Renal Disease and Dialysis
Transcript Renal Disease and Dialysis
Renal Disease and Dialysis 101
Chronic Kidney Disease
Types of dialysis
Continuous Veno-Venous hemofiltration
Solute removal via passive diffusion
◦ Inversely proportional to the size (ie effective
removal of K, urea, C; not of PO4)
use of hydrostatic pressure gradient to
induce convection (filtration of water)
solvent drag (pulls dissolved solutes)
removal of excess fluid
highly permeable membrane
fluid and solute removal via ultrafiltration
filtrate is discarded
replacement fluid is infused similar to
plasma (but no K, urea, Cr, PO4)
used in ICU, runs 12-24h, through double
less drastic fluid shifts
3-10 dwells per
night with 2-2.5 L
Indications for Dialysis
Arteriovenous fistula (AVF)
◦ 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
Easier to create
Maturation time 3-6
Poor patency (often
Bridge to AVF/AVG
Poor flow (decreased
High infection risk
Time: 2-5 hours
Blood flow rate: 400-450cc/min
Dialysate flow rate: 500-800cc/min
◦ Anemia (EPO, blood)
◦ Bone metabolism (vit D, calcitriol, etc)
◦ Meds (antibiotics)
Common Admissions on Eckel
Complications of missed HD
◦ SOB from fluid overload
◦ HTN crisis
And everything else…
Eckel 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: history
how did the last HD session go?
complications since being started on HD?
◦ multiple access points?
get run sheets from dialysis center
Eckel Pearls: physical exam
Vitals: no BP in the arm of the access
RN LK50: OMG’s K is 3.1. Can we
•Had dialysis 3rd shift. Finished 2hrs ago
Labs in ESRD
Get labs before or 4h after HD
Only the H/H is accurate
Floor RNs can’t use HD lines
Can ask to have cultures drawn at HD
from the line
RN LK20: New admit AMS on floor. Hard to
arouse. Please eval
ED presentation with abd pain
Workup initiated since there are no beds…
Pain meds: morphine 1mg, then 1mg, then 2
mg, then 3mg IVP
Sent to the floor
Medications in ESRD
◦ Renally dose
◦ Loading dose, then maintenance dose
No lovenox dvt ppx, use heparin
◦ Hepatic metabolism – but active metabolites
◦ Limit the other opioids
Dilaudid: hepatic metabolism – but metabolites can
constipation/GERD : avoid
magnesium/phosphate containing agents
RN: new admit OK. Called wound care for
After lunch you walk on over to the patient
room. ESRD admitted for access.
OK is doing ok. Vitals stable. Comfortable.
RN 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
You ask, “have you had a blood clot before?”
WAA nods yes.
Hmmm….amongst other things, CTPE?
Imaging in CKD
Avoid contrast in CKD patients
If 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
Imaging in ESRD
CT with contrast is ok
MRI with gadolinium is NOT:
◦ Nephrogenic Systemic Fibrosis (NSF)
◦ IF you must: HD x 3 over 3 consecutive days,
with the first right after
RN LK20: Lost access on GRR. Can you
order a PICC?
Finally, an easy question.
CKD. Sure, why not?
Access in CKD
Avoid PICC/midlines in CKD stage 4-5
Try to preserve access
Try for the feet/EJ
But if you need to, order a midline
PCP should refer CKD stage IV to
nephrologists in anticipation of HD
Don’t treat them lightly
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