FARMAKOTERAPI Hemodialysis

Dr. Diana Laila Ramatillah, M. Farm, Apt

PhD Clinical Pharmacy
Komplikasi Penyakit Ginjal
Definition HD (Hemodialysis)
Hemodialysis is a process or one of the
treatments in replacing renal function to excrete
metabolism residual (Kidney Disease Guideline)
Process of Hemodialysis

Fig 1. Description of Hemodialysis

(www.wikipedia.org)
Hemodialysis
• End-stage renal disease can be treated by renal replacement therapies, such
as Hemodialysis (HD), Transplantation, and Peritoneal Dialysis (PD)
(Indian Society of Nephrology, 2014).
• HD increases expected lifetime of the patients minimizing the effects of
neurological complications (Denhaerynck, 2007; Goksan, Kaarali-Savrun,
Ertan, & Saurun, 2004) and improves serum creatinine, albumin and
prealbumin, normalises the protein catabolic rate (nPCR) as well as
increases the dietary intake of patients (N. B. M. Yusop, Mun, Shariff, &
Huat, 2013).
• Despite its advantages, HD is highly associated with malnutrition and lower
quality of life (QOL) (T. Chang, Nam, Shin, & Kang, 2015). Severe
malnutrition among HD patients in Malaysia was reported to be
approximately 4.6% - 19%, while 72% - 90.9% are mildly malnourished (N.
B. M. Yusop et al., 2013).
• Hemodialysis dose given is generally 2 times a week with each hemodialysis
for 5 hours or as many as three times a week with each hemodialysis for 4
hours (Goksan et al., 2004).
Laboratory Values of HD Patients
Baseline laboratory values (hemoglobin, serum
creatinine, urea, albumin, calcium, phosphate,
and urea reduction ratio) were the mean values of
the first 3 months of dialysis measured during
routine monthly blood work and this must be
recorded for all HD and PD patients (Williams et
al., 2011).
Continue,..
• Monitoring of pre-dialysis biochemical and
hematological parameters should be performed
monthly for hemodialysed patients who undergo
hemodialysis in the hospital (Mactier et al.,
2007). Hemodialysed patients will experience
rising PTH level due to hypocalcemia and
reduced the active form of vitamin D
(International Society of Nephrology, 2017).
Hence, assessment of PTH level should be
conducted regularly (International Society of
Nephrology, 2017).
Continue,..
• Attention must be given to the rise of PTH level
to avoid complication such as bone mineral
disorder due to the lower of calcium level
(Tentori et al., 2015).
Monitoring of HD patients
• Monitoring of patients on hemodialysis process is important to be
monitored; before, during and after hemodialysis.

• Before hemodialysis, patient’s body weight and blood pressure

should be measured. Measuring the body weight before starting
hemodialysis process aims to predict how many liters of fluid to
excrete from the body by hemodialysis machine. Measuring blood
pressure purposes to decide whether hemodialysis process starts. If
the blood pressure to low, consideration of the starting of
hemodialysis process is important.
• During hemodialysis, patient’s blood pressure should be controlled
every frequently, to avoid the hypotension.
• After hemodialysis, blood pressure and body weight are to be
measured as shown in Table below. This record is for the physicians
to know the progress of hemodialysis.
The Monitoring of HD Process
No Time Process

1 Before Hemodialysis
 Record weight of patient
 Measure Blood Pressure in lying and standing position
 Assess patient for any new symptoms and examine patient
 Plan target Ultra Filtration (UF) and assess dry weight of
patient

2 During Hemodialysis
 The patient’s BP should be monitored and recorded as often
as necessary.
 In an unstable patient the BP should be checked every 15
minutes.
 In a stable patient BP is checked every 30 - 60 minutes.
 In diabetic patients attempts should be made to measure
the capillary blood glucose levels to detect any episode of
hypoglycemia.

3 After Hemodialysis
 Measure blood pressure
 Record the UF done
 Measure post dialysis weight
Clinical Practice Pattern of HD
• Usually, hemodialysis center in all of the
hospitals will do the treatment process
appropriate with the guideline that they used.
One of the guidelines which was famous for
hemodialysis ward is KDOQI Clinical Practice
Guideline Hemodialysis (National Kidney
Foundation, 2015).
Continue,..
• According to the clinical practice guidelines, the frequency of hemodialysis
is three times per week, the duration should not be less than 4 hours for
every session with careful consideration, meanwhile hemodialysed patients
who had frequency of hemodialysis two times in a week should get a higher
sessional dose of dialysis (Mactier, Nephrologist, Infirmary, & Glasgow,
2007).
• National Kidney Foundation guideline described the type of hemodialysis
based on the frequency and duration to be followed by physician or
hemodialysed patients as shown in Table 1. Heart failure and fluid overload
are common and a major cause of morbidity and mortality in the dialysis
population, hence, the proper duration of dialysis should be considered
(Arbor Research Collaborative, 2013).
Table 1

Proposed Name Time of Day Duration Frequency (sessions

per week)
(hours per Session)
Conventional HD Day time 3–5 3
Frequent HD
Short Day time <3 5–7
Standard Day time 3–5 5–7
Long Night time 5–7 5–7
Long HD
Long Thrice Weekly Night time or Daytime >5 3
Long every other night Night time >5 3.5
Long frequent Night time >5 5–7
Hepatitis Complication
• Hepatitis B or hepatitis C is one of the greater risk of seroconversion
which is common among hemodialysed patients (D. A. Goodkin et
al., 2001).
• According to Ministry of Health India guideline, the hemodialysed
patient is particularly susceptible to several infections both bacterial
occasioned by the decreased immunity and blood borne viral
infections. Bacterial infection is adding a higher short term
mortality and also rising the risk of long term cardiovascular
complications according to some studies (Ministry of Health &
Family Welfare Govt. of India, n.d.).
• The important infections that usually develop in hemodialysed
patients include viral infections such as hepatitis B and C, HIV and
bacterial infections, especially those involving vascular access.
Quality of Life Patients on HD
• One of the purpose for continues treatment or medication is to
increase quality of life of the hemodialysed patients. Hemodialysis is
one of the continuous treatment of renal failure. One of the
instruments to assess the quality of life patients is Kidney Disease
Quality of Life-24 (KDQoL-24).
• This instrument is valid and available in the RAND-health website.
The instrument has the English language version and some
translated into other language. If a translate version of the purposed
country is not available then instrument must be translated to into
purpose country language and pilot study is required to assess and
reliability for that country.
Continue,…
• In the KDQoL-24, there were 24 questions with
4 categories of questions; health (11 questions),
kidney disease (3 questions), effects of kidney
disease on daily life (8 questions) and
satisfaction with care (2 questions). The RAND
website also provide the manual scoring
(manual standard) as a guideline to determine
the value of the quality of life based on KDQoL
SF-36. Hence the manual standard can also be
used for KDQoL SF-24.
 Common risk factors
Kidney Failure
•Uremic toxins
Death
•Endocrine abnormalities; anemia and vitamin D and klotho
deficiency
•Sympathetic nervous system activation
•Chronic kidney disease mineral bone disorder; fractures, Dialysis-related factors
vascular calcification •Vascular access and infection
•Accelerated aging •Blood loss and intravenous iron requirement
•Inflammation and oxidative stress •Rapid electrolyte and lipid volume changes
•Impaired antibacterial defences •Post-dialysis fatigue
•Electrolyte abnormalities •Immune system activation
•Volume overload •Bio incompatible peritoneal dialysis fluids
•Poorly understood consequences of calcium and alkali
•Protein structure modification
•Altered lipid and lipoprotein profile and function balance
•Potential viral contamination
•Hemodialysis water impurities
Arteriosclerosis; arterial
Atherosclerosis
stiffness

Ischemia Diastolic dysfunction and left

ventricular hypertrophy Transplantation-related factors
•Major surgery (once)
•Immunosuppress drugs
Replacement of renal function? Increased infection
Increased malignancy
Adverse Cardiovascular risk
profile
•Chronic rejection: inflammation
No renal replacement Dialysis: insufficient Transplantation:
therapy corrections of all partial or full
renal functions corrections of all
Death renal functions
Continue Factors of Death among
HD Patients
• it was explained that artherosclerosis, ischemia, diastolic
dysfunction and left ventricular hyperthropy are
asscociated with death among hemodialysed patients.
Beside that, vascular access and infection, blood loss and
intravenous iron supplement, rapid electrolyte and lipid
volume changes, post dialysis fatigue, immune system
activation, potential viral contamination and
hemodialysis water impurities are other factors
associated with death during dialysis process.
 Table 2.9 Factors that Reduce Risk of Death in Dialysis Patients*
• *Adopted from guideline (Ministry of Health & Family Welfare Govt. of India, n.d.)

Factors to Reduce Risk of Death

No Component Process
1 Dialysis time Greater than four hours

2 Pre dialysis BUN Between 70 - 90 mg/dl with

adequate protein Catabolic rate
(PCR)

3 Erythropoietin & antihypertensive drugs Requirement for the low dose

4 Plasma albumin Greater than 4 gms/dl

5 Plasma cholesterol Between 200 - 300 mg/dl

6 Pre dialysis creatinine Greater than 12.5 mg/dl

Hemodialysis in Indonesia
• Indonesia is one of the countries that have high
prevalence of hemodialysed patients
(Prdjosudjadi, W., Suhardjono, 2009). Lack of
publication related to hemodialysis in Indonesia
made Indonesian Renal Registry (IRR) report
one of the valid data available on issue about
hemodialysis, causes, prevalence and mortality
incidence.
Distribution of Gender for Hemodialysed
patients from 2007 to 2012 in Indonesia*
Year Male (N) Female (N)

2007 1113 772

2008 1157 779

2009 2864 1843

2010 3154 2030

2011 4180 2771

2012 5602 3559

Distribution of Age for
Hemodialysed patients in 2012 in
Indonesia*
No Age (years New Patient Active Patient Active Patient up
old) up to 30th June to 31th Des

1 ≤ 14 0.41% 0.22% 0.19%

2 15-24 2.96% 2.11% 2.87%

3 25-34 7.73% 8.99% 8.70%

4 35-44 15.49% 17.46% 18.85%

5 45-54 27.82% 30.26% 29.21%

6 55-64 24.19% 25.92% 26.06%

7 >65 21.41% 15.03% 14.11%

The Percentage of AKI, ARF and
ESRD Patient in 2012 in Indonesia*
Disease Percentage Patient Number

AKI 5% 874

ARF 12% 1893

ESRD 83% 13213

The Etiology Related to
Hemodialysed Patients in 2012 in
Indonesia*
Disease Percentage Patient
Number

Hypertension 35% 5654

Nephropathy Diabetic 26% 4199
GNC (Glomerulopathic Primer) 12% 1966
PNG (Pyelonephritis Chronic) 7% 1083
Nephropathy Uric Acid 2% 224
Polytheistic Renal 1% 169
Others 6% 989
No Data 2% 359
The Causes of Mortality Among
Indonesian Patients on
Hemodialysis in 2012*
Causes Percentage Number of Patients

Cardiovascular 47% 1557

Cerebrovascular 12% 395

GI Bleeding 5% 157

Sepsis 13% 433

Others 8% 274

No Data 15% 516

Medication
• Prescribing medication should be based on the
guideline and it should cover all conditions in
terms of the effects caused by end-stage renal
disease. Every patient has different condition
due to severity of disease and type of
complication.
 No List of The Drugs

1 Supplement to prevent from loss of calcium

-IV alpha Calcitriol 1 mcg 3 times/week

-Rocaltriol 0.25 microgram 3 times/week
-IV Bonky 2 mcg 3x/week
-IV Bonky 3 mcg 3x/week
-Calcitriol 0.25 mcg 3x/week
-Rocaltriol 0.75 mcg 3x/week
-Calcitriol 0.75 mcg 3x/week
-Rocaltriol 0.5 mcg 3x/week
-Calcitriol 0.5 mcg 3x/week
-Calcitriol 0.25 mcg 2x/week
-IV Bonky 1 mcg 3x/week
-alpha Calcidol 4 mcg/ week
-alpha Calcidol 0.5 mcg 3 times/ week
-alpha Calcidol 2 mcg 3 times/ week
-IV Calsijex 4 mcg 3 times/week
-IV Calsijex 2 mcg 3 times/week + RoCaltriol 1,25 mcg OD

2 Rhu-EPO

-Erythropoietin (EPO) 2000/week

-EPO 4000/week
-EPO 6000/week
-EPO 8000/week
-EPO 10000/week
-EPO 12000/week

3 Antihypertensive
 No List of The Drugs

4 Antidiabetic drugs

-Insulin
-Gliquidone 30 mg BD
-Gliquidone 30 mg OD
-Gliquidone 15 mg OD
-Linagliptin 5 mg OD
-Novorapid insulin
-Gliclazide 80 mg OD
-S/C mixtard 10/10
-S/C mixtard 20/16
-Gliclazide 40 mg OD
-Actrapid 18ii TDS + Insulatard 26ii ON
-Actrapid 14ii TDS + Insulatard 16ii ON
-S/C mixtard 22/18
-Actrapid 20ii TDS + Insulatard 20ii ON
-S/C mixtard 18/16
-S/C mixtard 36/26
-SC Mixtard 14/4 BD
-SC Mixtard 12/1 BD

5 Cardiovascular drugs

-Nitrokaf 5 mg OD
-ISDN 5 mg OD
-Nitrokaf 5 mg OD + Miozidine 35 mg BD
-Nitrokaf 2.5 mg OD
-Adalat 10 mg OD
-Nitrokaf 5 mg BD
-ISDN 5 mg BD + Nitrokaf 2.5 mg OD
-Nitrokaf 2.5 mg BD
-Vasteral 20 mg tds + Digoxin 0,0625 mg
-Digoxin 0.0625 mg
-Isordil 10 mg TDS
-Adalat 10 mg TDS
-Adalat 20 mg TDS
-Vasteral 20 mg TDS
-Vasteral 20 mg BD + Trimetazidine 20 mg BD
-Vasteral 20 mg TDS + Isordil 10 mg TDS
6 Dyslipidemia drugs

-Simvastatin 20 mg ON
-Lipanthyl 300 mg OD
-Lovastatin 20 mg ON
-Simvastatin 40 mg ON
-Lovastatin 40 mg ON
-Simvastatin 40 mg ON + Gemfibrozil 300 mg BD
-Simvastatin 20 mg ON
-Gemfibrozil 300 mg OD + Simvastatin 20 mg ON
-Atorvastatin 40 mg ON
-Simvastatin 10 mg ON
-Atorvastatin 20 mg ON
-Gemfibrozil 300 mg BD
7 Antiplatelet

-Clopidogrel 75 mg OD
-Aspilet 80 mg OD + Clopidogrel 75 mg OD
-Aspirin 75 mg OD
-Aspirin 150 mg OD
-Cardiprin 100 mg OD
-Clopidogrel 75 mg OD
-Glyprin 1/1 OD
Continue,..
• Using of supplement to prevent from loss of calcium (calcitriol/rocaltriol)
will cover the reduction of calcium level in the body (Galvao, Nagode,
Schenck, & Chew, 2013; Quarles, Davida, Schwab, Bartholomay, &
Lobaugh, 1988; Sauders, 2003).
• Some studies have shown small reductions in both systolic and diastolic
pressures from the use of supplement to prevent from loss of calcium (I.
Reid et al., 2005; I. Reid, Ames, & Mason, 2010; I. R. Reid, Bolland,
Sambrook, & Grey, 2011).
• It can be caused by the effect of supplement to prevent from loss of calcium
in reduction of cardiovascular disease complication among hemodialysed
patients (I. R. Reid et al., 2011) and as mentioned in some studies and
guidelines that cardiovascular disease will increase probability of dying
among those patients (Culleton et al., 2007; K/DOQI Work Group, 2005).
Continue…
• Erythropoietin recombinant was given to hemodialysed patients
who had anemia. The lower hemoglobin level from the normal value
is one of the anemia indicators. Hemoglobin level prolonged the
duration of hemodialysis among hemodialysed patients in a HD
center Penang, Malaysia. The lowering of hemoglobin level indicates
the anemia in hemodialysed patients (Berns, 2006; Marry Anne &
Alledredge, 2013). Almost all those patients have a chance to get it
due to the reduction of erythropoietin in the (Marry Anne &
Alledredge, 2013; Mcallister, Li, Liu, & Simonsmeier, 2018).
Erythropoietin is a hormone to help bone marrow to produce red
blood cells (Marry Anne & Alledredge, 2013; Mcallister et al., 2018;
Price, 2008).
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