Bandar Lampung, 9 Februari 2019

DIALISIS
pada Anak
Dr. Hertanti Indah Lestari,
SpA(K)

FK Unsri / RSMH Palembang

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 UNIT HEMODIALISIS ANAK

• Unit HD Anak Mandiri:

• RSCM Jakarta

• HD kronik : 44 anak

• CAPD : 30 anak

• Terintegrasi dengan Unit HD Dewasa

• Harkit, Surabaya, Bandung, Yogyakarta, Solo,

• Palembang, Medan, Pekan Baru, Lampung, Manado,

 PASIEN DIALIS ANAK
RSMH PALEMBANG

2010 – 2018 JAN- FEB 2019

AKUT KRONIK

HD 24 4 5
PD 15 1 5
JML 39 5 10

• Usia terkecil : neonatus

• Usia tertinggi : 17 tahun

 Etiologi
NO Etiologi HD CAPD
1 Glomerulopati 5 3
2 Nefritis Lupus 2 1
3 Hipoplasia ginjal 4 5
4 CAKUT 1 2
5 Neurogenic bladder 2 2
6 Neonatal AKI 2
7 KAD 3
8 Tumor intraabdomen 2
9 Pielonefritis akut 1
10 intoxicasi 2
11 PDA closure 2
 INDIKASI DIALISIS
Acute kidney injury Chronic kidney
(AKI) disease (CKD)
 RENAL REPLACEMENT THERAPY
Traditional indications vs Early indications
• Severe hyperkalemia unresponsive to
conservative therapy.
• Uncontrolled acidosis that cannot be
safely corrected because of risk of
sodium or volume overload.
• Severe volume overload
• exceeding the thresholds of 10-20%
excess from the admission weight
• uncontrolled hypertension, pulmonary
edema or cardiac failure
• Progressive uremia with deterioration
in the general condition.
• Hypercatabolic states with increase in
blood urea by >10 mmol/L per day.
Early institution of dialysis in the
critically ill child with AKI in order to
maintain homeostasis and create
enough volume space so that the
nutritional and therapeutic needs may
be met, as severe fluid restriction
results in:
• Inadequate nutrition.
• Propensity to hypoglycemia.
• Insufficient volume space for blood products
• Difficulty in drug delivery, such as inotropic
support and antibiotic infusions.
• Chronic lung disease in premature neonates
• Increased mortality and prolonged
mechanical ventilation
Bellomo 2017, Selewski 2018
MODALITAS DIALISIS PADA
ANAK
HEMODIALISIS PERITONEAL DIALISIS
HEMODIALYSIS PADA ANAK
HEMODIALYSIS PADA ANAK
Dialyzer

SIZE
does
matter
VASCULAR
ACCESS
Vascular access for hemodialysis
Arterio-venous (AV) fistula Double Lumen Catheter (CDL)

2
4
 HD prescription

I. Dialysis prescription involves two main

components: K x t
– K (urea clearance)
• K, depends on:
– dialyzer size used (KoA),
– blood flow rate (QB),
– dialysate flow rate (QD)
– T (dialysis session length)
II. Adjusting K x t for patient size: Kt/V
III. Determine desired target or minimal Kt/V
 HD prescription
General strategy in initial prescription
to achieve desired urea clearance in children
• Step 1: Estimate patient’s V
– Antropometric equations (Mellits-Cheek method for children)

• Step 2: Multiply V by desired Kt/V

– Recommendation guideline Kt/V

• Step 3: Compute the required K for a given

t, or the required t for a given K
– Variaty combination: K depends on KoA, QB, QD

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Step 1: Estimate patient’s V Kt/V

• V, total body water (L)

– Mellits-Cheek method for children
• For boys:
– H <132,7 cm: V = -1,927 + 0,465xW(kg) + 0,045xH (cm)
– H >132,7 cm: V = -21,993 + 0,406xW(kg) + 0,209xH (cm)
• For girls:
– H <110,8 cm: V = 0,076 + 0,507xW (kg) + 0,013xH (cm)
– H >110,8 cm: V = -10,313 + 0,252xW(kg) + 0,154xH (cm)

– Approximately 60% of body weight

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Step 2: Multiply V by desired
Kt/V
Kt/V = - ln (C1/C0)

Step:
1. Tentukan Kt/V berdasarkan URR yang diinginkan
Desired URR = 30% (1st HD)

URR 30% 👉 C1/C0=0,7

-ln C1/Co = -ln 0,7 = - 0,357
👇
Kt/V
2. Kali-kan V sesuai dengan –ln C1/C2 yang didapatkan

(pediatric nephrology on the go)

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 Determined desired urea clearance
by determined URR

Kt/V = - ln (C1/C0)

Kt/V

4th session: 90%

3rd session: 70%

2nd session: 50%

1st session: 30%

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(pediatric nephrology on the go)
Step 3: Compute the required K for a given t,
or the required t for a given K Kt/V

Step:
1. Variasi kombinasi: K dipengaruhi KoA, QB, QD
2. Tentukan K berdasarkan QB dan KoA (K – KoA – QB
nomogram)
3. Menentukan “ t ” berdasarkan K yang telah ditentukan

(pediatric nephrology on the go)

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 Kt/V = - ln (C1/C0)

Dialyzer urea clearace, Fresenius

Dialyzer SA KoA Blood flow (Qb) ml/min
(m2) (urea)
50 75 100 125 150 200 250 300

F3 0,4 250 49 71 89 103 114 130 141 149

F4 0,7 369 50 - 96 - 130 154 171 184
F5 1,0 402 50 - 97 - 133 159 178 192
F6 1,3 458 50 - 98 - 137 166 188 203
F7 1,6 522 50 - 99 - 141 173 197 215
F80A 190 250

(pediatric nephrology on the go)

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Contoh kasus: Seorang anak laki-laki / 5 tahun / 22,5 kg/ 107 cm (SA 0,8)

1st HD prescription

1. Tentukan V pasien V = 13.348 ml

2. Tentukan Kt/V berdasarkan 1st HD : URR 30% 👉 C1/C0=0,7

URR yang diinginkan -ln C1/Co = -ln 0,7 = - 0,357 👉 Kt/V

3. Tentukan K berdasarkan QB F6 (SA 1,3 m2); KoA 458 ml/min;

dan KoA (K – KoA – QB nomogram) QB 150 ml/min
👉 K = 137 ml/min

Kt/V = - 0,357 =
(137 ml/min x t) / 13.348 ml = - 0,357
t = (13.348 * 0,357)/137
t = 34 min

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 DIALISIS
PERITONEAL
 Dialisis Peritoneal pada Anak
Indikasi
• Kesulitan akses vaskular
• Intoleransi tehadap
hemodialisis
• Gagal jantung kongestif
• Anak usia < 5 tahun
• Tinggal jauh dari center HD
• Pilihan pasien
Kontraindikasi
• Penyakit inflamasi usus
• Operasi abdomen
• Tumor abdomen
• Malnutrisi berat
• Gangguan intelektual atau
kejiwaan
• Personal higiene yang
buruk
DIALISIS
PERITONEAL

• Conventional
PD (acute PD)
• Automated PD
(APD)
• Continuous
Ambulatory PD
(CAPD)
 PERITONEAL DIALISIS

PD Akut CAPD Elektif

Kateter Tenckhoff
PD akut
PD pada bayi & neonatus
 Post-insersion PD order
• Antibiotik profilaksis perioperatif, cefazolin inravena 10 mg/kg,
dalam 1 jam sebelum insersi kateter PD, mengurangi kejadian
peritonitis onset dini

• Transfer set dipasang dan cek patency kateter Tenckhoff dan

peritoneal leak di ruang operasi dengan cara melakukan in-out
exchange dengan dialisat (dianeal 1,5%) 10 ml/kg.
 Post-insersion PD order
• Antibiotika cefazolin 125 ml/L selama 3 hari

• Jika terdapat leakage, jangan gunakan dulu kateter selama 2

minggu. Atau coba dialisis dengan volume rendah (300 ml/m2)
selama 2 minggu jika keadaan urgensi. Lindungi dengan antibiotika
IP atau IV minimal 5 hari setelah terjadi leakage.

• Intraperitoneal heparin: 250 U/L selama 3 hari. Dosis bisa dinaikkan

500-1000 U/L jika cairan masih berwarna kemerahan. Stop heparin
jika cairan sudah jernih.

• Tambahkan K 4 mmol/L jika kadar K <3,5 mmol/L

• Cek hitung sel dan kultur setelah antibiotik dihentikan.

• Fill volume dapat dinaikkan bertahap sampai maksimal 1400 ml/m2

pada anak >2 tahun.
Continuous
Renal
Replacement
Therapy
(CRRT)