.. 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: kidney@loxinfo.co.th

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.