.. 2557
Hemodialysis Clinical Practice
Recommendation 2014
.. 2557
ISBN 978-616-91290-7-3 : : 4 2 10320 02-716-6091, 02-716-7450 02-718-1900 E - mail: [email protected]
1 : 2557 (154 )
: 2,000
: : facebook.com/BanTaiSoiDesign : 39/205-206 84 10210 02-996-7392-4 02-996-7395
(hemodialysis)
(Thailand Renal Replacement
Therapy Registry, TRT) .. 2553
(prevalence case) 30,835
482.6
(incidence case) 6,244 97.73
..
2557
1 2557
.. 2555
31 2555
.. 2555
.. 2556
(Quality of Evidence)
(Strength of Recommendation)
(Guide to Develop
Clinical Practice Guidelines)
9 .. 2554
.. 2557
1 2557
.. 2555
.. 2555
31 2555
1 1
2
1.
19
2.
26
3. 34
4. 38
5. 44
6.
49
7. 53
8.
62
9. 68
10. 81
11. 90
12. 99
13.
104
14. 114
15. 122
16. 125
17. 130
3 .. 2557
1. 133
2. 134
3.
135
4.
137
1
24
2 . 42
. endotoxin
43
3 4Ts Scoring System
Heparin (HIT) 2 48
4
52
5 59
6
73
7
(Intradialytic Hypertension) 97
8
(Intradialytic Hypotension) 103
9 112
10
128
11
129
1
33
2 37
3 B C
61
4 80
5
98
6
113
1
1
1.
1.1
1. 4
2. 3
(estimated Glomerular Filtration
Rate, eGFR) 7 .//1.73
3. 1
1
(++/I)
1.2
4 (++/I)
1.3
1. eGFR 6 .//1.73
2 .. 2557
2. 5 eGFR 6 ./
/1.73
2.1
2.2
2.3
2.4
2.5
(++/I)
2.
2.1
3 arteriovenous fistula (AVF)
4-6 arteriovenous graft (AVG) graft
(++/III)
3
2.2
4
(+/IV)
2.3
AVF
AVG
(permanent catheter) (++/II)
2.4
(++/IV)
2.5 AVF
(+/II)
2.6 AVF
6 (+/IV)
2.7
internal jugular vein
(+/IV)
4 .. 2557
2.8 AVF
AVG (+/III)
3.
3.1
(++/IV)
3.2
(biocompatibility)
(++/I)
3.3 (reuse dialyzer)
(+/I)
3.4 (bloodline)
(-/IV)
4.
4.1
AAMI
regular pure European Pharmacopoeia
online hemofiltration hemodiafiltration
ultrapure (++/II)
5
4.2 reverse
osmosis (recirculation
loop) (++/IV)
4.3
(++/IV)
5.
5.1
unfractionated heparin
low molecular weight heparin (++/II)
5.2
(++/II)
5.3 heparin (hep-arin-induced thrombocytopenia, HIT) 2
(++/II)
6 .. 2557
5.4
(++/IV)
6.
6.1
(first few sessions) (++/IV)
6.2
(dialysis disequilibrium syndrome)
40 (++/III)
7.
7.1
(++/I)
7.2
(+/IV)
7
7.3
(standard precaution) (++/I)
7.4
(++/I-2)
7.5 external pressure
transducer
internal pressure transducer
(+/IV)
7.6
clamp
(disinfection)
(+/IV)
7.7
HIV 6-12
(+/I)
8 .. 2557
8.
8.1
3
(++/IV)
8.2
(Hb) 1
(++/IV)
8.3 (iPTH)
6
(++/IV)
8.4
18 24 / (++/III)
8.5
4 5.5 / (++/III)
8.6
Kt/V
/ urea reduction ratio 3 (++/II)
9
9.
9.1
6
(++/III)
9.2
30-35 / 1 /
1.2 / 1 / (++/I)
9.3
(++/III)
10.
10.1
(++/I)
10.2
(acute coronary
syndrome)
10 .. 2557
aspirin nitroglycerin
(++/IV)
10.3
(cardiac arrhythmia)
(++/IV)
10.4
(air embolism) clamp
blood pump 100%
(++/IV)
10.5
(anaphylaxis) A clamp blood line
B
(++/IV)
11.
11.1
30
(++/IV)
11
11.2
140/90 . 130/80 .
(++/III)
11.3 (non
pharmacological therapy)
/
1. 2-3
2. 18.5-23 .
3.
4.
(probing dry-weight)
5.
sodium profile (++/IV)
11.4 angiotensin
coverting enzyme inhibitor (ACEI) angiotensin II
receptor blocker (ARB)
b-blocker calcium
channel blocker (++/III)
12 .. 2557
11.5 (intra-dialytic hypertension)
(++/II)
11.5
(++/III)
12.
12.1 (intra-dialytic hypotension)
(++/I)
12.2
(++/II)
12.3
(++/II)
13
13.
13.1
3
(++/IV-1)
13.2
2.7-4.9 ./. 9.0-10.2
./. (++/IV-2)
13.3 (intact para-thyroid hormone, PTHi) 2 9
130-600 /. (++/IV-2)
13.4
(phosphate binder)
(++, III-2)
13.5 2
active (+, IV-1)
14 .. 2557
13.6
(+, IV-2)
14.
14.1
(hemoglobin, Hb)
13.0 /. 12.0 /.
15 (++/IV-1)
14.2
(erythropoiesis stimulating agent, ESA)
Hb 10 /.
(+/IV-1)
14.3 ESA
Hb 10-11.5 /. 13 /. (+/I-1)
14.4 ESA
ferritin 500 % TSAT
30
1-3
(++, III)
14.5 epoetin 300
( 450
15
) Hb
ESA
(+, IV-1)
15.
15.1
(residual renal function)
(+, IV-1)
15.2
(++, IV-2)
16.
16.1
(++, IV-1)
16.2
(narrow therapeutic index)
(++, III)
16.3
(++, III)
16 .. 2557
17.
17.1
(++, IV-1)
17.2 (withhold) (withdraw)
1.
2.
3.
4.
5. ( )
17
6. 75
2 4
1)
1
2) comorbidity score ( Charleson
comorbidity score > 8 French Renal Epidemiology and Information Network (FREIN) 6-Month Prognosis Clinical
Score > 9)3)
(Functional Status) ( Karnofsky Perfor-mance Status score 40)
4) (++, IV-1)
19
2
1.
1.1
1. 4
2. 3
(estimated Glomerular Filtration Rate,
eGFR) 7 .//1.73
3. 1
1
(++/I)
.. 2552
20 .. 2557
(1)
1)
3 (eGFR 30 - 59 .//1.73 )
2) 4 (eGFR 15 - 29 .//1.73 )
(renal replacement therapy)
(2)
( 1
)
1.2
4 (++/I)
4
21
(vascular access)
(3)
1.3
1, eGFR 6 .//1.73
2. 5 eGFR 6 ./
/1.73
2.1
2.2
2.3
2.4
2.5
(++/I)
22 .. 2557
4
eGFR 5 - 7 .//1.73
eGFR 10 - 14 .//1.73
6 (4)
(5)
4
(6)
1
1. Smart NA, Titus TT. Outcomes of early versus late nephrology referral in chronic kidney disease: a systematic review. Am J Med 2011; 124:1073 - 80.
2. Chan MR, Dall AT, Fletcher KE, et al. Outcomes in patients with chronic kidney disease referred late to nephrologists: a meta - analysis. Am J Med 2007; 120:1063 - 70.
3. Luxton G; CARI. The CARI guidelines. Timing of referral of chronic kidney disease patients to nephrology services (adult). Nephrology (Carlton) 2010;15 Suppl 1:S2 - 11.
23
4. Cooper BA, Branley P, Bulfone L, et al. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med 2010; 363:609 - 19.
5. Harris A, Cooper BA, Li JJ, et al. Cost - effectiveness of initiating dialysis early: a randomized controlled trial. Am J Kidney Dis 2011; 57:707 - 15.
6. Pollock CA, Cooper BA, Harris DC. When should we commence dialysis? The story of a lingering problem and todays scene after the IDEAL study. Nephrol Dial Transplant 2012; 27:2162 - 6.
24 .. 2557
1
Estimated GFR*
(.// 1.73
)
(./)
< 30 30 - 300 > 300
A1 A2 A3
G1 > 90 /
G2 60 - 89
G3a 45 - 59 G3b 30 - 44
G4 15 - 29
G5 < 15 ( )
- - -
25
* Estimated glomerular filtration rate (eGFR)
CKD - EPI (Chronic Kidney Disease
Epidemiology Collaboration)
enzymatic method ( modified kinetic Jaffe
reaction )
Serum Creatinine
(./.) eGFR
< 0.7 144 x (SCr/0.7) - 0.329 x (0.993)Age
> 0.7 144 x (SCr/0.7) - 1.209 x (0.993)Age
< 0.9 141 x (SCr/0.7) - 0.411 x (0.993)Age
> 0.9 141 x (SCr/0.7) - 1.209 x (0.993)Age
26 .. 2557
2.
2.1
3 arteriovenous fistula (AVF)
4 - 6 arteriovenous graft (AVG) graft
(++/III)
(temporary double lumen catheter)
(permanent)
6 - 8 AVF AVG
graft
2 - 4 (1)
2.2
27
4
(+/IV)
(patency)
4(2)
2.3
AVF
AVG
(permanent catheter) (++/II)
AVF (throm-bosis)
AVG
1 6 1 10
28 .. 2557
(3,4)
2.4
(++/IV)
(informed consent)
2.5 AVF
(+/II)
(isometric exercise)
AVF
AVF (2,5)
29
2.6 AVF 6
(+/IV)
AVF
(continuous thrill)
(arterial anastomosis) (outflow
vein) stethoscope (bruit)
diastole systole
6 Rule of Six
6 AVF,
600 ./, 6 ..
6 .. AVF
6 AVF
accessory vein
pulse
systole
(6)
2.7 internal
jugular vein
(+/IV)
30 .. 2557
internal jugular
vein (stenosis)
subclavian vein femoral
vein internal jugular vein
(exit site)
(tunnel)
2.8 AVF
AVG (+/III)
AVF AVG
pulse
dynamic venous pressure, static intra -
access pressure access flow
recirculation ( urea - based method) pre - pump
31
negative pressure
(7)
1) blood flow
2)
3) static intra - access pressure
/ access flow
4)
5)
( 1
)
32 .. 2557
2
1. Ortega T, Ortega F, Diaz - Corte C, Rebollo P, Ma Baltar J, Alvarez - Grande J. The timely construction of arteriovenous fistulae: a key to reducing morbidity and mortality and to improving cost management. Nephrol Dial Transplant 2005; 20:598 - 603.
2. Hakim RM, Himmelfarb J. Hemodialysis access failure: A call to action. Kidney Int 1998; 54:1029 - 40.
3. Rayner HC, Pisoni RL, Gillespie BM, et al. Creation, cannulation and survival of arterio - venous fistulae - data from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Kidney Int 2003; 63:323 - 30.
4. Thomson P, Stirling C, Traynor J, Morris S, Mactier R. A prospective observational study of catheter - related bacteraemia and thrombosis in a haemodialysis cohort: univariate and multivariate analyses of risk associations. Nephrol Dial Transplant 2010; 25:1596 - 60.
5. Salimi F, Majd Nassiri G, Moradi M, et al. Assessment of effects of upper extremity exercise with arm tourniquet on maturity of arteriovenous fistula in hemodialysis patients. J Vasc Access 2013; 14:239 - 44.
6. Sands J. Vascular access: the past present and future. Blood Purif 2009; 27:22 - 7.
7. McCauley P, Wingard RL, Shyr Y, Pettus W, Hakim RM, Ikizler TA. Vascular access blood flow monitoring reduces access morbidity and costs. Kidney Int 2001;
60:1164 - 72.
33
1
Vascular Access: AV fistula graft
Arm swelling Difficult cannulation Loss of continuous bruit Prolonged bleeding Decreased URR/Kt/V >10% x 2
without other causes Recurrent clotting >2/mo Dialyzer clotting or poor reuse
Hemodynamic Dynamic venous pressure
>120 mmHg @ BFR 200 ml/min x 3 Static venous pressure
>0.5 ratio @ BFR 0 ml/min x 2 Recirculation >10% (by BUN) Inability to achieve BFR Decreased Intra-access flow
Intervention : Stent, Thrombolysis, Revision, Graft replacement w/AVF
Surgical Correction
Doppler U/S
Fistulogram
Intervention
34 .. 2557
3.
3.1
(++/IV)
3.2
(biocompatibility)
(++/I)
neutrophil monocyte
(1)
urea kinetic model
( 8.6)
35
3.3 (reuse dialyzer)
(+/I)
(2)
- -
American Association for the Advancement
of Medical Instrumentation (AAMI)
total cell volume (TCV) ultrafiltration
(UF) coefficient TCV
80% UF coeff 75%
(3) ( 2
)
(CDC)
(4)
36 .. 2557
3.4 (bloodline)
( - /IV)
5
3
1. Takemoto Y, Naganuma T, Yoshimura R. Biocompati-bility of the dialysis membrane. Contrib Nephrol 2011; 168:139 - 45.
2. Galvao TF, Silva MT, Araujo ME, Bulbol WS, Cardoso AL. Dialyzer reuse and mortality risk in patients with end - stage renal disease: a systematic review. Am J Nephrol 2012; 35:249 - 58.
3. Association for the Advancement of Medical Instru-mentation. Reuse of Hemodialyzers. AAMI Recommended Practice ANSI/AAMI RD47:2002 and RD 47:2002/A1:2003. Arlington, VA: Association for the Advancement of Medical Instrumentation, 2003.
4. Fabrizi F, Messa P, Martin P. Transmission of hepatitis C virus infection in hemodialysis: current concepts. Int J Artif Organs 2008; 31:1004 - 16.
37
2 (3)
Dialyzer Reprocessing 1. Rinse / Pre-clean 2. Clean 3. Inspect / Test 4. Disinfect 5. Document / Store
1. Rinse / Pre-clean Remove some of
the blood from the blood component
RO water preferably used, within 10 min
2. Clean Peracetic acid Bleach
(sodium hypochlorite) Hydrogen peroxide
3. Inspect / Test Inspect: crack, defect Performance Test
TCV > 80% baseline UF coefficient > 75%
Pressure Leak Test
4. Disinfect Peracetic acid Formaldehyde Glutaraldehyde Heat disinfection
with acetic acid
5. Document / Store Record summary Storage conditions:
clean; minimize deterioration, contamination, and breakage
Dialyzer
Reprocessing
Safe and effective way to keep the cost of dialysis within reasons
Reuse: To use own dialyzer, after being reprocessed, for multiple treatments
38 .. 2557
4.
4.1
AAMI
regular pure European Pharmacopoeia
online hemofiltration hemodiafiltration
ultrapure (++/II)
AAMI (1) European
Best Practice Guideline(2)
endotoxin online hemofil-tration hemodiafiltration
endotoxin
ultrapure(3) ( 2
endotoxin )
4.2 reverse
osmosis (recirculation
loop) (++/IV)
39
reverse osmosis (RO)
RO membrane
endotoxin
(recir-culation)
6
endotoxin
4.3
(++/IV)
.. 2550 (4)
40 .. 2557
1) AAMI 1
2) 1 spread
plate membrane filtration Tryptone
glucose extract agar Reasoners agar No. 2 (20o - 22o
7 )
3) endotoxin 3 1
hemofiltration hemodiafiltration
limulus amoebocyte lysate (LAL)
6
endotoxin (
100 CFU/mL endotoxin 0.25 EU/mL)(5)
AAMI action level ( 50 CFU/mL
endotoxin 0.125 EU/mL)
biofilm
41
4
1. Association for the Advancement of Medical Instrumentation. Guidance for the preparation and quality management of fluids for hemodialysis and related therapies, ANSI/AAMI/ISO 23500:2011, Arlington, VA: Association for the Advancement of Medical Instrumentation, 2011.
2. European Directorate for the Quality of Medicines. Purified water. In: European Pharmacopoeia 6.3. Strasbourg, 2009, pp 4344 - 6.
3. Damasiewicz MJ, Polkinghorne KR, Kerr PG. Water quality in conventional and home haemodialysis. Nat Rev Nephrol 2012; 8:725 - 34.
4. . .. 2550. [ 1 .. 2557]. : www.nephrothai.org/news/news. asp?type=KNOWLEDGE &news_id=133
5. International Organization for Standardization. Quality of dialysis fluid for hemodialysis and related therapies (ANSI/AAMI/ISO 11663:2009). Arlington, VA, Associaltion for the Advancement of Medical Instrumentation, 2010.
42 .. 2557
2
.
AAMI (201
1)
European
Pharm
acopoeia
(./
)
AA
MIEu
ropea
n Ph
armac
opoe
ia
Aluminum
0.01
00
0.01
00
AA spec
trometry
Chloramines
0.10
00
0.10
00
Colorim
etry
Free
chlorine
0.50
00
0.50
00
Colorim
etry
Cop
per
0.10
00
0.10
00
AA spec
trometry
Fluo
ride
0.20
00
0.20
00
Molec
ular pho
toluminesce
nce
Lead
0.00
50
0.00
50
AA spec
trometry
Nitrate
2.00
00
2.00
00
Colorim
etry
Sulfa
te
100
100
Turbidim
etric
metho
d
Zinc
0.10
00
0.10
00
AA spec
trometry
Calcium
2 (0.05
/)
2 (0.05
/)
AA spec
trometry
Magn
esium
4 (0.16
/)
2 (0.08
/)
AA spec
trometry
Potassium
8 (0.2
/
)
2 (0.08
/)
Flame
pho
tometry
Sodium
70 (3.0
/)
50 (2.2
/)
Flame
pho
tometry
Antim
ony
0.00
60
0.00
60
AA spec
trometry
Arsen
ic
0.00
50
0.00
50
AA spec
trometry
43
(./
)
AA
MIEu
ropea
n Ph
armac
opoe
iaBa
rium
0.10
00
0.10
00
AA spec
trometry
Berylliu
m
0.00
04
0.00
04
AA spec
trometry
Cadmium
0.00
10
0.00
10
AA spec
trometry
Chrom
ium
0.01
40
0.01
40
AA spec
trometry
Cya
nide
0.02
00
0.02
00
Spec
tropho
tometric
Mercu
ry
0.00
02
0.00
10
AA spec
trometry
Selenium
0.09
00
0.09
00
AA spec
trometry
Silver
0.00
50
0.00
50
AA spec
trometry
Thalliu
m
0.00
20
0.00
20
AA spec
trometry
2
.
e
ndotoxin
AAMI
(201
1)
Europ
ean
Pharm
acop
oeia
Regu
lar
water
Ultrap
ure
water
Sterile
wate
r for
substit
ution
(CFU
/ml)1
Action
leve
l< 10
0< 50
< 10
0< 0.1
< 0.00
0001
e
ndotox
in (EU
/ml)2
Action
leve
l< 0.25
< 0.12
5< 0.25
< 0.03
< 0.03
1
spread p
late
m
embrane
filtratio
n
low n
utrie
nt m
edia
Tryptone
glucose
extract agar (TGEA
)
Reasone
rs a
gar No. 2 (R2A
)
20o - 2
2o
7
2 Lim
ulus a
mebocyte lysate test
turbidim
etric kinetic
assay
gel clot
44 .. 2557
5.
5.1
unfractionated heparin low
molecular weight heparin (++/II)
unfractionated heparin
(1) 50 IU/.
loading dose maintenance dose
800 - 1,500 IU 2
(constant infusion)
infusion pump (repeated bolus)
30
heparin kinetics heparin
activated clotting time
(ACT) 80% low molecular
weight heparin
unfrac-tionated heparin (
bolus ) (
)
45
heparin
protamine sulfate
1 protamine sulphate 100
unfractionated heparin
heparin kinetics heparin
5.2
(++/II)
100 - 300 .
30 citrate
citrate unfrac-tionated heparin
ACT
40% low molecular weight hepain
anti - Xa - level 0.2 - 0.3 0.4 IU/mL(2)
46 .. 2557
5.3 heparin (heparin -
induced thrombocytopenia, HIT) 2
(++/II)
HIT 0.32
100
50%
150,000/. heparin
2 HIT 1
1 - 2
heparin
(immune - mediated reaction)
heparin HIT 2
heparin
platelet factor 4
4 - 20 ( 10)
(
3 4Ts Scoring System HIT 2)(2)
heparin low molecular
weight heparin cross - reaction
citrate ( 3
1 50 blood
flow 250 ) (3)
47
5.4
(++/IV)
(thrombus)
heparinized saline 1,000 IU/mL
4% citrate
(4)
5
1. Shen JI, Winkelmayer WC. Use and safety of unfrac-tionated heparin for anticoagulation during mainte-nance hemodialysis. Am J Kidney Dis 2012; 60:473 - 86.
2. Warkentin TE, Heddle NM. Laboratory diagnosis of immune heparin - induced thrombocytopenia. Curr Hematol Rep 2003; 2:148 - 57.
3. Syed S, Reilly RF. Heparin - induced thrombocytopenia: a renal perspective. Nat Rev Nephrol 2009; 5:501 - 11.
4. Besarab A, Pandey R. Catheter management in hemodialysis patients: delivering adequate flow. Clin J Am Soc Nephrol 2011; 6:227 - 34.
48 .. 2557
3
4Ts Sc
orin
g System
H
eparin
(HIT)
2
2
1
0
Throm
bocy
tope
nia
> 50%
20 - 1
00 x 10
9 /
3
0 - 5
0%
10 - 1
9 x 1
09/
10 IU/L
No
Anti-HBs (+) > 10 IU/L / HBsAg (-) / anti-HBc (+/-)
VACCINATION
+ve
RE-VACCINATION (double dose)
Yes Anti-HBs (+) > 10 IU/L
No
HBsAg (+)
1
Anti-HCV antibody test
1
(-ve)
HCV RNA levels
(+ve)
(+ve)
HCV genotyping
(-ve)
Liver function test
62 .. 2557
8.
8.1
3
(++/IV)
3
( - )
8.2
(Hb) 1
(++/IV)
63
1
Hb (11 /.)
( 15)
8.3 (iPTH)
6
(++/IV)
(metabolic bone disease)
iPTH 6
ferritin, iron total iron binding
capacity 3 - 6 ( 13
14 )
8.4
18 - 24 / (++/III)
(metabolic acidosis)
()
64 .. 2557
lactate
(catabolism) (anabolism)
thyroxine leptin
beta - 2 - microglobulin
(16 - 24 /)
(1,2)
(sodium load)
18 - 24 /
8.5
4 - 5.5 / (++/III)
65
3 - 5(3)
/
angiotensin coverting enzyme inhibitor (ACEI) angio-tensin II receptor blocker (ARB), beta - blockers, NSAIDs
5.6 4 /
(4)
cation
exchange resin
8.6
Kt/V
/ urea reduction ratio 3 (++/II)
urea Kt/V
single pool (spKt/Vurea) urea reduction ratio
66 .. 2557
(URR)
spKt/V = - ln(R - 0.008 x t) + (4 - (3.5 x R)) x UF/BW
R postdialysis/predialysis BUN ratio
t dialysis session ()
UF ultrafiltration volume ()
BW predialysis weight ()
URR = 100 x (predialysis BUN - postdialysis BUN)/
predialysis BUN
(GFR 5 ./)
3 spKt/V 1.2 URR
65%
(5) 3
spKt/Vurea URR
2
spKt/V 1.8
spKt/V 1.8 5
spKt/V 1.8 - 2.1
spKt/V (6)
2
67
8
1. Lowrie EG, Lew NL. Death risk in hemodialysis patients: The predictive value of commonly measured variables and an evaluation of death rate differences between facilities. Am J Kidney Dis 1990; 15: 458 - 82.
2. Bommer J, Locatelli F, Satayathum S et al. Association of predialysis serum bicarbonate levels with risk of mortality and hospitalisation in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2004; 44:661 - 71.
3. Morduchowicz G, Winkler J, Drazne E et al. Causes of death in patients with end - stage renal disease treated by dialysis in a centre in Israel. Isr J Med Sci 1992; 28:776 - 9.
4. Kovesday CP, Regidor DL, Mehorta R et al. Serum and dialysate potasium concentrations and survival in haemodialysis patients. Clin J Am Soc Nephrol 2007; 2:999 - 1007.
5. Lowrie EG, Zhu X, Lew NL. Primary associates of mortality among dialysis patients: trends and reassessment of Kt/V and urea reduction ratio as outcome - based measures of dialysis dose. Am J Kidney Dis 1998; 32(Suppl 4): S16 - S31.
6. Krairittichai U, Supaporn T, Aimpun P, et al. Thailand registry patient survival report on chronic hemodialysis. J Am Soc Nephrol 2005; 16:292A.
68 .. 2557
9.
9.1
6
(++/III)
6
(
), , sub-jective global assessment malnutrition inflammation
score (1) ( 6
)
normalized
protein catabolic rate normalized protein nitrogen
appearance (nPNA) two - BUN, single - pool, variable -
volume model
69
Midweek PNA = predialysis BUN/[25.8 + (1.15)/(spKt/V)
+ (56.4)/(spKt/V)] + 0.168
spKt/V Kt/V
single pool
nPNA (g/kg/d) = (PNA)/(TBW/0.58)
TBW total body water
- Watson formula:
Males: TBW = 2.447 - (0.09156 x age) +
(0.1074 x height) + (0.3362 x weight)
Females: TBW = - 2.097 + (0.1069 x height) +
(0.2466 x weight)
- Hume - Weyer formula:
Males: TBW = (0.194786 x height) +
(0.296785 x weight) - 14.012934
Females: TBW = (0.34454 x height) +
(0.183809 x weight) - 35.270121
nPNA 1.2
nPNA
(2)
70 .. 2557
9.2
30 - 35 / 1 /
1.2 / 1 / (++/I)
.. 2553(3)
30 - 35 / 1 /
1.2 / 1 /
(high biological
value)
negative nitogen calcium balance
9.3
(++/III)
(protein energy wasting)
18 - 75 International Society
71
of Renal Metabolism and Nutrition (ISRMN)
3 4 (1)
, (2) , (3) ,
(4) (4)
(systemic inflam-mation)
72 .. 2557
androgen,
growth hormone carnitine
(5) ( 4
)
1. Pupim LB, Cuppari L, Ikizler TA. Nutrition and metabo-lism in kidney disease. Semin Nephrol 2006; 26:134 - 57.
2. Combe C, McCullough KP, Asano Y, Ginsberg N, Maroni BJ, Pifer TB. Kidney Disease Outcomes Quality Initiative (K/DOQI) and the Dialysis Outcomes and Practice Patterns Study (DOPPS): nutrition guidelines, indicators, and practices. Am J Kidney Dis 2004; 44(5 Suppl 2):39 - 46.
3. . .. 2553. : ; 2553.
4. Leinig CE, Moraes T, Ribeiro S, et al. Predictive value of malnutrition markers for mortality in peritoneal dialysis patients. J Ren Nutr 2011; 21:176 - 83.
5. Ikizler TA, Cano NJ, Franch H, et al. Prevention and treatment of protein energy wasting in chronic kidney disease patients: a consensus statement by the Inter-national Society of Renal Nutrition and Metabolism. Kidney Int 2013; 84:1096 - 107.
73
6
3
< 30 - 35 /../ < 1.2 /../
* 3
7 - 10 3 - 6
(BMI) 3
18.5 ../2
Subjective global assessment (SGA)
6
B/C on 3 - point scale (A/B/C) 1 - 5 on 7 - point scale
3
3.5 /.
: serum creatinine, serum cholesterol serum cholesterol
74 .. 2557
Subjective Global Assessment Rating Form
- : ______________ HN : _______ : _______
() : Severe Mild - Moderate
Normal
RATING 6 < 5 5 - 10 > 10
2
1 2 3 4 5 6 7
(.) = . (6 ) - . x 100 / . (6 ) RATING ________ ()
1 2 3 4 5 6 7
RATING
____________________________________< 2 ,> 2
____________________________________, 1 - 2 /, 3 - 4 /,
1 2 3 4 5 6 7
- Normal: < 2 - Mild to Moderate: < 2 - Severe: > 2
75
()
RATING
6
2
1 2 3 4 5 6 7
/ RATING __________________ __________________
1 2 3 4 5 6 7
-
() : Severe Mild - Moderate
Normal
RATING , triceps, 1 2 3 4 5 6 7 , , , , ,
() : OVERALL RATING A. (Rating 6 - 7 )
B. - (Rating 3 - 5 )
C. (Rating 1 - 2 )
76 .. 2557
Modified Subjective Global Assessment -
Dialysis Malnutrition Score
- : _________________ HN : _______ : _______
(A) :
1. ( 6 ) :
1 2 3 4 5
< 5%
5 - 10%
10 - 15%
> 15%
2. :
1 2 3 4 5
3. :
1 2 3 4 5
4. () :
1 2 3 4 5
77
5. :
1 2 3 4 5 < 1
1 - 2
2 - 4 > 75
> 4
(B) :
1. (, triceps, ) :
1 2 3 4 5
()
2. (, , , , , , ) :
1 2 3 4 5
()
7 = ( 35 )
1, 2 (A)
3 - 5 (B)
> 6 (C)
78 .. 2557
Malnutrition Inflammation Score (MIS)
- : _________________ HN : _______ : _______
(A) :1. ( 3 - 6 ) :
0 1 2 3
< 0.5 .
(0.5 - 1 .)
1 .
< 5%
> 5%
2. :0 1 2 3
3. :
0 1 2 3
4. () :0 1 2 3
( )
5. :
0 1 2 3 < 1
1 - 4
( MCC*)
> 4
( MCC* 1 )
(
MCC* > 2 )
79
(B) ( SGA criteria):6. (, triceps, ) :
0 1 2 3 ()
7. (, , , , , , ) :
0 1 2 3 ()
(C) :8. : BMI = Wt (kg)/Ht 2 (m)
0 1 2 3BMI > 20 BMI 18 - 19.99 BMI 16 - 17.99 BMI < 16
(D) 9. (/.) :
0 1 2 3> 4.0 3.5 - 3.9 3.0 - 3.4 < 3.0
10. total iron binding capacity (TIBC, ./.)p :0 1 2 3
> 250 200 - 249 150 - 199 < 150 10 = ( 30 )
1, 2 (A)
3 - 5 (B)
> 6 (C)
* MCC (Major Comorbid Conditions) CHF class III or IV, full blown AIDS, severe CAD, moderate to severe COPD, major neurologic sequelae, metastatic malignancies s/p recent chemotherapy.
P transferrin (./.) : > 200 (0), 170 - 200 (1), 140 - 170 (2), < 140 (3)
80 .. 2557
4
:
,
,
BMI, S
.Albu
min
Co
ntinu
ous n
utritio
nal c
ouns
eling
Optim
ize he
modia
lysis
treatm
ent a
nd di
etary
nutrie
nt int
ake
Ma
nage
como
rbidit
ies (a
cidos
is, D
M, in
flamm
ation
, CHF
, dep
ressio
n)
Poor
appe
tite an
d/or p
oor o
ral in
take
Un
inten
tiona
l weig
ht los
s > 5%
of IB
W
E
DW
3
S.A
lbumi
n < 3.
8 g/dl
DPI
3.8 g
/dl
Maint
enan
ce nu
tritio
nal th
erapy
goals
S.Albu
min >
4.0 g
/dl
DP
I > 1.
2 g/kg
/day
DE
I 30-3
5 kca
l/kg/d
ay
Inten
sified
thera
pies
di
alysis
pres
cripti
on
paren
teral
(
S.Albu
min 140/90 . > 130/80 .
1 Non-pharmacological therapy 1. < 2-3 / 0.5-1 ./ ( 18.5-23 . ) 2. ( 0.3 .) 3. sodium profile ( 1 mEq/L 140 136 mEq/L Sodium ramp)
140-159/90-99 . - ACEI ARB > 160/100 . - 2 ACEI ARB calcium channel blocker - Furosemide
- - - / -blockers
- 2o cause(s)
- vasodilators -
2 Pharmacological therapy
+ve -ve
99
12.
12.1 (intra-dialytic hypotension)
(++/I)
15 - 55
20 .
10 .
(1)
2
/
( 8
)
100 .. 2557
12.2
(++/II)
1) (supine)
(Trendelenburg position)
2)
3)
4) normal saline 100 - 250 . 50%
glucose 50 - 100 . hypertonic
saline albumin
5) dopamine
norepinephrine
(2,3)
1)
bioimpedance
inferior vena cava
101
2)
( 0.5 - 1 .)
3)
4)
5) sodium
modeling
6) 35 - 36o
7)
Midodrine (alpha agonist) 5 - 10 . 30
(), Sertraline
(serotonin uptake inhibitor) 50 - 100 ./ carnitine
20 - 30 ././
102 .. 2557
12.3
(++/II)
/
12
1. NKF. K/DOQI clinical practice guidelines for cardiovas-cular disease in dialysis patients. Am J Kidney Dis 2005; 45 (4 Suppl 3):S1153.
2. Palmer BF1, Henrich WL. Recent advances in the prevention and management of intradialytic hypoten-sion. J Am Soc Nephrol 2008; 19:8 - 11.
3. Agarwal R. How can we prevent intradialytic hypo-tension? Curr Opin Nephrol Hypertens 2012; 21:593 - 9.
103
8
(Intradialytic Hypotension)
- Excessive interdialytic weight gain (more than 3% of body weight)
- Interdialitic food con-sumption
- Autonomic neuropathy- Myocardial infarction- Left ventricular hyper-trophy
- Diastolic dysfunction- Arrhythmia- Pericardial tamponade
- Limit interdialytic weight gain by reducing salt and water intake
- Prohibit food ingestion during hemodialysis
- Midodrine, sertraline, l - carnitine
- Treat underlying cardio-vascular diseases
- High ultrafiltration rate- Dialysis with acetate- High dialysate tempera-ture
- Electrolyte abnormalities
- Reduce ultrafiltration rate
- Dialysis with bicarbonate- Cool dialysate- Ultrafiltration modeling- Dialysate sodium mod-eling
- Increase dialysate cal-cium
- Prescribe antihipertensive or other medications that lower blood pres-sure before dialysis
- Incorrect calculation of dry weight
- Consider adjusting an-tihypertensive medica-tions or timing
- Establish an accurate dry weight
104 .. 2557
13.
13.1
3
(++/IV-1)
3
3 6
1
13.2
2.7-4.9 ./. 9.0-10.2
./. (++/IV-2)
105
(bone turnover)
(vascular calcification)
(1,2)
2.7-4.9 ./. 9.0-
10.2 ./.
13.3 (intact para-thyroid hormone, PTHi) 2 9
130-600 /. (++/IV-2)
(second generation) N-terminal
(bio-active) C-terminal (inactive) PTH
C-terminal PTH (3)
15 40(4)
(5)
(6,7)
PTHi 2
106 .. 2557
9 130-600 /.
adynamic bone disease
PTHi
13.4
(phosphate binder)
(++, III-2)
(8) (9)
-
coronary calcification
(10,11)
107
( 9
)
calcium carbonate
elemental
calcium 1,500 ./ 1)
, 2) Ca x P 63 (./.)2, 3)
2
2 4)
osteomalacia
7 ./.
4
13.5 2
active (+, IV-1)
2 active
108 .. 2557
2 ( 300
/.)
active alfacalcidol (1--hydroxyvitamin D3) calcitriol
(pulse)
(12)
1)
, 2)
, 3)
, 4) adynamic bone disease
5)
13.6
(+, IV-2)
( 900 /.)
(1)
(active vitamin D pulse therapy)
subtotal
total parathyroidectomy with autotransplantation
109
(13,14)
calcimimetics(15) ( 6
)
13
1. Block GA, Klassen PS, Lazarus JM, Ofsthun N, Lowrie EG, Chertow GM. Mineral metabolism, mortality, and morbidity in maintenance hemodialysis. J Am Soc Nephrol 2004; 15:2208-18.
2. Tentori F, Blayney MJ, Albert JM, et al. Mortality risk for dialysis patients with different levels of serum calcium, phosphorus, and PTH: the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2008; 52:519-30.
3. Herberth J, Fahrleitner-Pammer A, Obermayer-Pietsch B, et al. Changes in total parathyroid hormone (PTH), PTH-(1-84) and large C-PTH fragments in different stages of chronic kidney disease. Clin Nephrol 2006; 65:328-34.
4. Souberbielle JC, Boutten A, Carlier MC, et al. Inter-method variability in PTH measurement: implication for the care of CKD patients. Kidney Int 2006; 70:345-50.
110 .. 2557
5. Herberth J, Branscum AJ, Mawad H, Cantor T, Monier- Faugere MC, Malluche HH. Intact PTH combined with the PTH ratio for diagnosis of bone turnover in dialysis patients: a diagnostic test study. Am J Kidney Dis 2010; 55:897-906.
6. Coco M, Rush H. Increased incidence of hip fractures in dialysis patients with low serum parathyroid hormone. Am J Kidney Dis 2000; 36:1115-21.
7. Danese MD, Kim J, Doan QV, Dylan M, Griffiths R, Chertow GM. PTH and the risks for hip, vertebral, and pelvic fractures among patients on dialysis. Am J Kidney Dis 2006; 47:149-56.
8. Shinaberger CS, Greenland S, Kopple JD, et al. Is controlling phosphorus by decreasing dietary protein intake beneficial or harmful in persons with chronic kidney disease? Am J Clin Nutr 2008; 88:1511-8.
9. Kalantar-Zadeh K, Gutekunst L, Mehrotra R, et al. Understanding sources of dietary phosphorus in the treatment of patients with chronic kidney disease. Clin J Am Soc Nephrol 2010; 5:519-30.
10. Daugirdas JT, Finn WF, Emmett M, Chertow GM. The phosphate binder equivalent dose. Semin Dial 2011; 24:41-9.
11. Block GA, Raggi P, Bellasi A, Kooienga L, DM S. Mortality effect of coronary calcification and phosphate binder choice in incident hemodialysis patients. Kidney Int 2007; 71:438-41.
111
12. Duranton F, Rodriguez-Ortiz ME, Duny Y, Rodriguez M, Daurs JP, Argils A. Vitamin D treatment and mortality in chronic kidney disease: a systematic review and meta-analysis. Am J Nephrol 2013; 37:239-48.
13. Iwamoto N, Sato N, Nishida M, et al. Total parathy-roidectomy improves survival of hemodialysis patients with secondary hyperparathyroidism. J Nephrol 2012; 25:755-63.
14. Sharma J, Raggi P, Kutner N, et al. Improved long-term survival of dialysis patients after near-total parathyroid-ectomy. J Am Coll Surg 2012; 214:400-7.
15. Garside R, Pitt M, Anderson R, et al. The effectiveness and cost-effectiveness of cinacalcet for secondary hyperparathyroidism in end-stage renal disease patients on dialysis: a systematic review and economic evaluation. Health Technol Assess 2007;11:iii, xi-xiii, 1-167.
112 .. 2557
9
*
pH depen-dence
Calcium carbonate
Capsule,tablet
Elemental Ca 40% .
1.0 Constipation, GI discomfortSoft tissue and vascular calcification Hypercalcemia
Calcium acetate
Tablet ElementalCa 25% .
1.0 Metallic tasteConstipation, GI discomfortSoft tissue and vascular calcification Hypercalcemia
Aluminumhydroxide
Liquid, Tablet
Aluminum 138 mg (500 mg tablet)
1.5 X ConstipationOsteomalaciaAdynamic bone diseaseMicrocytic anemia Encephalopathy
Lanthanum carbonate
Chewable tablet
Lanthanum 418 mg
1.2 X GI discomfort
Sevelamer carbonate
Film coated tablet
0.75 X GI discomfort
* RPBC: relative phosphate-binding coefficient calcium carbonate(10)
113
6
Phosphate restricted diet
Phosphate binder
Phosphate
- calcium containing phosphate binder (elemental Ca 1,500 ./)
- calcium free phosphate binder
-
intact
PTH
2-9
> 2-9
Serum calcium, phosphate
Serum calcium / phosphate
Calcitriol 0.25-0.5 g Alfacalcidol 0.5-1 g
twice thrice a week, post HD ( 12 g/week of Calcitriol)
calcium
/
dialysate calcium 2.5 mEq/L
Calcium free phosphate binder
- low dialysate calcium 2.5 mEq/L
- Calcium free phosphate binder
Follow up
S. albumin, corrected calcium, phosphate 3
Phosphate Calcium
calcitriol / alfacalcidol
Serum calcium / phosphate
Parathyroidectomy PTHi
/
114 .. 2557
14.
14.1
(hemoglobin, Hb)
13.0 /. 12.0 /.
15 (++/IV-1)
(hemoglobin, Hb) 2
Hb 13.0 /. 12.0 /.
15 (1)
normocytic, normochromic anemia
erythropoietin (EPO)
(2)
1. Complete blood count (CBC) Hb, red
blood cell indices (mean corpuscular haemoglobin [MCH],
mean corpuscular volume [MCV], mean corpuscular
haemoglobin concentration [MCHC]),
115
2. peripheral blood smear
3. Red cell distribution width (RDW) corrected
reticulocyte count
4.
ferritin transferrin saturation (% TSAT)
5. ( vitamin
B12 folate
)
14.2
(erythropoiesis stimulating agent, ESA)
Hb 10 /.
(+/IV-1)
Hb
10 /.
Hb
(blood transfustion)
Hb
ESA Hb 10 /.
(2,3)
ESA
ferritin
116 .. 2557
100 (
200-500
) % TSAT 20
ESA 3-6 (2)
14.3 ESA
Hb 10-11.5 /. 13 /. (+/I-1)
Hb ESA
/
Hb
ESA 10-11.5 /.(4)
ESA
Hb 10-11 /.(5)
Hb 13 /.
(4)
ESA Hb
1-2 /.
117
Hb short acting
ESA (epoetin alfa epoetin beta) 80-120
( 6,000 ) 2-3
2-4
25 Hb 11 /. ESA
ESA
19-25
. 5-11 .
30
(antibody) ESA
(pure red cell aplasia)
ESA biosimilar(6)
14.4 ESA
ferritin 500 % TSAT
30
1-3
(++, III)
ferritin 500 % TSAT
50 ESA
118 .. 2557
1-3 elemental
iron 200 1
2
iron sucrose iron gluconate (non-dextran
iron) iron sucrose 100
10 maintenance
dose 50-100 1-2 iron gluconate 125
8 62.5-125 1-2
60
non-dextran iron anaphy-lactoid anaphylaxis iron dextran
ferritin 800
% TSAT 50
119
3
(iron overload) (4)
14.5 epoetin 300
( 450
) Hb
ESA
(+, IV-1)
ESA
ESA
Hb
pure red cell aplasia (PRCA)
(7)
120 .. 2557
1. ESA 3
2. Hb 0.5-1 /.
1-2
3. absolute reticulocyte count 10,000
4.
- erythroblast
5
- neurtalizaing anti-erythro-poietin antibodies
PRCA ESA
(corti-costeroids cyclophosphamide cyclosporine)
PRCA
(cold-chain)
121
14
1. World Health Organization, Centers for Disease Control and Prevention. In: de Benoist B, McLean E, Egli I, Cogswell M, eds. Worldwide prevalence of anaemia 19932005. Geneva, World Health Organization, 2008.
2. NKF. K/DOQI clinical practice guidelines and clinical recommendations for Anemia in Chronic Kidney Disease. Am J Kidney Dis 2006; 47(Suppl. 3):S9145.
3. http://www.fda.gov/Drugs/DrugSafety/ucm259639.htm (Accessed on July 1, 2014).
4. KDIGO Anemia Work Group. KDIGO clinical practice guideline for anemia in chronic kidney disease. Kidney Int Suppl 2012; 2: 279335.
5. Thaweethamcharoen T, Sakulbumrungsil R, Nopmanee-jumruslers C, Vasuvattakul S. Cost-utility analysis of erythropoietin for anemia treatment in Thai end-stage renal disease patients with hemodialysis. Value Health Regional Issue 2014; 3:44-49.
6. Praditpornsilpa K, Tiranathanagul K, Kupatawintu P, et al. Biosimilar recombinant human erythropoietin induces the production of neutralizing antibodies. Kidney Int 2011; 80:88-92.
7. Pollock C, Johnson DW, Hrl WH, et al. Pure red cell aplasia induced by erythropoiesis-stimulating agents.
Clin J Am Soc Nephrol 2008; 3:193-9.
122 .. 2557
15.
15.1
(residual renal function)
(+, IV-1)
(mid-dle molecule)
eGFR 5 .//1.73 (1,2)
24
urea clearance
Urea Clearance (Kr) = UUN x urine flow rate (./)
0.9 x BUN
(0.9 blood urea nitrogen (BUN)
90 BUN )
Kr 3 ./ eGFR 5
.//1.73 24 .
800 . urine urea nitrogen (UUN) 300 .
. BUN 60 .. Kr = (300 x
0.56) / 0.9 x 60 = 3.1 ./
123
15.2
(++, IV-2)
(3)
1.
-
(biocompatibility)
- (bicarbo-
nate-based) (ultrapure)
-
-
2.
-
-
140/90 . 130/80 .
ACEI / ARB (4)
124 .. 2557
-
NSAIDs, COX-2 inhibitors, aminoglycosides, radio-contrast media
-
15
1. Chandna SM, Farrington K. Residual renal function: considerations on its importance and preservation in dialysis patients. Semin Dial 2004; 17:196-201.
2. Termorshuizen F, Dekker FW, Van Manen JG, Korevaar JV, Boeschoten EW, Krediet RT. Relative contribution of residual renal function and different measures of adequacy to survival in hemodialysis patients: An analysis of the Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD)-2. J Am Soc Nephrol 2004; 15:1061-70.
3. Brener ZZ1, Kotanko P, Thijssen S, Winchester JF, Berg-man M. Clinical benefit of preserving residual renal function in dialysis patients: an update for clinicians. Am J Med Sci 2010; 339:453-6.
4. Xydakis D, Papadogiannakis A, Sfakianaki M, et al. Residual renal function in hemodialysis patients: the role of Angiotensin-converting enzyme inhibitor in its preservation. ISRN Nephrol 2012; 2013:184527.
125
16.
16.1
(++, IV-1)
(drug interaction)
(1,2) ( 10
)
16.2
(narrow therapeutic index)
(++, III)
(therapeutic index, TI)
(median toxic dose, TD 50)
(median effective dose,
ED 50) TI 2
126 .. 2557
aminoglycoside
(3) ( 11
)
16.3
(++, III)
30
(4)
127
16
1. Pai AB, Cardone KE, Manley HJ, et al. Dialysis Advisory Group of American Society of Nephrology. Medication reconciliation and therapy management in dialysis- dependent patients: need for a systematic approach. Clin J Am Soc Nephrol 2013; 8:1988-99.
2. Cardone KE, Bacchus S, Assimon MM, Pai AB, Manley HJ. Medication-related problems in CKD. Adv Chronic Kidney Dis 2010; 17:404-12.
3. Dosage of antimicrobial drugs in adult patients with renal impairment. In: Gilbert DN, Moellering RC, Eliopoulos GM, Sande MA, editors. The Sanford Guide to Antimi-crobial Chemotherapy 2010. 40th ed. Antimicrobial Therapy Inc.; 2008. p.186-93.
4. Bailie GR, Mason NA. 2013 Dialysis of Drugs. Renal Pharmacy Consultants, LLC, Saline, Michigan, USA.
128 .. 2557
10
Aminoglycosides Furosemide
Antacids Iron, fluoroquinolone, ketoconazole, tetracycline
Beta-blockers Prazosin first-dose syncope
Calcium acetate Fluoroquinolone antibiotics
chelation
NSAIDs Diuretic
Phenobarbital Calcium channel blockers, propranolol, quinidine, warfarin
Salicylates Heparin, warfarin
129
11
Acyclovir Delirium, tremor, seizures, hypotension
Aminoglycosides Auditory or vestibular nerve damage, curare-liked block
Cyclosporin Hypertension, neurotoxicity, liver dysfunction
Carbamazepine Diplopia, ataxia, blood dyscrasias
Digoxin Arrhythmia, nausea, vomiting, diarrhea, hallucination, visual aberrations
Fluoroquinolones GI distress, headache, dizziness, insomnia
Lidocaine Arrhythmia, cardiovascular depression, seizure
Lithium Tremor, sedation, ataxia, aphasia
Phenobarbital Sedation
Phenytoin Nystagmus, diplopia, ataxia, sedation
Procainamide Drug-induced lupus erythematosus, torsade de pointes
Quinidine Headache, tinnitus, cardiac depression, GI upset, torsade de pointes
Tacrolimus Peripheral neuropathy, gastrointestinal distress, hyperglycemia
Theophylline GI distress, tremor, insomnia, vomiting, hypotension, arrhythmia, seizure
Valproic acid GI distress, hepatotoxicity
Vancomycin Fever, chill, phlebitis, ototoxicity, red man syndrome
130 .. 2557
17.
17.1
(++, IV-1)
17.2 (withhold) (withdraw)
(1,2)
1.
2.
3.
4.
5. ( )
131
6. 75
2 4
1)
1
2) comorbidity score ( Charleson
comorbidity score > 8 French Renal Epidemiology and Information Network (FREIN) 6-Month Prognosis Clinical
Score > 9)3)
(Functional Status) ( Karnofsky Perfor-mance Status score 40)
4)
(++, IV-1)
132 .. 2557
(terminal stage)
(2,3)
17
1. Moss AH. Revised dialysis clinical practice guideline promotes more informed decision-making. Clin J Am Soc Nephrol 2010; 5:2380-3.
2. Swidler M. Considerations in starting a patient with advanced frailty on dialysis: complex biology meets challenging ethics. Clin J Am Soc Nephrol 2013; 8:1421-8.
3. Moss AH. Ethical principles and processes guiding dialysis decision-making. Clin J Am Soc Nephrol 2011; 6:2313-7.
133
(Strength of Recommendation)
++
(cost
effective)
/ (strongly recommend)
+
/ (recommend)
+/-
(neither recommend nor against)
-
(against)
- -
(strongly against)
134 .. 2557
(Quality of Evidence)
I
I - 1
I - 2
(systematic review) - (randomize - controlled clinical trials) - 1 (a well - designed, randomize - controlled, clinical trial)
II
II - 1
II - 2
II - 3
II - 4
(non - randomized, controlled, clinical trials) (well - designed, non - randomized, controlled clinical trial) (cohort) (case control analytic studies) / (multiple time series)
III
III - 1III - 2
(descriptive studies) (fair - designed, controlled clinical trial)
IV
IV - 1
IV - 2
(consensus) 2
135
.. 2553 - 2555
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
136 .. 2557
.. 2555 - 2557
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
137
.. 2553 - 2555
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
138 .. 2557
.. 2555 - 2557
1.
2.
3.
4.
5.
( )
6.
7.
8.
9.
10.
11.
12.
13.
14.