IP4_2_2024_Dialysis
Page 1: Title Page
WIRIN ANLAMLERT PHARM D, BCP
Faculty of Pharmaceutical Sciences, Naresuan University
Renal Replacement Therapy
Page 2: Outline
Introduction
Treatment options for renal replacement therapy
Indication for renal replacement therapy
Dialysis options
Hemodialysis
Peritoneal dialysis
Complications
Drug elimination in dialysis patients
Page 3: Renal Replacement Therapy (RRT)
RRT is a treatment method that replaces the function of damaged kidneys.
Can be temporary during acute kidney injury
May serve as long-term treatment for chronic kidney failure (end-stage renal disease)
Page 4: Prevalence of Hemodialysis in Asia
Comparison of prevalence, modality, and cost in Asia
Hong Kong: 818 pmp, 26% In-Center Hemodialysis
Indonesia: 320 pmp, 99% In-Center
Japan: 2532 pmp, 97% In-Center
Jordan: 511 pmp, 97%
Malaysia: 1295 pmp, 90%
Singapore: 1695 pmp, 88%
South Korea: 1820 pmp, 91%
Taiwan: 3251 pmp, 91%
Thailand: 1392 pmp, 72%
pmp = per million population; PD = peritoneal dialysis
Page 5: Prevalence of Hemodialysis in Thailand
Data from 2016 to 2020
2016: 72,622 HD, 20,216 PD, 8,132 Transplants
2017: 84,910 HD, 24,001 PD, 5,360 Transplants
2018: 97,265 HD, 26,070 PD, 5,652 Transplants
2019: 114,262 HD, 30,869 PD, 6,212 Transplants
2020: 129,724 HD, 34,467 PD, 6,583 Transplants
Page 6: Treatment Options in RRT
Hemodialysis
Peritoneal dialysis
Kidney transplantation
Page 7: Hemodialysis Process
Blood is drawn from the patient, filtered through a dialyzer to remove waste and excess fluid, then returned to the patient.
Dialyzer: A filter that purifies blood by removing waste
Needles connect the patient to the dialysis machine.
Page 8: Hemodialysis Equipment
Components:
Heparin pump (to prevent clotting)
Blood pump
Pressure monitors for inflow and venous pressure
Air trap and detector
Page 9: Hemodialysis Types
Intermittent Hemodialysis
Sustained Low Efficiency Dialysis (SLED)
Continuous Renal Replacement Therapy (CRRT)
Page 10: Intermittent Hemodialysis
Performed 3 times a week for 4-5 hours per session
Uses diffusion and convection principles
Hemodiafiltration: Focus on convection for blood purification
Page 11: Waste Removal Mechanisms
Diffusion and Convection:
Diffusion: movement from high to low concentration
Convection: pressure-driven movement carrying solutes and fluid
Page 12: Molecular Size in Removal
Molecules 1,500 – 50,000 Dalton can be removed through dialysis
Small molecules (Urea, Sodium) are effectively dialyzed out
Page 13: SLED Overview
Extended maintenance of metabolic stability
Performed over prolonged periods (6-8 hours)
Utilizes smaller filters without the need for high blood flow rates
Page 14: Continuous Renal Replacement Therapy (CRRT)
Continuous process, available 24 hours a day
Page 15: CRRT Techniques
Types include:
Continuous venovenous hemofiltration (CVVH)
Continuous venovenous hemodialysis (CVVHD)
Continuous venovenous hemodiafiltration (CVVHDF)
Page 16: Continuous Hemodialysis
Blood flow and replacement fluid parameters adjusted for continuous operation
Page 17: Hemofiltration Techniques
Techniques and protocols for effective dialysis treatment
Page 18: Indications for RRT
Severe acute kidney injury
End-stage renal disease (ESRD) patients
Page 19: Absolute Indications for Hemodialysis
Refractory acidosis
Refractory hyperkalemia (serum potassium >6 mEq/L)
Refractory volume overload
Uremia with high BUN levels
Dialyzable drug toxicity (e.g., metformin)
Page 20: Relative Indications for Hemodialysis
Multi-organ failure with acute kidney injury
Significant volume overload requiring treatment
Need for hemodynamic stability maintenance
Page 21: ESRD Patient Indications
eGFR ≤ 6 mL/min/1.73 m²
Ongoing complications from kidney disease not responding to treatment
Page 22: Hemodialysis Equipment
Specialized equipment for blood filtration processes
Page 23: Dialyzer Overview
LST120 PAS Hollow Fiber Hemodialyzer
Page 24: Dialyzer Function
Blood enters, waste passes through a membrane into dialysate
Blood is cleaned and returned to the patient
Page 25: Dialyzer Characteristics
Removal based on the molecular size of wastes
Protein-bound substances typically not removed
Page 26: Dialysate Composition
Includes various electrolytes tailored for patient condition
Page 27: Hemodialysis Vascular Access Types
Fistula, graft, and catheter access methods
Page 28: Arteriovenous (AV) Fistula Process
Surgical formation for long-term use with low infection risk
Page 29: AV Fistula Advantages and Drawbacks
Advantages: lowest infection risk, longest lasting
Drawbacks: requires 2-4 months to mature
Page 30: AV Graft Considerations
Used when AV fistula is not viable; quicker access but higher infection risk
Page 31: Catheter Access
Immediate use but has a higher risk of complications
Page 32: RRT Comparison Table
Concepts comparing intermittent hemodialysis, prolonged intermittent KRT, and continuous KRT
Page 33: Peritoneal Dialysis Overview
Waste removal using the peritoneum as a filter
Conventional vs. automated methods
Page 34: Suitable PD Patients
Patients with specific conditions like acute kidney injury related to heart disease
Page 35: PD Treatment Description
Abdominal cavity used for waste removal via diffusion and ultrafiltration
Page 36: PD Prescription Guidelines
Individualized based on patient characteristics and dialysis needs
Page 37: Continuous PD Regimens
Multiple exchanges every day or using night-time autodialysis
Page 38: CAPD Techniques
Manual exchanges required multiple times a day
Page 39: Automated PD Techniques
Automated cyclical exchanges outlined
Page 40: Complications of Hemodialysis
Includes hypotension, cramps, nausea, headache, and vascular access issues
Page 41: Hypotension in Dialysis
Causes:
Hypovolemia, medications, and diet prior to treatment
Page 42: Hypotension Management
Acute treatment options to manage episodes of hypotension
Page 43: Hypotension Prevention Strategies
Strategies and medications to prevent occurrence
Page 44: Cramps During Dialysis
Causes:
Muscle hypoperfusion, electrolyte imbalance
Page 45: Cramps Management Strategies
Treatment and preventive measures to manage cramps
Page 46: Nausea and Vomiting Factors
Associated with hypotension and reactions to dialysis
Page 47: Headaches in Patients
Caused by disequilibrium syndrome and caffeine withdrawal
Page 48: Hypertension Causes
Various factors such as plasma sodium and volume status affecting blood pressure
Page 49: Pruritus Factors
Related to dialysis efficacy and individual electrolyte imbalances
Page 50: Fever and Chills Causes
Often linked to infection connected to dialysis treatment
Page 51: Access Infection Management
Treatment and prevention strategies of access-related infections
Page 52: Management of Access Infection Types
Strategies for treating infections depending on access type
Page 53: Vascular Access Thrombosis Management
Nonpharmacologic and pharmacologic strategies to manage thrombosis
Page 54: Complications of Peritoneal Dialysis
Various complications related to fluid management, diabetes, and infection risks
Page 55: Factors Affecting Drug Removal in Hemodialysis
Drug properties: Solubility, Volume of distribution, Molecular weight
Dialysis system characteristics
Page 56: Drug Properties for Dialysis
Drugs with high volume distributions and protein bindings impact removal efficacy
Page 57: Dialysis System Properties
Includes blood flow rate and dialysate flow rates impacting drug clearance
Page 58: Factors in Peritoneal Dialysis Drug Removal
Volume of distribution and protein binding
Molecular size affecting removal
Page 59: Comparative Factors in RRT
Diffusion and convection dynamics over different periods and methods
Page 60: Examples of Drug Removal via Dialysis
Table comparing various drugs with properties and removal efficiency
Page 61: Conclusion and Limitations
Summary of various RRT methods and their respective advantages and complications.