Renal Disease and Dialysis

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Transcript Renal Disease and Dialysis

Renal Disease and Dialysis 101
Shalini Bumb
August 2013
 Dialysis
 Access
 Eckel pearls
 Scenarios
Chronic Kidney Disease
Types of dialysis
Hemodialysis (HD)
Ultrafiltration (UF)
Continuous Veno-Venous hemofiltration
Peritoneal Dialysis
Semipermeable membrane
 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
lumen catheter
 less drastic fluid shifts
Peritoneal Dialysis
membrane =
partially permeable
 dextrose dialysate
 diffusion and
osmosis until
 3-10 dwells per
night with 2-2.5 L
per dwell
Indications for Dialysis
 Electrolytes
 Ingestions
 Overload
 Uremia
Arteriovenous fistula (AVF)
 Graft
 Tunneled catheter
Arteriovenous 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 Graft
Easier to create
Maturation time 3-6
Poor patency (often
requires thrombectomy
or angioplasty)
Steal syndrome
Tunneled Catheter
Immediate use
 Bridge to AVF/AVG
Poor flow (decreased
HD efficiency)
 High infection risk
 Venous stenosis
 Thrombosis
Dialysis Rx:
Time: 2-5 hours
 Bath
 Blood flow rate: 400-450cc/min
 Dialysate flow rate: 500-800cc/min
 Anticoagulant
 Additives:
◦ Anemia (EPO, blood)
◦ Bone metabolism (vit D, calcitriol, etc)
◦ Meds (antibiotics)
Dialysate Bath
Common Admissions on Eckel
Complications of missed HD
◦ SOB from fluid overload
◦ HTN crisis
◦ Hyperkalemia
Line infections
 Access issues
 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?
◦ infections?
◦ multiple access points?
medically compliant?
 get run sheets from dialysis center
Eckel Pearls: physical exam
Vitals: no BP in the arm of the access
 Volume status
 Access:
◦ Infection?
◦ Aneurysms
◦ Bruits/thrills
Page 1
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
Page 2
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
 No 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 3
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.
Calcinosis cutis
Page 4
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
(treat empirically)
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
Page 5
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
The end.
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Cartoons from August 2013.