Dialysis

Question 1

What is dialysis?

Answer 1

removal of waste products

Question 2

By what mechanism does dialysis work?

Answer 2

Diffusion

Question 3

What does “CKD5D” mean?

Answer 3

Someone whose GFR is <15 ml/min that is on dialysis

Question 4

What does “CKD5ND” mean?

Answer 4

Someone whose GFR is <15 ml/min who is not on dialysis.

Question 5

What is ESRD

Answer 5

End stage renal disease

Question 6

Requirement for dialysis

Answer 6

ESRD w/ >3 months needed to sustain life.

Question 7

Methods/Mechanisms of drug removal during dialysis

Answer 7

Diffusion
Convection - ultrafiltration

Question 8

Dialysis Modalities/ Types of Dialysis

Answer 8

-Hemodialysis
-Peritoneal dialysis
-Continuous kidney replacement therapy (CKRT)

Question 9

Direction of fresh dialysate

Answer 9

top - bottom

Question 10

Direction of clean blood

Answer 10

bottom to top

Question 11

Hemodialysis access points

Answer 11

Arteriovenous fistula
Arteriovenous graft
Central venous catheter

Question 12

HD Access w/ highest risk of infection and thrombosis

Answer 12

Central venous catheter

Question 13

HD Access w/ lowest risk of infection and thrombosis

Answer 13

Arteriovenous fistula

Question 14

How long does arteriovenous fistula take to mature

Answer 14

3 months

Question 15

Preferred HD Access

Answer 15

Arteriovenous fistula

Question 16

Types of peritoneal dialysis

Answer 16

CAPD: continuous ambulatory peritoneal dialysis
APD: Automated peritoneal dialysis (nighttime)

Question 17

Peritoneal Access

Answer 17

Catheter

Question 18

What is Continuous kidney replacement therapy?

Answer 18

A “slow hemodialysis” for critically ill pts w/ unstable hemodynamics

Question 19

CKRT Modalities

Answer 19

• CVVH
• CVVHD
• CVVHDF

Question 20

Which clearance mechanism is better for large solutes?

Answer 20

Convection

Question 21

Drug factors influencing dialysis drug removal

Answer 21

• Molecular weight
• Protein binding
• Volume of distribution/Lipophilicity

Question 22

Patient factors influencing dialysis drug removal

Answer 22

• Albumin
• Fluid status
• Blood pressure

Question 23

Drug removal is increased by

Answer 23

Small molecular weight
Low protein binding
Small Vd/lipophilicity
High flux hemodialysis
Semi-synthetic/synthetic dialysis membranes

Question 24

What to do prior hemodialysis? (Dosing)

Answer 24

• Hold AntiHTN drugs
• Therapeutic dose monitoring

Question 25

What to do during hemodialysis? (Dosing)

Answer 25

Give intra-dialytic meds: - ESA's - Active Vitamin D

Question 26

What to do after hemodialysis? (Dosing)

Answer 26

- Supplemental doses of drugs removed - Administer meds significantly removed eg ABx

Question 27

What drugs need a supplemental dosing

Answer 27

Drugs removed >30 - 40%

Question 28

How much supplemental dose needed? (Equation)

Answer 28

Normal dose x fraction removed by HD

Question 29

CrCl IN CKRT

Answer 29

Assume 20 - 25 ml/min ***difficult to predict drug removal ***use drug literature

Question 30

Complications of drug dosing

Answer 30

Hypotension Cramping Fatigue Infection*** Thrombosis Bleeding ***#2 cause of mortality in HD

Question 31

Causes of hypotension w/ Hemodialysis

Answer 31

- Hypovolemia - excessive fluid removal - antiHTN admin prior to HD - autonomic dysfunction

Question 32

How to prevent hypotension w/ HD

Answer 32

- Select the appropriate dry weight - Hold the antiHTN meds

Question 33

How to manage hypotension w/ HD

Answer 33

- Small fluid bolus 100 - 250 ml 0.9% NaCl - Decrease fluid removal (ultrafiltration) - Midodrine

Question 34

Midodrine MOA

Answer 34

alpha 1 agonist pro drug for peripheral vasoconstriction

Question 35

Midodrine dosing

Answer 35

2.5 - 10 mg PO 30 mins before HD

Question 36

Midodrine Adverse Effects

Answer 36

bradycardia, hypertension (???), peripheral ischemia, urinary retention

Question 37

Midodrine DDIs

Answer 37

- MAOi's - sympathetic activating drugs

Question 38

Causes of cramping w/ Hemodialysis

Answer 38

- hypovolemia - decreased muscle perfusion

Question 39

How to prevent cramping w/ Hemodialysis

Answer 39

Selection of appropriate dry weight

Question 40

How to manage cramping w/ Hemodialysis

Answer 40

- small fluid bolus 0.9% NaCl - decrease fluid removal - Vitamin E 400 IU PO QHS ***NEVER GIVE QUININE (FDA WARNING)

Question 41

Site of infection in Hemodialysis

Answer 41

Bloodstream leading to pneumonia

Question 42

#2 leading cause of death in Hemodialysis?

Answer 42

Infection

Question 43

How to treat MRSA?

Answer 43

Vancomycin

Question 44

What type of ABx to use in dialysis infections?

Answer 44

Broad spectrum gram +ve or -ve ABx's

Question 45

Causes of Thrombosis w/ Hemodialyis

Answer 45

Virchow's Triad - use of ESA'S

Question 46

How to prevent thrombosis w/ Hemdialysis

Answer 46

Heparin w/ dialysis ***Risk of HIT

Question 47

How to manage thrombosis w/ Hemodialysis

Answer 47

Alteplase (Cathflo) 2mg/2ml for 30 -120 mins

Question 48

Complications of Peritoneal Dialysis

Answer 48

- Peritonitis - Fluid Overload - Hyperglycemia

Question 49

Vancomycin in ESRD