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Renal 3 > Alex: Dialysis > Flashcards

Alex: Dialysis Flashcards

1
Q

What are 4 options for end stage renal disease?

A
  1. Hemodialysis
  2. Transplantation
  3. Peritoneal dialysis
  4. No treatment
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2
Q

What stage of CKD should the patient be referred to a nephrologist?

A

Stage 4 (GFR under 30)

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3
Q

What plants must be made as part of pre-dialysis assessment for hemodialysis?

A
  1. Dialysis access surgery
  2. Type of renal replacement therapy (RRT)
    * Advanced planning is essential
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4
Q

What the decision to initiate RRT based on?

A

A variety of factors:

  • Symptoms
  • Signs
  • Laboratory results
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5
Q

What GFR do the majority of patients start dialysis at?

A

Under 10cc/min

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6
Q

What are laboratory indicators for the initiation of renal replacement therapy?

A
  • Unmanageable hyperkalemia
  • Severe Metabolic acidosis
  • Uremic Symptoms / Encephalopathy: Nausea, vomiting, altered mental acuity, seizures, anorexia
  • Pericardial friction rub
  • Unmanageable volume overload
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7
Q

Is there a specific BUN, creatinine, or GFR level that mandates immediate dialysis?

A

NO

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8
Q

What are the 3 options for RRT and associated %

A
  1. Hemodialysis: 65%
  2. Transplant: 25%
  3. Peritoneal dialysis: 10%
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9
Q

What 5 things are needed for dialysis?

A
  1. Vascular access to the circulation
  2. Dialysis filter
  3. Dialysis machine
  4. Nursing staff to establish the vascular access and monitor the dialysis procedure
  5. Dialysis facility
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10
Q

What are options for vascular access foe hemodialysis?

A

SHUNTS

  1. Fistula
  2. Graft
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11
Q

What is the angioacess of choice for dialysis?

A

A side-to-side arteriovenous fistula

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12
Q

What are the 2 sites where arteriovenous fistulas are usually placed?

A
  1. The radial artery and cephalic vein in the non-dominant arm*
  2. In the upper arm between the brachial artery and brachiocephalic vein (if necessary)
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13
Q

What can be placed in patients with poor vessels and in those whom previous AVF have failed?

A

An arteriovenous graft between the artery and vein

Forearm, upperarm, thigh

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14
Q

What are the 2 options for dialysis access?

A
  1. Arteriovenous fistula

2. Arteriovenous graft (synthetic material)

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15
Q

What is an arteriovenous graft also called and what is it made of?

A

GORE-TEX graft…it’s made of Teflon

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16
Q

In dialysis, what is the arterial line for?

A

Blood flow from the patient to the dialyzer

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17
Q

In dialysis, what is the venous line for?

A

Blood return from the dialyzer to the patient

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18
Q

What can inserted into the internal jugular vein and used for vascular access until proper access can be created?

A

A tunneled, cuffed double lumen catheter

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19
Q

Why is a tunneled catheter the least desirable alternative for dialysis access?

A
  1. Infection
  2. Thrombosis
  3. Inefficient dialysis
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20
Q

What should be avoided with a tunneled catheter?

A

Subclavian vein cannulation

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21
Q

What kind of lumen does a tunneled catheter have?

A

Double

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22
Q

What does the separate inner lumen do in a double lumen tunneled catheter?

A

It return blood back to the patient after dialysis

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23
Q

What do small pores in the catheter do in a double lumen tunneled catheter?

A

They allow blood to be pulled out and circulated through the dialyzer

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24
Q

What are 2 methods of hemodialysis clearance?

A
  1. Diffusion

2. Convection (ultrafiltration)

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25
Q

What is diffusion?

A

The rate of mass transfer between 2 compartment separated by a semi-permeable membrane

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26
Q

What is diffusion determined by?

A
  1. Characteristics of the membrane

2. Solute concentration gradient between the 2 compartments: Plasma and dialysate compartments

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27
Q

What is fluid filtration through a porous membrane with the clearance directly related to the volume of fluid removed?

A

Ultrafiltration: Convective mass transfer

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28
Q

In convection or ultrafiltration, what does positive pressure lead to?

A

Negative suction

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29
Q

What must be established in dialysis?

A

2 compartments separated by a semi-permeable membrane

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30
Q

What are the 2 compartments in dialysis?

A
  1. Blood

2. Dialysate

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31
Q

What is a synthetically created sterile solution containing electrolytes and glucose, but minimal K and no urea?

A

Dialysate compartment: Hollow fiber dialyzer

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32
Q

What are the levels of Na, K, Cl, HCO3, Glucose, and Ca in typical dialysate?

A
  1. Na: 140mEq/L
  2. K: 2.0mEq/L
  3. Cl: 100mEq/L
  4. HCO3: 36mEq/L
  5. Glucose: 200mg/dL
  6. Calcium: 2.5mEq/L
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33
Q

True or False: The K level in dialysate is adjustable?

A

True

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34
Q

Why is the HCO3 intentially higher than normal in the dialysate?

A

So it moves into the patient to neutralize the acidosis

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35
Q

What is the flow rate of blood in hemodialysis?

A

300-500cc/min

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36
Q

What kind of membrane is used in hemodialysis?

A

Semi-permeable

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37
Q

What is the flow rate of dialysate in hemodialysis?

A

800cc/min

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38
Q

How many gallons are required per patient, per treatment for hemodialysis?

A

40 gallons

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39
Q

What is in dialysate?

A

Purified sterile water and electrolytes

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40
Q

How many dialysis units are in the US?

A

Over 4000

41
Q

What are 2 methods for hemodialysis clearance?

A
  1. Diffusion

2. Convection: Ultrafiltration

42
Q

Are diffusion and convection (ultrafiltration) both clearance methods in the human kidney?

A

NO

43
Q

What is normal glomerular filtration maintained by?

A

CONVECTION ONLY (ultrafiltration)

44
Q

Does diffusion occur in a normal human kidney?

A

NOOOOOOO

45
Q

For how long and how often are most patients treated with hemodialysis?

A
  1. 3-4 hours

2. 3 times a week (M-W-F or Tu-Th-Sa)

46
Q

What is the proper dose of dialysis based on?

A

It is individualized, but an expected decrease in BUN by greater than 65% each treatment is desired (urea reduction ratio)

47
Q

If the pre-dialysis BUN is 80, what should the post-dialysis BUN be?

A

28

48
Q

Why is creatinine not used as a marker for renal function once the patient is on dialysis?

A

Creatinine is not toxic and therefore isn’t a reflection of nitrogenous waste

49
Q

What lines the walls of the abdominal cavity and encapsulates internal organs (stomach, liver, spleen)?

A

Peritoneum

50
Q

What is the overall adult peritoneal surface area?

A

Approximately 1.75 +/- 0.5 m^2

51
Q

What kind of pores does the peritoneum contain?

A
  1. Large pores: 25mm
  2. Small pores: 5nm
  3. Ultra small pores: Involved in water transport
52
Q

What is a virtual space normally without significant fluid (ascites)?

A

Peritoneal cavity

53
Q

What happens to the peritoneal cavity if a dialysate solution is infused?

A

It will expand the space between the intestines and solid organs–> This increases the surface area for diffusion

54
Q

In peritoneal dialysis, what is the solution infused similar to?

A

Dialysate

55
Q

What sits in the peritoneum and allows diffusion of solutes across the blood vessels into the peritoneal cavity?

A

Infused solution used in peritonel dialysis

56
Q

What allows for removal of uremic toxins in peritoneal dialysis?

A

Drainage of the dialysate and replacement with a fresh batch

57
Q

What are the 2 options for peritoneal dialysis?

A
  1. CCPD: Continuous cycling peritoneal dialysis

2. CAPD: Continuous ambulatory peritoneal fialysis

58
Q

How does CCPD work?

A

Cycle at night for 8-10 hours

About 10 liters is exchanged

59
Q

How does CAPD work?

A

About 4 exchanges per day with 2-2.5 liters per exchange

60
Q

Does CAPD require a machine?

A

No

61
Q

In CAPD how many liters of fluid is infused and how may times a day?

A

1.5-3 liters of fluid is infused 4 times per day

62
Q

What is the exchanging time in CAPD?

A

30-40 minutes

63
Q

How is dialysate solution managed in CCPD?

A

It is exchanged by a machine at night (it’s automated)

64
Q

What is the fill volume in CCPD?

A

2L

65
Q

How many exchanges occur in CCPD?

A

There are 4-6 exchanges over 8-10 hours each night

66
Q

What does the patient do during the day with CCPD?

A

They disconnect and are independent of any further exchanges until the next night

67
Q

What are some reasons peritoneal dialysis an excellent choice for many independent patients?

A
  1. Can be used in rural locations without hemodialysis clinics
  2. Can be used in countries without good city water sources
  3. Can be used in young children
68
Q

What are 3 potential problems with peritoneal dialysis?

A
  1. Ability to follow strict sterile techniques
  2. Previous abdominal surgery
  3. IBD, diverticulitis, recurrent hernias
69
Q

What is the stronger clearance method in peritoneal dialysis?

A

Diffusion (over convection/ultrafiltration)

70
Q

Who performs treatment in hemodialysis versus peritoneal dialysis?

A
  1. Hemodialysis: Staff performs treatment…leads to regular contact with people in the unit (social sturcture)
  2. Peritoneal dialysis: Patients is very involved in care and has control over their schedule and freedom
71
Q

Which type of dialysis is diet and fluid intake restricted in?

A

Hemodialysis

Peritoneal dialysis has a less restricted diet

72
Q

Which type of dialysis results in a more steady physical condition?

A

Peritoneal dialysis (hemodialysis has unstable physical conditions

73
Q

What is the difference in terms of external access for the 2 types of dialysis?

A
  1. Hemodialysis has no external access required

2. Peritoneal dialysis requires a permanent external catheter

74
Q

What can be an issue in hemodialysis?

A

HD access

75
Q

What can be an issue with peritoneal dialysis?

A

The effectiveness of the peritoneaum

76
Q

Which type of dialysis does infection affect?

A

Both hemodialysis and peritoneal dialysis

77
Q

What offers a degree of independence for the patient, but requires greater patient involvement?

A

Peritoneal dialysis

78
Q

What can be avoided with peritoneal dialysis?

A
  1. Potential problems of vascular access

2. Avoids the hemodynamic stress of HD

79
Q

What is required in peritoneal dialysis?

A

A peritoneal cavity that is accessible and without extensive adhesions

80
Q

When patients start dialysis, what is the GFR?

A

Usually under 10cc/min

81
Q

What is the actual GFR during a 3-4 hour dialysis session?

A

300cc/min

82
Q

Since dialysis is only 3 times a week, what is the average GFR of a dialysis patient?

A

20cc/min

HEMODIALYSIS DOE NOT RETURN THE GFR TO NORMAL

83
Q

What stage of CKD does hemodialysis take a patient too?

A

Takes them from a stage 5 CKD to a stage 4 CKD

84
Q

What happens because dialysis doesn’t correct the CKD?

A

The patient will continue to be exposed to uremic toxins and experience accelerated atherosclerosis and premature death

85
Q

What stage of CKD does peritoneal dialysis put patients in?

A

Stage 4

86
Q

Is there a survival advantage between the 2 types of dialysis?

A

NO…patient choice dictates what technique to use

87
Q

What is the leading cause of death among ESRD patients?

A

CV disease

88
Q

What contributes to CV disease being the leading cause of death among ESRD patients?

A
  1. HTN
  2. Hyperlipiemia
  3. Ca/phos deposition in vessels
  4. Large number of diabetics
89
Q

Who is the incidence of ESRD 2-3 times higher in?

A

Black patients

90
Q

Who is the rate of ESRD rising every year especially in?

A

Elderly

91
Q

How many indicators are there for initiating dialysis?

A

5

92
Q

Is GFR an absolute reason to begin dialysis?

A

No…but most patients start at a GFR under 10cc/min

93
Q

What do hemodialysis and peritoneal dialysis use primarily for clearance?

A

Diffusion and come convection

94
Q

What does the human kidney use for clearance?

A

Only convective (ultrafiltration)

95
Q

What is the best vascular access?

A

AV fistula

96
Q

Is there a survival advantage between one form of dialysis compared to another?

A

NO

97
Q

What stage of CKD does dialysis put the patient into?

A

Stage 4 CKD

98
Q

True or false: Overall death rates from CV disease remain much higher than the general population?

A

TRUE

Renal 3 (17 decks)

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