Peresepan Hemodialysis

Faktor dializer

Harun Rasyid Lubis

Divisi Ginjal dan Hipertensi
Departemen Ilmu Penyakit Dalam
FKUSU/ RS HAM/RS Dr Pirngadi
M e d a n.
First Randomised Controlled Trial In Dialysis

• The National Cooperative Dialysis Study

(NCDS) adalah multicentric, randomized and
controlled yang pertama menyelidiki impact
dari dosis dialysis thd outcome pasien. 160
pasien di-randomized kedalam 2 konsentrasi
urea dgn waktu sama (TAC; 100 vs 50 mg/dl)
and to two waktu dialisis berbeda (2.5 –
3.5 vs 4.5–5.5 h) dan di followed‐up selama
6 bulan..
NCDS 1980
Dialysis adequacy and death

Effect dosis dialysis

thd survival
First Randomised Controlled Trial In Dialysis

Predialysis urea 38 vs 26 mmol. Dialysis 2.5-35h vs 4.5-5 h

kt/v tinggi dan

dialysis lama

kt/v tinggi dan

dialysis pendek

kt/v rendah dad

dialysis lama

kt/v rendah dan

dialysis pendek

NCDS 1980
KOMPONEN PERESEPAN HEMODIALISIS

1. Dializer (membran, konfigurasi, luas permukaan)

2. Waktu
3. Kecepatan aliran darah
4. Kecepatan aliran dialisat
5. Kecepatan Ultrafiltrasi
6. Komposisi dialisat
7. Temperatur dialisat
8. Anti-koagulasi
9. Obat obatan sewaktu dialisis
10. Frekwensi Dialisis
KOMPONEN PERESEPAN HEMODIALISIS

Waktu dan Frekwensi Dialisis

Internasional: 3 x 4 jam/minggu
Indonesia : 2 x 5 jam /minggu.

Kecepatan aliran darah: 200 – 600 ml/menit

Kecepatan aliran dialisat: 500 ml/menit
800 ml/menit
(P ↑↑, Toxicity)
300 ml/menit
( SLED, UF ↑ ↑)
KOMPONEN PERESEPAN HEMODIALISIS

Anti-koagulasi:
Regular Heparin
Low/minimal Heparin
Non- Heparin

Na-Citrate.

Obat obatan : Obat anti Hipertensi

dll.
 KOMPONEN PERESEPAN HEMODIALISIS

Kecepatan UF:

( Kidney Int
KOMPONEN PERESEPAN HEMODIALISIS

Komposisi Dialisat.
Bebas K+, K = 2 meq/L
Bebas Ca++, Ca ++…..

Temperatur Dialisat.
normal, 36,50C
 Dializer
……..the Kidney Disease Outcomes Quality Initiative
(KDOQI) Clinical Practice Recommendation for
Dialyzer Membranes and Reuse states that though the
selection of dialyzer membranes and reuse practices
are not included in the prescription of small-solute
clearance, they can be important determinants of
patient survival and quality of life.

Clinical Practice Recommendation 5:

Dialyzer Membranes and Reuse.
Am J Kidney Dis. 2006;48: S2-S90 (suppl 1)
 Dializer
……..the Kidney Disease Outcomes Quality Initiative
(KDOQI) Clinical Practice Recommendation for
Dialyzer Membranes and Reuse states that though the
selection of dialyzer membranes and reuse practices
are not included in the prescription of small-solute
clearance, they can be important determinants of
patient survival and quality of life.
( …. dapat berperan penting dalam keselamatan dan
kualitas hidup pasien)

Clinical Practice Recommendation 5:

Dialyzer Membranes and Reuse.
Am J Kidney Dis. 2006;48: S2-S90 (suppl 1)
 MEMBRANES
1. Cellulose .
Cellulose Unmodified/Cuprophane
Cellulose Acetate
Cellulose Diacetate
Cellulose Triacetate (CTA)
2. Synthetic.
Polysulfone (PS)
Polyethersulfone (PES)
Polymethylmethacrylate (PMMA)
Polyacrylonitril (PAN),
PEPA, EVAL dll
3. Vit E coated membranes
 BIO-COMPATIBILITY

interaksi dengan komponen darah

disertai gejala klinis.

CELLULOSE < SYNTHETIC < ANTI-OXIDANT ELUTED

 Kapasitas Dializer

1. Kapasitas untuk pembersihan zat terlarut

(uremic toxins) = KoA
2. Kapasitas untuk pengeluaran cairan
(ultra-filtrasi) = Kuf
3. Biocompatibility

Ciri lain: Priming volume rendah

(SIMETRIS)

(ASIMETRIS))
KoA = efisiensi pembersihan larutan
dengan diffusi

Ko = koefficient transfer zat terlarut

A = luas permukaan dializer.

 F4 HPS F5HPS F6 HPS
Art-No 5007041 5007051 5007061
QB (mL/min) 200 / 300 200 / 300 200 / 300

Clearance (mL/min) Urea 170 179/227 186/243

QD= 500 Ml/min, UF=0 Creatinine 149 162/196 173/215
Phosphate 123 139/162 148/175
Vitamin B12 75 84 / 91 92 / 100
K0A Urea mL/min 495 606 746
UF-coefficient mL/mmHg 8 10 13
V (blood priming volume) mL 51 63 78
Max. dialysate flow mL/min 800 1000
P (pressure drop blood,QB = 300 mL/min mmHg 142 111 91
P (pressure drop blood,QD = 500 mL/min mmHg 23 21 19
A (effective surtace area) m2 0,8 1,0 1,3
TMP max mmHg 600
Membrane Fresenius Polysulfone ®
Sterilisation methode INLINE steam
 F7 HPS F8HPS F9 HPS
Art-No 5007071 5007081 5007201
QB (mL/min) 200 / 300 300 / 400 300 / 400

Clearance (mL/min) Urea 188/2477 252/290 259/300

QD= 500 Ml/min, UF=0 Creatinine 175/220 224/251 230/259
Phosphate 155/186 193/212 208/231
Vitamin B12 102/113 118/124 131/139
K0A Urea mL/min 789 846 945
UF-coefficient mL/mmHg 16 18 21
V (blood priming volume) mL 96 113 132
Max. dialysate flow mL/min 1000
P (pressure drop blood,QB = 300 mL/min mmHg 71 62 52
P (pressure drop blood,QD = 500 mL/min mmHg 16 14 12
A (effective surtace area) m2 1., 1,8 2,2
TMP max mmHg 600
Membrane Fresenius Polysulfone ®
Sterilisation methode INLINE steam
 Recommended Blood Flow Range

F10 HPS ---2,4

---2,2

F8 HPS ---2

Surface area [m2]

F7 HPS ----1,8
---1,6
---1,4
F6 HPS
---1,2
F5 HPS ---1

F4 HPS ---0,8
---0,6
0 100 200 300 400 500 600

Blood Flow [mL/min]

Performance Dialyser Polypure S High Flux :

Membrane Material Polysulfone

Housing Material Polycarbonate
Potting material Polyurethane
Seterilization Type Steam

Code / Type Blood Priming Surface Area Ultrafiltrasi/UF

Dialyser ( mL ) ( M² ) ( mmHg )
POLYPURE 10 S 59 1‚2 32
POLYPURE 13 S 69 1,3 43
POLYPURE 14 S 75 1,4 47
POLYPURE 16 S 86 1,6 53
POLYPURE 18 S 105 1,8 58
POLYPURE 20 S 109 2‚0 66
POLYPURE 22 S 115 2,2 74
Performance Dialyser Polypure S High Flux :

Clearance in Vitro
(ml/min)

QD = 500 ml / min. UREA CREATININE PHOSPHATE

QF = 0 ml/min , Temp :
37⁰C
Maximum TMP
QB ml/min 200 300 400 200 300 400 200 300 400
Polypure 10 S 185 241 275 170 207 231 158 191 211
Polypure 13 S 191 258 299 178 225 254 172 211 237
Polypure 14 S 192 261 303 180 231 261 176 219 243
Polypure 16 S 193 264 310 183 234 267 178 225 254
Polypure 18 S 194 270 319 187 245 281 183 236 270
Polypure 20 S 196 275 328 189 250 289 186 241 278
Polypure 22 S 197 279 335 191 256 298 188 247 287
PRAKTIS DALAM PEMILIHAN DIALIZER.

Postur pasien: kecil ------------ besar

BB pasien: rendah --------------> tinggi

OPTION?

JENIS MEMBRANE ?
Ko?
A !!!
 DECISION

Direktur RS ?

Supervisor/Penanggung Jawab?

Ka Ruangan/Klinik?

Perawat HD in Charge?
 F4 HPS F5HPS F6 HPS
Art-No 5007041 5007051 5007061
QB (mL/min) 200 / 300 200 / 300 200 / 300

Clearance (mL/min) Urea 170 179/227 186/243

QD= 500 Ml/min, UF=0 Creatinine 149 162/196 173/215
Phosphate 123 139/162 148/175
Vitamin B12 75 84 / 91 92 / 100
K0A Urea mL/min 495 606 746
UF-coefficient mL/mmHg 8 10 13
V (blood priming volume) mL 51 63 78
Max. dialysate flow mL/min 800 1000
P (pressure drop blood,QB = 300 mL/min mmHg 142 111 91
P (pressure drop blood,QD = 500 mL/min mmHg 23 21 19
A (effective surtace area) m2 0,8 1,0 1,3
TMP max mmHg 600
Membrane Fresenius Polysulfone ®
Sterilisation methode INLINE steam
 F7 HPS F8HPS F9 HPS
Art-No 5007071 5007081 5007201
QB (mL/min) 200 / 300 300 / 400 300 / 400

Clearance (mL/min) Urea 188/2477 252/290 259/300

QD= 500 Ml/min, UF=0 Creatinine 175/220 224/251 230/259
Phosphate 155/186 193/212 208/231
Vitamin B12 102/113 118/124 131/139
K0A Urea mL/min 789 846 945
UF-coefficient mL/mmHg 16 18 21
V (blood priming volume) mL 96 113 132
Max. dialysate flow mL/min 1000
P (pressure drop blood,QB = 300 mL/min mmHg 71 62 52
P (pressure drop blood,QD = 500 mL/min mmHg 16 14 12
A (effective surtace area) m2 1., 1,8 2,2
TMP max mmHg 600
Membrane Fresenius Polysulfone ®
Sterilisation methode INLINE steam
 Recommended Blood Flow Range
---2,4
F10 HPS
---2,2

F8 HPS ---2

Surface area [m2]

F7 HPS ----1,8
---1,6
---1,4
F6 HPS
---1,2
F5 HPS ---1

F4 HPS ---0,8
---0,6
0 100 200 300 400 500 600

Blood Flow [mL/min]

Performance Dialyser Polypure S High Flux :

Membrane Material Polysulfone

Housing Material Polycarbonate
Potting material Polyurethane
Seterilization Type Steam

Code / Type Blood Priming Surface Area Ultrafiltrasi/UF

Dialyser ( mL ) ( M² ) ( mmHg )
POLYPURE 10 S 59 1‚2 32
POLYPURE 13 S 69 1,3 43
POLYPURE 14 S 75 1,4 47
POLYPURE 16 S 86 1,6 53
POLYPURE 18 S 105 1,8 58
POLYPURE 20 S 109 2‚0 66
POLYPURE 22 S 115 2,2 74
Performance Dialyser Polypure S High Flux :

Clearance in Vitro
(ml/min)

QD = 500 ml / min. UREA CREATININE PHOSPHATE

QF = 0 ml/min , Temp :
37⁰C
Maximum TMP
QB ml/min 200 300 400 200 300 400 200 300 400
Polypure 10 S 185 241 275 170 207 231 158 191 211
Polypure 13 S 191 258 299 178 225 254 172 211 237
Polypure 14 S 192 261 303 180 231 261 176 219 243
Polypure 16 S 193 264 310 183 234 267 178 225 254
Polypure 18 S 194 270 319 187 245 281 183 236 270
Polypure 20 S 196 275 328 189 250 289 186 241 278
Polypure 22 S 197 279 335 191 256 298 188 247 287
pgzkn-5wvbm-g8t92-key69