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Dialysis Flashcards

1
Q

How is a fistula made

A

Artery attached to vein. High pressure arterial blood -> vein enlarges and thickened wall, allows two large bore cannulas to be placed on a regular basis

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2
Q

Why is fistula preferred for haemodialysis

A

Lower infection risk that neck line

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3
Q

how often do you have haemodialysis

A

4 hours 3 x a week

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4
Q

Types of RRT

A

Intermittent haemodialysis
Continuous haemofiltration
Continusous haemodialysis
Peritoneal dialysis

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5
Q

What is continious therapy used for

A

AKI when improved benefits over intermittent therapy - improved tolerability as result slower removal of solute and water

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6
Q

How does haemodialysis work

A

Blood -> dialysis machine which has a membrane so solutes diffuse between dialysate fluid and blood

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7
Q

How long does it take for an AV fistula to become usable

A

6-8 weeks

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8
Q

Complications of haemodialysis

A

Access related - bactaraemia -> endocarditis, discitis
Venous stenosis
Access failure
Haemodynamic instability
N+V
Headahce
Cramps, esp leg
Reactions to dialysis membranes

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9
Q

How does peritoneal dialyisis

A

Diasylate fluid -> abdominal cavity,filtration across peritoneal membrane, after several hours used fluid drained

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10
Q

What patients are not suitable for peritoneal dialysis

A

Functional peritoneal membrane
eg no prev intra abdominal pathology - prev peritonitis, surgery, adhesions

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11
Q

What is Continuous ambulatory peritoneal dialysis (CAPD)

A

Manual dialysate exchanges are typically performed 3-5 x a day
20-40 minutes per exchange

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12
Q

Automated dialysis what is

A

machine performs exchanges overnight
12 hours

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13
Q

Complications of peritoneal dialysis

A

Bacterial/fungal peritonitis
Catheter problems: infection, blockage, kinking, leaks, displacement (more likely if patient becomes constipated)
Weight gain
Worsening glycaemic control in patients w diabetes
failure of peritoneal membrane requiring switch to haemodialysis
Encapsulating peritoneal sclerosis

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14
Q

Cloudy peritonitis peritoneal fluid means

A

Peritonitis
Intraperitoneal disease - appendicitis, cholecystis, bowel ischaemia
Retroperitoneal disease - pancreatitis, renal cell carcinoma
Drugs - vancomycin, amphotericin B
Allergic reaction - increased eosinophils

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15
Q

Bloody haemodialysis drained fluid

A

Coagulopathy
Retrograde menstruation
Ovulation
Strenous exercise
Ovarian cyst rupture
Adhesions
Catheter ass trauma

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16
Q

Chylous peritoneal fluid drainage (White)

A

High triglycerides
Lymphatic obstruction
Trauma
Abdominal lymphomes
Pancreatitis
Drugs - CCB

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17
Q

Gold standard for RRT

A

Renal transplant

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18
Q

How does renal transplant work

A

Old kidneys left in place
L or R iliac fossa

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19
Q

Benefits of transplantation

A

obviates the
need for dialysis, can ameliorate anaemia and renal bone disease
and improves quality of life and long-term survival.

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20
Q

Contraindications to transplantation

A

Active or recent malignancy
Active infection
Significant comorbidity

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21
Q

Complications of renal transplantation

A

Operative comps
Stenosis of graft artery or ureter
Side effects from immunosupressive therapy Opportunisitic CMV
Malignancy
Recurrence of OG disease
Hyperacute graft rejection
Acute graft rejection
Chronic allograft rejection

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22
Q

Malignancy from renal transplantation

A

Epstein Barr virus -> non hodgkin B cell lymphomas, non melanoma skin cancers (squamous and basal)

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23
Q

Side effects of immunosupressive therapy

A

(nephrotoxicity + HPTN secondary to tacrolimus or ciclosporin)

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24
Q

hyeracute graft rejection

A

untreatable and should not occur if
appropriate cross-matching has been performed

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25
How does acute graft present
Creatinine rise in 1st week to 3 months Diagnosed by graft biopsy Initial treat - IV steroids All have some level of acute rejection
26
How does a chronic allograft nephropathy present
Multiple reasons Doesn't normally respond to increased immunosupression
27
Peritonitis signs
Abdominal pain varying severeity Cloudy effluent Vomitting, nausea, paralytic ileus, sometime bowel perforation TREAT - intra peritoneal anitbiotics
28
When considered for transplant
eGFR <15% Within 6 months of dialysis Medically fit All tests done
29
Basics of drug metabolism
Absorption Distribution Metabolism Excretion
30
Why is oral absorption reduced in kidney disease
Nephrotic/fluid overload -> oedema in gut Uraemia - N+V Reduced gut motility Increased gut pH Concurrent medication Phosphate binders eg calcium acetate
31
Gut motility in diabetes
Reduced - drugs stay in stomach longer
32
Role of phosphate binders in kidnye disease
33
Distribution of drugs how effected in kidney imapriemnt
Oedema - larger volume of distribution into water soluble compartment Changes in hydration status Long term malnutrition and muscle mass
34
What are patients with CKD on long term dialysis more at risk of that effects drug distribution
Malnutrition -> reduced muscle mass -> reduced protein binding, reduced tissue bindinG OF DRUGS
35
What drugs is metabolism slower for in CKD
Vitamin D Insulin
36
What is the problem with excretion in renal impairemnt?
Any drug predominantly excreted by the kidney will accumulate
37
What does accumulation from impaired excretion of drugs cause?
Increased side effects Increased toxic effects Increased therapeutic effects
38
What are aminoglycosides toxic to?
Tubular cells
39
What drugs can directly cause acute intersitial nephritis
Trimethoprin, penicillins, vancomycin, NSAIDs
40
What renal damage can immune modulators cause
Nehropathies Tubular damage Acute intersitial nephritis
41
What drugs are indirectly renotoxic and why
Drugs that cause altered haemodynamics compromising renal perfusion eg ACEi/ARB, diuretics, vasodilators
42
Ideal drugs for renally impaired
Not metabolised or excreted by kidneys Wide therapeutic index Few/benign side effects Doesnt interact with other drugs Not affected by hydration status Low protein binding Low Na content (will cause more oedema if not) Low infusion volume
43
Drugs to absolutely avoid in renal impairemnt
Preominantly renally excreted Nephrotoxic Serious dose related adverse effects Narrow TI not possible to monitor levels
44
Theoretical eGFR for Different dialysis (function of kidney assumed)
150-200 druing, 0 in between (overall average <10) 5-10 peritoneal dialysis 15-25 - CVVH 30-40 CVVHDF
45
CVVH mechanism of action
Continious - works by convection
46
CKD supportive medications
Renal anaemia Bone chemistry Acid/base balance Analgesia Antidepressants Extra vitamins Laxatives
47
Who is laxatives with CKD particuarly important in?
Peritoneal dialysis
48
What drugs could be used for bone chemistry
Alfacalcidol, phosphate binders, cincalcet, etelcalcitide
49
What medication used for acid base balance in CKD
Na bicarbonate
50
What is renavit used in
Extra vitamins for haemodialysis intermittent patients
51
What is the active form of vitamin D
Alfacalcidol - drug unaffected by dialysis
52
statin risks with CKD on ITU
Risk of accumulation therefore increased risk of myopathy
53
Why is calcium acetate required in dilaysis patients?
Phosphate is not removed in dialysis so needs to be removed seperately
54
What happens if patient vitamin D intake is too high?
Hypercalcemia and hyperphosphatemia
55
What happens to EPO dose on dialysis
Needs to be increased as less functioning kidney to produce hormone
56
What can ACEi cause that is dangerous in a renal patient?
Hyperkalemia - less ability to be removed through kidneys, solely relying on dialysis
57
Why are patients told to eat a low potassium diet if renal impairment on ACEis
ACEis can cause hyperkalemia
58
Why is oxycodone used over morphine for pain relief in renal impairment
active metabolites of oxycodone less renotoxic than morphine Still reduce dose if renal impairment worse
59
Why can sodium bicarbonate be discontinued on dialysis
Given through dialysis machine rather than oral
60
Drug factors in dialysis
Molecular weight Protein binding Water solubility Absorption of drug molecule onto dialysis membrane (membrane or drug charged)
61
Dialysis factors in drug dosing in RRT
Duration of dialysis Flow rate - blood and dialysate Type of membrane used - permeability
62
How use creatinine clearnace on dialysis
don't calculate on dialysis as not accurate - dose as if <10
63
What consider when prescribing for every renal patient
Choice, starting dose, frequency (lower dose, less frequent as rule of thumb) Adjust dose according to response Monitor for toxicity Back up dosage pescriptions with serum drug level monitoring where possible
64
Hyperacute liver failure what is it
Jaudniced encephalopathy less than or = to one week after incident
65
Biochemical picture in hyperacute liver failure
Significantly elevated PT Low to mod rise in bilirubin Marked increase INR Rapid progression
66

GI, liver, kidney (50 decks)

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