HD and PD

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  1. In what stage of CKD do you usually start planing for dialysis?
    Stage r
  2. What are factors to consider when deciding if dialysis should be initiated?
    • Clinical status: persistent anorexia, N/V, fatigue, pruritis, uncontrolled HTN or CHF, low albumin, neurologic deficits
    • Dialysis accessibility
    • Transplantation option
    • Vascular access
    • Age
    • Declining health
    • Fluid balance (fluid overloaded)
    • Compliance with diet and medications
  3. What is dialysis?
    A process that removes substances from blood that cannot be cleared due to decreased renal function
  4. What are some advantages of HD?
    • Higher soluble clearance --> intermittent use
    • Low technique failure rate
    • Closer patient monitoring
  5. What are some diadvantages of HD?
    • Requires multiple weekly visits to dialysis center
    • Disequilibrium, hypotension, muscle cramps are common
    • Vascular access complications
  6. What are som eadvantages of PD?
    • More hemodynamic stability
    • Suitable for pt that cannot tolerate HD
    • Sense of independence (no machine)
  7. What are some disadvantages of PD?
    • Protein and amino acid loss and decreased appetite --> malnutrition
    • Catheter malfunction and/or infection
    • Patient burnout (decreased compliance)
  8. What is convection (aka ultrafiltration)?
    • Movement of water
    • The rate depends on hydrostatic pressure gradient across the membrane and dialyzer composition
  9. What is the preferred type of vascular access and why?
    • Arteriovenous fistula
    • Long lasting
    • Lowest rate of complications
    • Require at least 2 months to "mature" before use
  10. What is the 2nd line preferrred vascular acess?
    AV graft
  11. How long does it take for an AV graft to endothelialize before use?
    2-3 weeks
  12. Do AV fistulas or grafts last longer?
    AV fistulas
  13. What type of vascular acess is placed in the subclavian or internal jugular vein?
    Cuffed or tunneled venous catheters
  14. Do low-flux or high-flux membranes act similar to the body?
  15. When is heparin administered?
    After blood pump and before dialyzer
  16. What is a common HD regimen?
    3-4 hrs TIW (MWF or TThS)
  17. What are the two goals of HD?
    • Achieve dry weight
    • Adequate removal of endogenous waste products
  18. How can you calculate a dialysis dose?
    Urea Reduction Ratio
  19. Urea-reduction ratio only accunts for urea removal via ________
  20. What is the URR calculation?
    (Pre BUN- Post BUN)/ Pre BUN x 100
  21. What is the most common complication of HD?
  22. What are some predisposing factors to hypotension?
    • Excessive ultrafiltration
    • Target dry weight is too low
    • Vasodilation with acetate containing buffer solutions
    • Diastolic dysfunction
    • Taking antihypertensive meds pre HD
    • Eating food before HD
  23. What are some non-pharmacologic preventions of hypotension?
    • Adjust dry weight
    • Use bicarbonate buffer solutions
    • Avoid food before HD
  24. What are the acute treatment options for hypotension?
    • Trendelenburg position (lay on bed with head below feet to maintain perfusion to the brain)
    • Decrease ultrafiltrate rate
    • Give IV fluids : 100-200 mL bolus of 0.9% NaCl
  25. What are the pharmacologic treatment options for hypotension?
    • Midodrine 2.5-10 mg PO 30 minutes prior to HD (alpha 1 agonist that causes vasoconstriction; pro drug so it has to be started prior to HD)
    • Caffeine
    • Levocarnitine
    • Fludrocortisone
  26. What is the possible reason of muscle cramps due to HD?
    Plasma volume contraction and decreased muscle perfusion
  27. What are the acute treatment options for muscle cramps?
    • IV Fluids
    • 100-200 ml bolus of 0.9% NaCl
    • 10-20 ml hypertonic soln over 3-5 minutes
    • 50 mL D50-- for non-diabetic patients
  28. What are non-pharmacologic preventative methods for muscle cramps?
    • Adjust dry weight
    • Stretching exercises
  29. What are pharmacologic options for preventing muscle cramps?
    • Vitamin E 400 IU QHS
    • Less studied options: oxazepam, prazosin, hydroquinine
  30. Is thrombosis more common in venous catheters or AV grafts?
    Venous catheters
  31. What are nonpharmacologic options for treating thrombosis?
    • Forced saline flush
    • Surgical thrombectomy
    • Exchange of catheter over guidewire
  32. What are two drug options for thrombosis?
    • Alteplase
    • Reteplase
  33. What is the most pre-dominant bacteria that causes infections related to HD?
    S. aureus
  34. What should you do if a patient experiences a fever during HD?
    Culture blood immediately
  35. How should you treated an infection of a tunneled cuffed catheter that has no drainage?
    Topical antibiotics
  36. How should you treated an infection of a tunneled cuffed catheter that has drainage?
    Systemic gram-positive coverage
  37. How should you treated an infection of a tunneled cuffed catheter that is bactermic with or without systemic symptoms?
    Gram positive coverage
  38. If a patient is symptomatic, how long should you wait before removing the catheter?
    36 hours
  39. If patient does not experience symptoms of infection what should be done?
    Change catheter and give culture-specific antibiotics for a minimum of 3 weeks
  40. In a local AV graft infection how long should a patient be treated?
    Narrow antibiotics once cultures returned for 2-4 weeks
  41. In an extensive AV graft infection how long should a patient be treated with antibiotics?
    • Narrow once cultures return and treat for 2-4 weeks
    • Total resection of graft
  42. What type of infection should be treated like bacterial endocarditis? How long should the patient be on antibiotics?
    • AV fistula
    • 6 weeks
  43. What are symptoms of a Type B reaction to HD?
    • Chest pain
    • Back pain
    • Compliment activation
  44. In a Type A dialyzer reaction, a patient has a hypersensitivity to what?
    Sterilizating agent
  45. When does a Type A reaction typically happen?
    Usually on initial exposure
  46. What drug can cause a Type A interaction with a bioincompatible or high-flux membrane?
    ACE inhibitor
  47. In PD which compartment is filled with dialysate?
    Peritoneal cavity
  48. What are 4 differences between PD and HD?
    • No intimate contact btwn dialysate and blood
    • No countercurrent flow
    • No way to control blood flow rates
    • Slower process
  49. What types of peritoneal access are available?
    • Permanent indwelling catheter: 40-45 cm with 20-22 cm in peritoneal cavity
    • Tunneled inside abdominal cavity: cuffs provide mechanical support and stability to the catheter
  50. What does the dialysate in PD contain?
    • Electrolytes
    • Osmotic gradients: dextrose in hyperosmolar concentrations (induces ultrafiltration) or icodextrin a starch-derived glucose polymer (alternative to dextrose)
  51. Describe the procedure of CAPD
    • 1-3 L of dialysate flows into peritoneal cavity under gravity over around 15 minutes
    • Dwells in peritoneal cavity for 4-6 hours
    • Drain
    • Replace with fresh dialysate
    • Repeated 3-4 times a day (usually single exchange with higher dextrose solution over night)
  52. What type of patients should use APD?
    For patients unable or unwilling to perform aseptic technique to catheter
  53. Describe the procedure for APD
    • Device set up in evening and catheter attached at bedtime
    • Nocturnal intermittent PD (NIPD)
    • Continuous cycling peritoneal dialysis (CCPD)
    • Nocturnal tidal PD (NTPD)
  54. What is the Kt/Vd goal for PD?
    > 2
  55. What is the total weekly CrCl?
    > 60 L/week/1.73 m2
  56. What are two mechanical complications of PD?
    • Kinking of catheter
    • Catheter obstruction
  57. List the complications of PD
    • Mechanical
    • Exacerbation of DM
    • Peritonitis
  58. What percentage of glucose from the dialysate is absorbed during each exchange?
  59. What are some symptoms of PD?
    • Abdominal pain/tenderness
    • Cloudy effluent
    • Fever and chills
    • N/V
  60. What are two signs of peritonitis?
    • Cloudy effluent
    • WBC > 100 cells with at least 50% neutrophils
  61. What is the incidence of peritonitis?
    1 episode every 24 months
  62. What is the most common bacteria that causes peritonitis?
    S. epidermidis
  63. What is the preferred route of administration for peritonitis?
  64. What are the options for gram + coverage?
    First generation cephalosporin or vancomycin
  65. What are the options for gram - coverage?
    Third generation cephalosporin or aminoglycoside
  66. What is the treatment duration for peritonitis?
    14-21 days depending on organism
  67. What type of filtration is Continuous venovenous hemofiltration?
    Convection (ultrafiltration)
  68. What type of filtration is Continuous venovenous hemodialysis?
  69. What type of filtration is Continuous venovenous hemodiafiltration?
    Combines HD and hemofiltration (convection)
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HD and PD
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