2155 (ic17) RRT

Question 1

What are the 3 ways that waste is removed in dialysis?

Answer 1

Diffusion
Ultrafiltration
Convection

Question 2

Typical schedule of HD

Answer 2

4hours, 3 times a week

Question 3

3 types of AV access

Answer 3

AV fistula
AV graft
Venous catheter

Question 4

+ and - of AV fistula

Answer 4

Gold standard
Connecting artery to vein
Advantages
Longest survival (AV fistula can last very long)
Lowest complication rates
Disadvantages
Requires >2 months to mature
Difficult in patients with very small veins eg. elderly, diabetes, peripheral vascular disease

Question 5

+ and - for av graft

Answer 5

Using synthetic graft
Only takes 2-3 weeks
Shorter survival, higher rates of complications

Question 6

+ and - for venous catheter

Answer 6

Only a temporary access, when permanent access is not ready yet
For children, DM, severe PVD, obese, failed AVF or AVG attempts
For emergency dialysis
Disadvantages:
Short lifespan (weeks-months)
Prone to complications and clotting
Low blood flow - compromise dialysis adequacy
Proper cleaning and care required

Question 7

Goal URR

Answer 7

> 65%

Question 8

Goal Kt/V for HD

Answer 8

1.4

Question 9

Goal Kt/V for PD

Answer 9

1.7

Question 10

Why is PD less efficient than HD?

Answer 10

Blood is not in direct contact with peritoneal membrane → metabolic waste must travel some distance to peritoneal cavity
Cannot regulate blood flow to surface of peritoneal membrane
No countercurrent blood flow and dialysate

Question 11

Suitability of PD patients

Answer 11

For hemodynamically unstable pts
With significant residual kidney function
No abdominal surgery in the past
Motivated, adherent to therapy
Be able to store dialysate fluid at home
Good hygiene, prevent infection

Question 12

When should non diabetics and diabetics start dialysis?

Answer 12

Non diabetics: GFR < 15
Diabetics: GFR < 20
Higher for diabetics as if diabetes causes CKD, progression to CKD will happen faster

Question 13

What are 2 most common complications during HD?

Answer 13

Hypotension (most common)
Due to excessive fluid removal
Advise patient to take BP meds after dialysis
Avoid heavy meals
Eat too much → splanchnic dilation, blood travels to gut and cause hypotension
Can decrease dialysate temperature
Lower temperature causes vasoconstriction → increase BP

Cramps
Caused by electrolyte imbalance

Question 14

How to manage hypotension during HD?

Answer 14

Place patient in trendelenburg position
Reduce rate or turn off ultrafiltration → water not removed
Administer 100 - 200ml bolus of IV normal saline
Increase dialysate Na conc
Switch to bicarbonate buffered dialysate (instead of lactate dialysate which causes vasodilation)
Set dry weight accurately
Lower dialysate temp
Give Midodrine (a1 adrenergic agonist)
Cause vasoconstriction
Contraindicated with CV conditions
Correct anaemia
Administer O2
Avoid food before/during HD

Question 15

Non pharm ways of catheter thrombosis (3 pts)

Answer 15

Force saline through (push clot out)
Mechanically remove clot
Remove catheter

Question 16

Pharm ways of thrombosis

Answer 16

Alteplase, Urokinase, Reteplase

Question 17

Symptoms during CRBSI

Answer 17

Fever, chills, high WBC count

Question 18

What are the 2 types of CRBSI?

Answer 18

Exit site and Catheter related bacteremia

Question 19

Treatment for exit site infection

Answer 19

Treat with topical antibiotics (mupirocin ointment) or IV (gram positive)

Question 20

Treatment for Catheter related Bacteremia

Answer 20

Adopt empiric therapy
Start with gram positive (+) eg. Cefazolin, Vancomycin, and (-) antibiotic coverage
(asymptomatic) Culture specific Antibiotics for 3 weeks

(symptomatic > 36hrs) Remove catheter

Do not place fistula, graft until blood culture performed after stopping antibiotics and negative for 48 hours

Staph Aureus (Gram positive (+)) eg. MSSA (Methicillin Sensitive S.Aureus)
Use Cefazolin
MRSA (Methicillin Resistant S.Aureus)
Vancomycin

Gram negative (-) coverage
Gentamicin, Ceftazidime

Question 21

BP goal for dialysis patients w hypertension

Answer 21

140/90 for predialysis
130/80 post dialysis

Question 22

What are some medical complications of peritoneal dialysis?

Answer 22

Fluid overload
Increase ultrafiltration, diuretics if have kidney function
Electrolyte abnormalities eg. Hyperkalemia (cos PD solution does not contain K)

Malnutrition
During PD, patients lose more amino acids → increase protein intake

Increased glucose load (if dialysate contains dextrose)
Exacerbate DM
Can administer intraperitoneal insulin or increase subcutaneous insulin

Fibrin formation
Causes drainage bag to look cloudy
Cause outflow obstruction
Administer IP heparin

Question 23

Antibiotics for peritonitis

Answer 23

Gram (+): Cefazolin, Vancomycin
Gram (-): Gentamicin
(+) and (-): Cefepime

Question 24

Other conditions to treat during peritonitis?

Answer 24

Treat Hypokalaemia
Dont use H2RA
Treat GI problems eg. constipation
Do Antifungal prophylaxis eg. oral Nystatin or Fluconazole

Question 25

What should we do during fungal peritonitis

Answer 25

Remove catheter immediately