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Kaufhold, 1996 1
Renal Replacement Renal Replacement TherapyTherapy
PreparationOptions
Complications
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Preparation of the Preparation of the PatientPatient
Manage CRF Control BP Control glucose
stop oral agents! Prevent Hyper
PTH Vit D Calcium acetate Phosphate binder
Diet Education
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Preparation of the Preparation of the PatientPatient
Manage Fluids Dialysis education Access Placement Prevent anemia Prevent
Malnutrition
metolazone NKF program AV fistula, PD
cath Epogen, Iron This can get tricky
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Progression of CRFProgression of CRF
PTHclimbs
PO4rising
K, UrateUp
AnemiaSx
0
10
20
30
40
50
60
70
80
PTHclimbs
PO4rising
K, UrateUp
AnemiaSx
GFR
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Transition to End StageTransition to End StageEffect of MalnutritionEffect of Malnutrition
74
76
78
80
82
84
86
25 15 10 5
Edema
Body mass
GFR
Measured Wt = 85 Kg
Wt
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Indications for DialysisIndications for Dialysis
A acidosis E electrolyte abnormalities I intoxication/poisoning O fluid overload U uremia symptoms/complications
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Dialysis for IntoxicationsDialysis for Intoxications
T theophylline A aspirin B barbiturates L lithium E ethylene glycol, methanol
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Relative Relative ContraindicationsContraindications
Alzheimer’s disease Multi-infarct Dementia Hepatorenal syndrome Advanced cirrhosis with
encephalopathy Advanced malignancy HIV with dementia
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Types of Renal Types of Renal ReplacementReplacement
Acute RRT: Standard Hemodialysis Redy 2000 Acute Peritoneal Dialysis CAVHD CVVHD Hemoperfusion
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Acute RRT choicesAcute RRT choices
Volume Status Hemodynamic
status Access Bleeding Poisoning
CAVHD? Tolerate Hemo? Abdominal
surgery? Anticoagulation? How catabolic is
pt Hemoperfusion?
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Renal Replacement Renal Replacement TherapyTherapy
Chronic RRT Standard Hemodialysis Peritoneal Dialysis
Continuous vs Intermittent Ambulatory vs Cyclic Cycler Plus*
Combinations
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The Mystery of DialysisThe Mystery of Dialysis
Its no mystery! Clearance
simple diffusion Ultrafiltration
dialysate pump Monitors to make
sure nothing bad happens
blood in
blood out
dialysate in
dialysate plusUltrafiltrate out
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HemodialysisHemodialysis
Advantages standard
treatment widely used Pt has days off Good
reimbursement for Nephrologist
We have control
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HemodialysisHemodialysis
Disadvantages Pt has no control strict attn to diet travel restricted need for vascular
access Specific risks Inadequate
clearance
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Peritoneal DialysisPeritoneal Dialysis
Clearance How much fluid
the patient puts in Ultrafiltration
How much fluid comes out
Dextrose used as osmotic agent
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Peritoneal DialysisPeritoneal Dialysis
Advantages continuous middle molecules pt has control vary tx with diet adjust to lifestyle no need for
vascular access no need for
anticoag.
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Peritoneal DialysisPeritoneal Dialysis
Disadvantages Abdominal
surgery limited clearance limited Uf Needs motivated,
compliant pt risk of peritonitis
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RRT ChoicesRRT Choices
Renal Transplant should be goal Peritoneal Dialysis for the right pt Hemodialysis for everyone else
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DialysisDialysisChronic ComplicationsChronic Complications
Not seen until after chronic access possible
1967 Alfree reported dialysis dementia
Due to impurities in water (100L/tx)
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DialysisDialysisComplicationsComplications
Bleeding disorders
Anemia
Bone disorders
Arthritis
Neuropathy
Cardiovascular
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Dialysis ComplicationsDialysis ComplicationsBleeding disorderBleeding disorder
Due to platelet dysfunction Prolonged bleeding time
Treatment: - more dialysis - dDAVP 0.3 microgm/Kg - Estrogen
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Dialysis ComplicationsDialysis ComplicationsAnemiaAnemia
Due to reduced Erythropoietin - blood loss, reduced response
Treatment: - more dialysis - rHuEPO 2,000 units/tx - Androgens
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Dialysis ComplicationsDialysis ComplicationsArthritisArthritis
Due to accumulation of - Beta-2-microglobulin
Treatment: - more dialysis - Biocompatable membranes - Joint replacement (Hips)
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Dialysis ComplicationsDialysis ComplicationsNeuropathyNeuropathy
Manifestations: - Peripheral Neuropathy - Autonomic dysfunction - Dementia - Dysequilibrium syndrome
Treatment - More dialysis - gradual start of tx - remove water impurities - prevention is best.
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Dialysis ComplicationsDialysis ComplicationsCardiovascularCardiovascular
Manifestations: - Accelerated atherogenesis - Lipid abnormalities - Associated disorders (DM etc) - Leading cause of mortality
Treatment - More dialysis - Treatment of lipid disorders - Control of HTN - Carnitine?
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Adequacy of DialysisAdequacy of Dialysis
Markers mortality hospitalization nutrition
NCDS Gotch and Sargent KT/V = clearance NPCR = nutrition