O

Aspek Pemilihan Dializer

OVERVIEW MESIN HD FRESENIUS 4008S NG

Bali Uronephrology Secientific Comunnication (BUN SC )
HOTEL SANUR PARADISE DENPASAR BALI; 19 MARET 2016

Harry Hidriana, AMK

Clinical Resources Specialist

Title, Subject, Author (c) Copyright 5/3/2016

Konsep Adekuasi Dialisis

Doses minimal dialisis yang diperlukan
untuk bertahan hidup

Dosis dialisis yang diperlukan agar

pasien bisa hidup secara optimal
Lacson E, Wish J B.
In: Dialysis, 2nd. Ed: WilliamL.Henrich. Lippincott Williams & Wilkins, Philadelphia. P. 99-113
Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 2

OPTIMAL DIALYSIS

Anemia
management
Good
nutrition

BP control
Dialysis
adequacy

Kt/v

Fluid and
electrolytes
hemostasis

Adequate
solute
removal

BMD
management

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 3

Pentingnya Adekuasi Dialysis Pada Indikator

Penilaian KARS

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 4

Faktor faktor yang mempengaruhi

adekuasi dialisis
Resep HD
- Dibuat sebelum hemodialisis dilakukan
- Bersifat individual

Pemilihan dializer
Bahan:
Cellulose : cuprophan, Cellulose yang disubstitusi : Triacetate.
Synthetic : Polysulfone, Polycarbonate, polyamide dan PMMA

Hal lain: flux (pori membran,), efficiency (luas

membran)
o
o
o

Low Flux
High flux dialyzer
High efficiency dialyzer

Frekuensi Dialisis
o
o

HD 2 X seminggu (BB ringan , masih ada sisa fu`ngsi ginjal): 5

jam
HD 3 x seminggu: 4 jam
Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 5

Aspek Pemilihan Dializer

Pemilihan Dializer,
Dapat ditentukan
berdasarkan

Pertimbangan Teoritis :

1.Fluks
2.Bahan dasar Dializer
3.Struktur Membran
4.Sterilization
5.Koefisien Ultrafiltrasi

Pertimbangan Klinis :
Gejala intradialisis, mordibitas
dan mortalitas

6.Solute Clearance.
7.Biocompatibility.

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 6

Tipe Dializer

Tipe Dializer
Coil Dializer

Dializer model pertama, dimana kompartemen darah terdiri

dari satu atau dua tabung membran yang panjang.

Parallel Plat Dializer

Lembaran membran yg dipasang pada papan plastik,

kemudian ditumpuk menjadi beberapa lapis, biasanya terdiri
dari 2 20 lapisan membran

Hollow Fiber Dializer

Ini adalah design yang paling efektif,mempunyai nilai

efisiensi yg tinggi serta resistensi atau reaksi virogen yg
rendah terhadap pasien, Terdiri dari serat polyurethane pada
setiap bundel serat dalam lembar tabung.
Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 7

Prinsip Kerja Dializer

Darah mengalir melalui sebanyak 20.000 serat sangat halus, yang
dikenal sebagai kapiler.

Pori-pori di kapiler menyaring racun sisa metabolisme dan kelebihan air

dari darah
keluar dari tubuh
( sel darah dan protein penting tetap dalam darah.)

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 8

Prinsip Kerja Dializer

Bundle
Kapiler di
dalam

Dialysate
Inflow

Blood
Outflow

Dialysate
Outflow

Blood
Inflow

Transportasi zat
terlarut di
seluruh
Dinding2 kapiler

Dialisat mengalir di luar Membran Kapiler,Sedangkan Darah Mengalir Secara

berlawanan (counter currently) di dalam Kapiler
Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 9

Prinsip Kerja Dializer

Erythrocyte,
Red Blood
Cell

Albumin, as
Example of a
Big Protein
Molecule

Electrolytes

Bacteria

Medium sized
Molecules, e.g. b2Microglobulin

Aliran air
kemungkinan
akan lebih
mudah keluar

Fungsi membran semipermeabel mirip dengan saringan halus, hanya

molekul yang cukup kecil bisa melewatinya.
Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 10

Organic Uremic Solutes

Comprehensive Clinical Neph, 4th ed, 2010

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 11

Klasifikasi Molecular Weights Dengan Satuan Dalton

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 12

Klasifikasi Membran Berdasarkan Bahan Dasar

Cellulose-based Membranes

Cellulosic:
Cuprophan
Cuprammonium
Semi-synthetic:
Hemophan
Celluloseacetat, diacetat; -triacetate

Synthetic Membranes

Synthetic:
Polysulfon PSU
Polyamid PA
Polycarbonat PC
Polyacrylethersulfon PEPA

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 13

Holow Fiber Dializer

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 14

Pemilihan Dializer Berdasarkan Struktur Membran

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 15

Pemilihan Dializer Berdasarkan Biocompatibility

Blood

Blood Membrane interaction

Sistem Humoral
Aktivasi Sistem kekebalan tubuh
Thromobogenesis
Kinin system activation
etc.

Tidak Terjadi Aktivasi

Atau Terjadi Reaksi
minimal dari Sistem
Kekebalan Tubuh
Terhadap Membran

BIOCOMPATIBLE membrane
Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 16

Pemilihan Dializer Berdasarkan Flux

LOW FLUX

HIGH FLUX

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 17

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 18

OCM; Online Clearance Monitor

Quality Assurance Tool

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 19

1. MESIN HD Fresenius 4008 NG; Next Generation

Mesin HD 4008 NG
DIASAFE

Bibag 5008

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 20

Tampak Belakang

MONITOR (REAR VIEW)

POWER SUPPLY UNIT

SAMPLING VALVE
BRACKET / DIALYZER CONNECTION
LINES
DIALYSATE OUTLET TUBE
DIALYSATE INLET
TUBE
DISINFECTION CONNECTOR
FILTER

VENT TUBING (OVERFLOW)

DIASAFE PLUS

WATER CONNECTOR (PERMEATE)

DRAIN
CDS RED OPTION
Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 21

User Interface: status indicator

Less incident breaking the light indicator
More visible the light indicator

alarm
Warning/info
operation

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 22

Sistem Monitoring
Integrated Online Clearance Monitor (OCM) and BPM
Tool untuk memonitor kualitas dari dosis dialisis yang di berikan
dan memastikan tingkat keamanan pasien

BPM
Plasma Na value
Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 23

Keuntungan Menggunakan OCM; .

Medical Affairs Asia-Pacific - Clinical Education

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 24

2. BPM; Blood Pressure Monitor

5008 BPM
Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 25

Blood Pressure Module (BPM)

Fully automated and non-invasive, operating on the principles of
oscillometry
Programmable measurement interval of 5 - 15 - 30 60 minutes and
quick measurement
Measurement of Systolic and Diastolic blood pressure, Mean Arterial
Pressure (MAP) and Pulse rate

BPM menu now part of the monitor

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 26

3.
Bibag 5008

5008
Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 27

Lanjutan, Bibag

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 28

Apakah kita sudah memberikan dialisis yang

Adekuat???
The cardiovascular mortality rate in dialyses patients is up to 20 times
higher than in the general population

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 29

4. DIASAFE PLUS

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 30

4008 S The next generation

Standar Tertinggi dalam Penatalaksanaan Pasien

Hemodialisis

DIASAFEplus ensures ultrapure

dialysate
Kualitas dan kemurnian dialisat sangat
keberhasilan dialisis

penting didalam

Pasien dialisis terpapar dengan dialisat 12.000 19.000 liter/

tahun

Kontaminasi mikro seperti fragmen endotoksin dapat masuk

kedalam darah, beresiko inflamasi dan komplikasi akut
lainnya, seperti hipotensi.
Resiko masuknya endotoksin dapat diminimalisir dengan
penggunaan Diasafe plus
Penggantian diasafe adalah setelah 100 tindakan atau
12 minggu pemakaian atau jika test integritas gagal.
Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 31

Resiko Endotoxin masuk dializer

Endotoxin yang membelah diri terdapat dalam dialisat dan dapat
masuk ke dalam kompartemen darah ( tidak diinginkan )
Low-Flux / High-Flux
Membrane
Dialysate Side

Blood side

Endotoxin fragments MW below <2000 Da

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 32

Annual adjusted Death Rates (%)

Dosis Dialysis dan Mortalitas

50

Small:
Medium:
Large:

40

BMI < 23.2 kg/m2

BMI 23.2 - 27.8kg/m2
BMI > 27.8 kg/m2

*
*

30

*
*

Small

20

Medium
Large

10
URR

< 60

eKt/V < 0.9

SpKt/V < 1.1

60-65

1.0
1.2

Size of circle reflects # of patients in group

65-70

70-75

1.12
1.32

1.3
1.5

>75

>1.5
>1.7

* p<0.05 compared to next lower URR group

F.K. Port et al. JASN 13:1061-1066, 2002

Medical Affairs Asia-Pacific - Clinical Education

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 33

PERAWATAN MESIN HD

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 34

DESINFECTAN MESIN ---KONSENSUS PERNEFRI

Tahapan Desinfectan di dalam Mesin Fresenius

Desinfection with
Hot Desinfectan
/ Front Suply

Menit 31-26--- rinse dengan air RO

Menit 26-25--- penyedotan desinfectan
Menit 25-10--- pembersihan sirkulit hidrolik
Menit 10-0 ---- Rinse kembali

PERNEFRI merekomendasikan bahwa bagian dalam mesin hemodialisis

harus didesinfeksi setiap kali prosedur dialis selesai (prosedur rutin meliputi
draining, disinfection, rinsing) sesuai dengan protokol yang dianjurkan
oleh pabrik
Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 35

CLINICAL UPDATE FMC

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 36

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 37

CSR : Advanced Renal Education Program

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 38

Dengan bangga disponsori

oleh
Fresenius Medical Care

Program pertukaran pendidikan

dialisis antara Australia and Asia
Tenggara.

Program sebelumnya:

Pertukaran jangka panjang

Indonesia-Australia
ISN-CREED
Program Fellowship
Kunjungan nephrologist Australia
Sponsor dokter ke acara ilmiah di
Australia & Hong Kong
Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 39

Fresenius Medical Care Indonesia

www.freseniusmedicalcare.com
Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 40

THANK YOU

Fresenius Medical Care Indonesia, Subject, Author Copyright 2013 Page 41