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In what stage of CKD do you usually start planing for dialysis?
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
- Declining health
- Fluid balance (fluid overloaded)
- Compliance with diet and medications
What is dialysis?
A process that removes substances from blood that cannot be cleared due to decreased renal function
What are some advantages of HD?
- Higher soluble clearance --> intermittent use
- Low technique failure rate
- Closer patient monitoring
What are some diadvantages of HD?
- Requires multiple weekly visits to dialysis center
- Disequilibrium, hypotension, muscle cramps are common
- Vascular access complications
What are som eadvantages of PD?
- More hemodynamic stability
- Suitable for pt that cannot tolerate HD
- Sense of independence (no machine)
What are some disadvantages of PD?
- Protein and amino acid loss and decreased appetite --> malnutrition
- Catheter malfunction and/or infection
- Patient burnout (decreased compliance)
What is convection (aka ultrafiltration)?
- Movement of water
- The rate depends on hydrostatic pressure gradient across the membrane and dialyzer composition
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
What is the 2nd line preferrred vascular acess?
How long does it take for an AV graft to endothelialize before use?
Do AV fistulas or grafts last longer?
What type of vascular acess is placed in the subclavian or internal jugular vein?
Cuffed or tunneled venous catheters
Do low-flux or high-flux membranes act similar to the body?
When is heparin administered?
After blood pump and before dialyzer
What is a common HD regimen?
3-4 hrs TIW (MWF or TThS)
What are the two goals of HD?
- Achieve dry weight
- Adequate removal of endogenous waste products
How can you calculate a dialysis dose?
Urea Reduction Ratio
Urea-reduction ratio only accunts for urea removal via ________
What is the URR calculation?
(Pre BUN- Post BUN)/ Pre BUN x 100
What is the most common complication of HD?
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
What are some non-pharmacologic preventions of hypotension?
- Adjust dry weight
- Use bicarbonate buffer solutions
- Avoid food before HD
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
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)
What is the possible reason of muscle cramps due to HD?
Plasma volume contraction and decreased muscle perfusion
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
What are non-pharmacologic preventative methods for muscle cramps?
- Adjust dry weight
- Stretching exercises
What are pharmacologic options for preventing muscle cramps?
- Vitamin E 400 IU QHS
- Less studied options: oxazepam, prazosin, hydroquinine
Is thrombosis more common in venous catheters or AV grafts?
What are nonpharmacologic options for treating thrombosis?
- Forced saline flush
- Surgical thrombectomy
- Exchange of catheter over guidewire
What are two drug options for thrombosis?
What is the most pre-dominant bacteria that causes infections related to HD?
What should you do if a patient experiences a fever during HD?
Culture blood immediately
How should you treated an infection of a tunneled cuffed catheter that has no drainage?
How should you treated an infection of a tunneled cuffed catheter that has drainage?
Systemic gram-positive coverage
How should you treated an infection of a tunneled cuffed catheter that is bactermic with or without systemic symptoms?
Gram positive coverage
If a patient is symptomatic, how long should you wait before removing the catheter?
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
In a local AV graft infection how long should a patient be treated?
Narrow antibiotics once cultures returned for 2-4 weeks
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
What type of infection should be treated like bacterial endocarditis? How long should the patient be on antibiotics?
What are symptoms of a Type B reaction to HD?
- Chest pain
- Back pain
- Compliment activation
In a Type A dialyzer reaction, a patient has a hypersensitivity to what?
When does a Type A reaction typically happen?
Usually on initial exposure
What drug can cause a Type A interaction with a bioincompatible or high-flux membrane?
In PD which compartment is filled with dialysate?
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
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
What does the dialysate in PD contain?
- Osmotic gradients: dextrose in hyperosmolar concentrations (induces ultrafiltration) or icodextrin a starch-derived glucose polymer (alternative to dextrose)
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
- Replace with fresh dialysate
- Repeated 3-4 times a day (usually single exchange with higher dextrose solution over night)
What type of patients should use APD?
For patients unable or unwilling to perform aseptic technique to catheter
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)
What is the Kt/Vd goal for PD?
What is the total weekly CrCl?
> 60 L/week/1.73 m2
What are two mechanical complications of PD?
- Kinking of catheter
- Catheter obstruction
List the complications of PD
- Exacerbation of DM
What percentage of glucose from the dialysate is absorbed during each exchange?
What are some symptoms of PD?
- Abdominal pain/tenderness
- Cloudy effluent
- Fever and chills
What are two signs of peritonitis?
- Cloudy effluent
- WBC > 100 cells with at least 50% neutrophils
What is the incidence of peritonitis?
1 episode every 24 months
What is the most common bacteria that causes peritonitis?
What is the preferred route of administration for peritonitis?
What are the options for gram + coverage?
First generation cephalosporin or vancomycin
What are the options for gram - coverage?
Third generation cephalosporin or aminoglycoside
What is the treatment duration for peritonitis?
14-21 days depending on organism
What type of filtration is Continuous venovenous hemofiltration?
What type of filtration is Continuous venovenous hemodialysis?
What type of filtration is Continuous venovenous hemodiafiltration?
Combines HD and hemofiltration (convection)