dialysis Flashcards
what are kidneys for?
To filter blood
Excretion
Potassium metabolism
Blood manufacture (EPO)
Acid/base metabolism
Salt/water/blood pressure
Calcium metabolism
how to measure excetion
Glomerular filtration rate -
inulin
56-Cr-EDTA
Creatinine
eGFR – calculated from creatinine, age,
(race)
creatinine an renal function
A raised creatinine (< 120)
often implies > 50% loss of
renal function
kidney damage stagin
how to treat hyperkalaemia
• K+
- ECG monitor
• No p waves, broad QRS or worse - IV calcium.
10ml calcium gluconate. Repeat until
complexes normalise. Give glucose & insulin.
• Peaked T’s - Glucose & insulin. 10 units
Actrapid in 50ml 50% glucose over 30 minutes.
Give as bolus if no pump available.
treat EPO depletion
Responds to pharmacological doses of ESA
– Erythropoiesis stimulating agents
ESA:
Recombinant products
s/c monthly to 3 times a week
risk of hypertension/hyerpviscosity
functional iron deficiency
iv iron
expense and funding issues
when do you get poor ESA response?
Intercurrent disease
infection
malignancy
Functional iron deficiency
Ferritin poor guide
% hypochromasia
Treat with INTRAVENOUS iron
how to treat metabloic acidosis
Consider treating with sodium bicarbonate
may produce overload and hypertension
renal bone diseases
Untreated:
Osteomalacia and Rickets
Tertiary hyperparathyroidism
Ectopic calcification
bone biochemistry
measure:
Ca2+
PO4
Alkaline Phosphatase
PTH
how to manage renal bone disease
When eGFR < , check PTH
Treat if PTH > twice normal
If phosphate is high, give phosphate binders
with food
When phosphate is controlled or if normal, give
vitamin D analogue daily
chronic implications of renal impairment
Progression to end-stage renal failure
Hypertension
Renal bone disease
Anaemia
Acidosis
Psychological
Fluid balance (overload/dehydration)
therapetic options
Haemodialysis
Peritoneal dialysis
Transplantation
Conservative therapy
CAPD
Continuous Ambulatory Peritoneal Dialysis (CAPD)
4 x 2 litre exchanges every day
Can be done anywhere
Less fluid restriction
Fewer dietary restrictions
malnutrition
decreased intake
uraemia/inadequate
dialysis
depression
absorbed glucose
(CAPD)
abdominal fullness
(CAPD)
altered taste
haemodialysis
intercurrent illness
anaemia
acidosis
loss of protein in CAPD
complications of dialysis
infection and
immunosuppression
line/cannula infections
Clostridium difficile
blood borne viruses
skin
pruritis
nodular prurigo
dry skin
pigmentation
Hypertension
Volume
pre-existing condition
calcium
non-volume dependent
hypertension
Cardiovascular
left ventricular
hypertrophy
Vascular calcification
ischaemic heart disease
sudden cardiac death
renal bone disease
bone pain
acute hot joint - pseudogout
pathological fractures
secondary hyperparathyroidism
tertiary hyperparathyroidism
ectopic calcification
can we determin who will not benefit from renal replacement therapy:?
Functional status (Karnovsky?)
Comorbidity and associated
prognosis
NSF standard 14
Each person approaching established renal
failure is given timely and understandable
information about their prognosis and the
choice of therapies available to them
including the option of choosing not to
dialyse. They are made aware of the relative
burdens and benefits of the different types of
dialysis
renal failure symtpoms near the end of life?
Anorexia, N+V, dry mouth, ammonia taste,
breath smells of urine, hiccups, myoclonic
jerks, constipation, diarrhoea ( uraemia )
SOB, Oedema ( fluid overload )
Itch ( multifactorial )
Tiredness ( anaemia, uraemia, cachexia)
Gastric problems ( gastrin levels )
Psychosocial problems