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Renal Disease and Renal Disease and DialysisDialysis 101 101
Shalini BumbAugust 2013
ObjectivesObjectivesCKDDialysisAccessEckel pearlsScenarios
Chronic Kidney DiseaseChronic Kidney Disease
Types of dialysisTypes of dialysis
1. Hemodialysis (HD)2. Ultrafiltration (UF)3. Continuous Veno-Venous
hemofiltration (CVVH)4. Peritoneal Dialysis
HemodialysisHemodialysisSemipermeable membraneSolute removal via passive
diffusion◦Inversely proportional to the size (ie
effective removal of K, urea, C; not of PO4)
UltrafiltrationUltrafiltrationuse of hydrostatic pressure
gradient to induce convection (filtration of water)
solvent drag (pulls dissolved solutes) across
removal of excess fluid
CVVHCVVHhighly permeable membranefluid and solute removal via
ultrafiltrationfiltrate is discardedreplacement fluid is infused similar
to plasma (but no K, urea, Cr, PO4)used in ICU, runs 12-24h, through
double lumen catheterless drastic fluid shifts
Peritoneal DialysisPeritoneal Dialysisperitoneal
membrane = partially permeable membrane
dextrose dialysate
diffusion and osmosis until equilibrium
3-10 dwells per night with 2-2.5 L per dwell
Indications for DialysisIndications for DialysisAcidosisElectrolytesIngestionsOverloadUremia
AccessAccessArteriovenous fistula (AVF)Graft Tunneled catheter
Arteriovenous FistulaArteriovenous Fistula
◦Highest patency◦Lowest risk of
infection◦Low risk of thrombus
◦Maturation time (3-4mo)
◦Steal syndrome (poor blood supply to the rest of the limb)
◦Aneurysm formation
Arteriovenous GraftArteriovenous GraftEasier to createMaturation time 3-6
weeks
Poor patency (often requires thrombectomy or angioplasty)
InfectionAneurysmsSteal syndrome
Tunneled CatheterTunneled CatheterImmediate useBridge to AVF/AVG
Poor flow (decreased HD efficiency)
High infection riskVenous stenosisThrombosis
Dialysis Rx:Dialysis Rx:Time: 2-5 hoursBathBlood flow rate: 400-450cc/minDialysate flow rate: 500-800cc/minAnticoagulantAdditives:
◦Anemia (EPO, blood)◦Bone metabolism (vit D, calcitriol, etc)◦Meds (antibiotics)
Dialysate BathDialysate Bath
Common Admissions on Common Admissions on EckelEckelComplications of missed HD
◦SOB from fluid overload◦HTN crisis◦Hyperkalemia
Line infectionsAccess issuesAnd everything else…
Eckel Pearls: presentationEckel Pearls: presentation
75 yo AAM with ESRD 2/2 DM (HD MWF via RUE AVF, at CDC East, nephrologist Dr. Wish, dry weight 82kg, oligouric)
Eckel Pearls: historyEckel Pearls: historyhow did the last HD session go?complications since being started
on HD?◦infections?◦multiple access points?
medically compliant?get run sheets from dialysis
center
Eckel Pearls: physical Eckel Pearls: physical examexamVitals: no BP in the arm of the
accessVolume statusAccess:
◦Infection?◦Aneurysms◦Bruits/thrills
Page 1Page 1RN LK50: OMG’s K is 3.1. Can
we replete?
•Had dialysis 3rd shift. Finished 2hrs ago
Labs in ESRDLabs in ESRDGet labs before or 4h after HDOnly the H/H is accurateFloor RNs can’t use HD linesCan ask to have cultures drawn
at HD from the line
Page 2Page 2RN LK20: New admit AMS on floor.
Hard to arouse. Please eval
ED presentation with abd painWorkup initiated since there are no
beds…Pain meds: morphine 1mg, then
1mg, then 2 mg, then 3mg IVPSent to the floor
Medications in ESRDMedications in ESRDAntibiotics
◦Renally dose◦Loading dose, then maintenance dose
No lovenox dvt ppx, use heparinNo morphine
◦Hepatic metabolism – but active metabolites◦Limit the other opioids
Dilaudid: hepatic metabolism – but metabolites can cause neuroexcitiation
constipation/GERD : avoid magnesium/phosphate containing agents
Page 3Page 3RN: new admit OK. Called wound care
for leg.
After lunch you walk on over to the patient room. ESRD admitted for access.
OK is doing ok. Vitals stable. Comfortable.
CalciphylaxisCalciphylaxis
Calcinosis cutis
Page 4Page 4RN LK20: Code white, WAA is hypoxic,
83% on RA. Now 92% on VM.
Acutely SOB. Looks uncomfortable.Your co-NF points that one leg is bigger
than the other.You ask, “have you had a blood clot
before?”WAA nods yes.Hmmm….amongst other things, CTPE?
Imaging in CKDImaging in CKDAvoid contrast in CKD patientsIf you have to, prep
◦volume expansion: isotonic IVFs 3 cc/kg x 1h before 1cc/kg x 6h after
◦? alkalinization: sodium bicarbonate◦? acetylcysteine ◦radiology can give you the protocol
(treat empirically)
Imaging in ESRDImaging in ESRDCT with contrast is okMRI with gadolinium is NOT:
◦Nephrogenic Systemic Fibrosis (NSF)◦IF you must: HD x 3 over 3
consecutive days, with the first right after
Page 5Page 5RN LK20: Lost access on GRR.
Can you order a PICC?
Finally, an easy question. CKD. Sure, why not?
Access in CKDAccess in CKDAvoid PICC/midlines in CKD stage
4-5Try to preserve accessTry for the feet/EJBut if you need to, order a midline
PCP should refer CKD stage IV to nephrologists in anticipation of HD
Don’t treat them lightlyDon’t treat them lightly
The end.The end.
ResourcesResources UpToDate Lavinia Negrea. “Dialysis Access.” Microsoft Powerpoint. August 2013. Claire Sullivan. “Intern Boot Camp: Renal Disease and Dialysis (ie surviving Eckel).”
Date last modified 2012. Microsoft Powerpoint. August 2013. Van Stone, JC. Hemodialysis: Hemodialysis apparatus. In: Handbook of Dialysis
Daugirdas, JT, Ing, TS (Eds), Little, Brown, Boston, 1994. p53. Yassine Mrabetis. “Hemodialysis Diagram." Online image. Dialysis Definition.
Creative Commons Attribution-Share Alike 3.0, Wikepedia. August 2013. “Peritoneal Dialysis Diagram.” Online Image. Alniche: Types of Dialysis. Alniche Life
Sciences Pvt. Ltd. August 2013. Po Ming Teng. “Aneurysm.” Online Image. Chronic renal failure and dialysis.
Surgical-tutor.org.uk. August 2013. “Calciphylaxis.” Online Image. The UK Calciphylaxis Study. The Renal Association.
August 2013. Jonathan Z. Li and William Huen. “Calciphylaxis with Arterial Calcification.” Online
Image. 2007. N Engl J Med. August 2013. Shaofeng Yan. “Calciphylaxis Histology.” Online Image. 2006. Mihm’s
Dermatopathology: Calciphylaxis. Martin C. Mihm, Jr. August 2013. “Nephrogenic Systemic Fibrosis.” Online Image. Skin & Allergy News: Nephrogenic
Fibrosis Is Tied to Contrast Agents : Moderate- to end-stage renal disease patients are most susceptible to the scleroderma-like syndrome. International Medical News Group, LLC. August 2013.
Michael Shaw. “They’re willing to throw in their kidneys.” Online image. 2008. New Yorker Cartoon. August 2013.
Cartoons from www.lightersideofdialysis.com. August 2013.