension 6. Corticosteroid treatment 7. Tissue resistance to growth hormone 8. Zinc deficiency 11. Anemia °“√¥·Ÿ ≈ºªŸâ «É ¬‡¥°Á ‰μ«“¬‡√Õ◊È √ß— ∑¡’Ë ¿’ “«–´¥’ √«à ¡¥«â ¬ ®”‡ªπì ∑μ’Ë Õâ ß„™°â “√√°— …“¥«â ¬recombinant human erythropoietin (rHuEPO) ‡πÕ◊Ë ß®“°‰μ √“â ß erythropoietin (EPO) ‰¡‡à 欒 ßæÕ „π∫∑∫“∑¢Õß欓∫“≈ μÕâ ß¡§’ «“¡√‡Ÿâ √Õ◊Ë ß°“√∫√À‘ “√¬“∑∂’Ë °Ÿ μÕâ ß∑ß—È „π‡√Õ◊Ë ß°“√®¥— ‡°∫Á ¬“´ß÷Ë ¡√’ “§“·æß °“√‡ Õ◊Ë ¡¢Õ߬“‡¡Õ◊Ë º ¡°∫— saline ·≈–°“√‡ΩÑ“√–«—ß¿“«–·∑√°´âÕπ ‚¥¬‡©æ“– side effect ∑’Ë∑”„À⇰‘¥ hypertension ¢Õß°“√„Àâ EPO ‚¥¬°“√«—¥§«“¡¥—π‚≈À‘μ°àÕπ„À⬓∑ÿ°§√—Èß ´÷Ëß·æ∑¬å®–°”Àπ¥§à“ systolic BP ∑’ËμâÕßߥ°“√„À⬓ ´÷Ëß®– ·μ°μà“ß°—π‰ª„πºŸâªÉ«¬·μà≈–√“¬ ‡°≥±å°“√°”À𥂥¬æ‘®“√≥“®“° classification of hypertension by age group ¥—ß· ¥ß„πμ“√“ß∑’Ë 3 236

Pediatric Care in Adult Hemodialysis Units: Nursing role 12. Immunization §«√®–¡’°“√ª√–‡¡‘π°“√„Àâ«—§´’π‡ªìπ√–¬– „À⇥Á°‰¥â√—∫«—§´’πμ“¡‡°≥±åÕ“¬ÿ Vaccine recommendation for patient on chronic dialysis - IPV ·∑π OPV - Influenza vaccine §«√‰¥â√—∫‡ªìπª√–®”∑ÿ°ªï „π‡¥Á°Õ“¬ÿπâÕ¬°«à“ 1 ªï §«√‰¥â√—∫«—§´’π split virus, ‡¥Á°Õ“¬ÿπâÕ¬°«à“ 8 ªï §«√‰¥â√—∫«—§´’π 2 §√—Èß „πªï·√° Àà“ß°—π 1-2 ‡¥◊Õπ - Hepatitis B §«√‰¥â√—∫«—§´’π„π¢π“¥ ßŸ 20 ¡°. ‚¥¬°“√μ√«®√–¥—∫¿¡Ÿ ‘§ÿâ¡°—π∑ÿ°ªï „π°√≥’ ∑’Ë√–¥—∫¿Ÿ¡‘§ÿâ¡°—ππâÕ¬°«à“ 10 mIU/ml §«√„Àâ«—§´’π°√–μÿâπ´È”Õ’°§√—Èß - MMR & Varicella vaccines („Àâ°àÕπª≈°Ÿ ∂à“¬‰μ) ª√–‡¡‘π¿Ÿ¡‘§ÿâ¡°—π°àÕπ√—∫°“√ª≈°Ÿ ∂à“¬ ‰μ 4 13. Emergency cart °“√‡μ√¬’ ¡√∂©°ÿ ‡©π‘ „π°√≥∑’ ¡’Ë º’ ªâŸ «É ¬‡¥°Á ´ß÷Ë ®”‡ªπì μÕâ ß„™‡â §√Õ◊Ë ß¡Õ◊ ·≈–Õªÿ °√≥∑å ¡’Ë ¢’ π“¥·μ° μà“ß®“°ºŸâ„À≠à ®÷ߢշπ–π”Õÿª°√≥å‡æ‘Ë¡‡μ‘¡®“°√∂©ÿ°‡©‘πºŸâ„À≠à ¥—ß√“¬°“√μàÕ‰ªπ’È 1. Ambubag 500 ¡≈. 2. Mask No 3, 4, 5 3. Oropharyngeal airway No. 3, 4, 5 4. Suction tube Fr. 8, 10, 12 5. Laryngoscope : Blade ‚§âß No. 1, 2, 3 : Blade μ√ß No. 0, 1, 2 6. Endotracheal tube No. 4, 4.5, 5, 5.5, 6, 6.5 7. Stylet 14. °“√‡√’¬π ºªâŸ «É ¬‡¥°Á °≈¡ÿà π®’È –¡ª’ ≠í À“‡√Õ◊Ë ß°“√¢“¥‡√¬’ π ‡πÕ◊Ë ß®“°μÕâ ß¡“√∫— °“√øÕ°‡≈Õ◊ ¥À√Õ◊ ¡ª’ ≠í À“ °“√‡®Á∫ªÉ«¬∑’ËμâÕß¡“√—∫°“√μ√«®√—°…“„π‚√ß欓∫“≈ ‡¥Á°°≈ÿà¡π’ȧ«√®–‰¥â√—∫°“√°√–μÿâπ„À≪‚√߇√’¬π ¡“°‡∑à“∑’Ë®–‡ªìπ‰ª‰¥â ‡æ◊ËÕ‰¡à„À⇰‘¥ªí≠À“„π°“√‡√’¬πÀ√◊Õ‡√’¬π‰¡à∑—π‡æ◊ËÕπ ®÷ß¡’§«“¡®”‡ªìπ∑’Ë®–μâÕß ª√—∫μ“√“ß°“√øÕ°‡≈◊Õ¥ ‡æ◊ËÕ‡Õ◊ÈÕ„À⇥Á°‰¥â¡’‚Õ°“ ‰ª‚√߇√’¬π ∫“ß»Ÿπ¬å≈â“ß‰μ®–‰¡à·π–π”„À⇥Á°¥∑Ÿ ’«’ À√◊Õ‡≈àπ‡°¡ å√–À«à“ßøÕ°‡≈◊Õ¥ ·μà„™â‡«≈“√–À«à“ß°“√øÕ°‡≈◊Õ¥¡“∑”°“√∫â“π·∑π 3 §«√®—¥„Àâ¡’ health conner ‡ªìπ¡ÿ¡°‘®°√√¡ ∑’Ë¡’Àπ—ß ◊Õ §Ÿà¡◊Õ «“√ “√ ”À√—∫ºŸâªÉ«¬øÕ°‡≈◊Õ¥ ·≈–Àπß—  Õ◊  “√§¥’ ∫π— ‡∑ß‘ √«¡∑ßÈ— Àπß—  Õ◊ ∏√√¡–μ“à ßÊ ‡æÕË◊ „Àºâ ªŸâ «É ¬·≈–≠“μ‘ ‰¥ºâ Õà π§≈“¬·≈–‰¥ªâ √°÷ …“ ·≈°‡ª≈’ˬπ¢à“« “√„π√–À«à“ß√Õ°“√øÕ°‡≈◊Õ¥ À√◊Õ‡æ◊ËÕæ—°ºàÕπ°àÕπ°≈—∫∫â“π 237