1. 신장내과 R4 김효식 /Prof. 전진석 혈액투석의 시작

2. Dialysis start Patients with eGFR >15 mL/min/1.73 m 2 Generally do not initiate chronic dialysis for such patients, ev en when they have possible symptoms related to ESRD. While some symptoms of kidney disease may be present in patients with eGFR > 15 mL/min/1.73 m 2, they usually can b e managed by medical therapy, and dialysis is rarely require d. When patients with eGFR >15 mL/min/1.73 m 2 present with symptoms of ESRD, other causes should be excluded or tre ated before considering dialysis.

3. Asymptomatic patients with eGFR 5 to 15 mL/min/1.7 3 m 2 Closely follow such patients (eg, monthly) for the emergenc e of ESRD-related signs and symptoms, but do not initiate di alysis in the absence of signs or symptoms

4. Patients with eGFR 5 to 15 mL/min/1.73 m 2 with signs or symptoms that could be due to ESRD Exclude other causes of signs and symptoms and try to treat medically, if possible, especially if the eGFR is >10 mL/min/ 1.73 m 2. Initiate dialysis for those patients whose signs and symptom s are refractory to medical therapy. Absolute indications for dialysis : uremic pericarditis, pleuritis, uremic e ncephalopathy As the eGFR declines below 10 mL/min/1.73 m 2, patients oft en develop symptoms of ESRD that no longer can be treate d medically and require dialysis

5. Patients with eGFR ≤5 mL/min/1.73 m 2 Most nephrologists initiate dialysis for most patients (who pl an to do so) when eGFR is ≤5mL/min/1.73 m 2, regardless of the absence or presence of ESRD-related signs or symptom s.

6. Indications Progressive, severe uremia (pericarditis, bleeding, uremic encephalopathy) Refractory fluid overload (pulmonary edema) Refractory hyperkalemia, hyperphosphatemia Refractory metabolic acidosis Declining nutritional status Fatigue and malaise Mild cognitive impairment

7. The 2014 Canadian Society of Nephrology guidelines : Symptomatic patient : eGFR declines below 15 mL/min/1.73 m 2 Asymptomatic patient : eGFR declines to below 6 mL/min/1.73 m 2 or when symptoms occur European guidelines : Symptomatic patient : eGFR declines below 15 mL/min/1.73 m 2 While recognizing that the majority of patients will be symptomatic and need to start dialysis with GFR in the range of 6 to 9 mL/min/1.73 m 2 No minimum eGFR that defines an absolute need for dialy sis, most nephrologists initiate dialysis when the eGFR de creases below 5 mL/min/1.73 m 2.

8. Forms of renal replacement therapy Dialysis Hemodialysis Peritoneal dialysis Kidney Transplantation

9. Principles of dialysis Use a semi-permeable membrane Waste Management Diffusion, convection Fluid Management Ultrafiltration

10. Diffusion Movement of a solute across a membrane via a concentration gradient

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12. Convection Movement of solutes through a membrane by the force of water “Solvent drag”

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14. Ultrafiltration Plasma water is forced across a semipermeable membrane by hydrostatic pressure

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16. 투석중 요질과 수분의 제거기전 Solvent drag

17. Three essential components Dialyzer Composition and delivery of the dialysate Blood delivery system Blood flow rate : 250–500 mL/min Dialysate flow rate : 500–800 mL/min (counter-current direction)

18. Dialyzer Hollow fiber dialyzers m/c They contain thousands of hollow fibers similar in structure to a human capillary

19. Dialysate Crystalloid solution containing various amounts of electrolytes, glucose, buffers

20. Anticoagulation to prevent thrombosis in the blood circuit Heparin (m/c) LMWH At risk of bleeding No-heparin hemodialysis Minimum-dose heparin Regional anticoagulation with protamine reversal Regional citrate anticoagulation Prostacyclin regional anticoagulation (Futhan ® )

21. Hemodialysis Access Arteriovenous fistula Arteriovenous graft Catheters (Temporary, tunneled)

22. Arteriovenous Fistula Preferred form of dialysis access 4-6weeks mature time Types Radiocephalic (first choice) Brachiocephalic (second choice) Brachiobasilic

23. Arteriovenous graft Synthetic conduit between an artery and a vein Polytetrafluoroethylene (Gortex) – m/c AVFAVG Infection2%26% Thrombosis11%64% Maturation time2-3mo2wks Intraaccess blood flow600-800ml/min800-1000ml/min PalpationSoft, compressibleFirm, compressible Mean patency2-4y18-22mo

24. Catheter Double lumen catheters Venovenous vs arteriovenous Rt. jugular v. > femoral v. > Lt. jugular v. > subclavian v. Tunneled Temporary

25. Kt/V and the adequacy Kt/V K - dialyzer clearance of urea t - dialysis time V - volume of distribution of urea Single pool Kt/V Minimally adequate Kt/V : 1.2 Target recommended Kt/V : 1.4