Renal: RRT

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Renal: RRT
2013-04-14 18:58:55
renal replacement therapy

An overview of hemodialysis and peritoneal dialysis and its associated complications
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  1. HD Advantages
    Higher solute clearance -> intermittent use

    Better defined monitoring parameters

    Low technique failure rate

    Better control of hemostasis parameters

    Closer patient monitoring
  2. HD Disadvantages
    Requires multiple weekly visits to dialysis center

    Disequilibrium, hypotension, muscle cramps are common

    Infections (higher risk)

    Vascular access complications (infections and thrombosis)

    Decline of residual renal function more rapid
  3. PD Advantages
    More hemodynamic stability

    Increased clearance of larger solutes

    Better preservation of residual renal function

    Convenient drug administration

    Suitable for pt that cannot tolerate HD

    Sense of independence (no machine)

    Less blood loss and iron deficiency

    No systemic heparinization
  4. PD Disadvantages
    Protein and amino acid loss and decreased appetite -> malnutrition

    Risk of peritonitis

    Catheter malfunction and/or infection

    Inadequate ultrafiltration

    Patient burnout (decreased compliance)

    Mechanical problems: hernias, dialysate leaks, hemorrhoids, back pain
  5. HD Vascular Access
    AV Fistula (pref)

    AV graft (shorter duration, more complications)

    Cuffed/Tunneled Venous Catheter (short-term)
  6. HD Dialysate
    Purified H2O and Electrolytes

    Heated to body temp

    Pumped countercurrent to blood
  7. HD Anticoagulation
    Usu. IV heparin bolus

    Initiate 3-5min before HD

    d/c 1 hour before end of HD
  8. HD Individualization
    Usu. 3-4 hrs 3 x weekly

    Achieve dry weight and adequate waste removal

    Can calculate desired urea level
  9. Urea-reduction ratio (URR)
    (PreHD BUN – PostHD BUN)/PreHD BUN x 100
  10. HD Hypotension Acute Tx
    Trendelenburg position

    Decrease ultrafiltrate rate

    100-200 mL NS bolus
  11. HD Hypotension Prevention
    Adj. dry weight

    Buffer soln. w/bicarb

    Avoid food PreHD

    Midodrine 2.5-10 mg PO 30 min PreHD
  12. HD Muscle Cramps Acute Tx
    • 100-200 mL NS bolus
    • OR
    • 10-20 mL 23.4% NaCl over 3-5 min
    • OR
    • 50 mL (1 amp) D50 in non-diabetics
  13. HD Muscle Cramps Prevention
    Adjust dry weight

    Stretching exercises

    Vit E 400 IU qhs
  14. HD Thrombosis
    Catheters > grafts or fistulas

    Forced saline flush

    Surgical thrombectomy

    Exchange catheter

    Alteplase OR Reteplase
  15. HD Infxn
    Catheter > graft > fistula

    S. aureus most common

    Fever during HD -> get culture
  16. HD Infxn w/Catheter
    • Localized w/o drainage -> topical Abx
    • Localized w/drainage -> systemic v. Gram(+)

    Bacterememia -> Gram (+) coverage, @ 36 hrs w/symptoms remove catheter, else change catheter and continue Tx x 3 wks
  17. HD Infxn w/Graft
    Local infxn -> Empiric Abx, narow w/ cultures and continue x 2-4 wks

    Extensive infxn -> as local + resection graft
  18. HD Infxn w/Fistula
    As bacterial endocarditis (x 6wks)
  19. Anaphylactic Dialyzer Rxn
    Hypersensitivity to sterilizing agent

    Usu. on initial exposure

    Usu. bioincompatible membranes or some high-flux membranes w/ACEi use
  20. Non-specific Dialyzer Rxn
    Chest pain

    Back pain

    Compliment activation
  21. PD Peritoneal Access
    Permanent indwelling catheter

    40-45 cm (20-22 cm internal)

    Luer-lock at external end
  22. PD Dialysate
    Hyperosmolar Dextrose (4-6h dwell)

    Icodextrin (8-16h dwell)
  23. Cont. Ambulatory PD (CAPD)
    1-3 L of dialysate over ~ 15 minutes

    ~4-6 hours dwell -> drain -> replace

    Repeated 3-4 times a day

    Single exchange w/ high conc. soln. over night
  24. Automated Peritoneal Dialysis (APD)
    Pts unable/unwilling to use aseptic technique

    Automated cycler performs exchanges

    Set up in evening & catheter attached QHS

    Nocturnal intermittent peritoneal dialysis (NIPD)

    Continuous cycling peritoneal dialysis (CCPD)

    Nocturnal tidal peritoneal dialysis (NTPD)
  25. PD Individualization
    Kt/Vd quantifies body H2O cleared of urea

    Goal Kt/Vd > 2

    weekly CrCl > 60L/week/1.73 m2
  26. PD Complications
    Catheter kinking/obstruction

    DM exacerbation (~60% of Glu is absorbed)

  27. Peritonitis S/Sx
    Abdominal pain/tenderness

    Cloudy effluent

    Dialysate WBC > 100 & 50%+ neutrophils


  28. Peritonitis Tx
    Intraperitoneal Abx

    Init. empiric Tx -> narrow w/cultures

    Tx x 14-21d

    Vanc may cause chem peritonitis