Dialysis Flashcards
Steps to prevent filter clotting?
Increase blood flow rate
Use pre-filter replacement fluid
Change catheter
Use CVVHD instead of CVVH
Use anticoagulation
What is the preferred temporary line site?
Right internal jugular
What is the most likely cause for hypotension with someone receiving citrate anticoagulation?
Hypocalcemia
Electrolyte abnormalities seen in citrate lock?
Increased total serum calcium
Decreased ionized calcium
Acid/base abnormalities with citrate anticoagulation?
Metabolic alkalosis: liver converts citrate to bicarbonate
Metabolic acidosis: accumulation of citric acid in setting of non functioning liver
What is the formula for Urea Reduction Ratio?
URR=
(Pre BUN - Post BUN) / Pre BUN
What is the formula for Filtration Fraction?
FF =
UF / (Blood flow rate * 1-HCT)
What is the Kt/V goal for patients on PD?
1.8+
What is the formula for creatinine clearance?
CrCl =
(UCr * V) / SCr
What are the risks for targeting a Hb > 9-11 in ESRD patients?
Thrombosis
Hypertension
Malignancy
What is the starting epoetin dose for ESRD patients with anemia?
50-100 units/kg three times weekly
What are the diagnostic criteria for PD associated peritonitis?
Abdominal pain/cloudy dialysate
Effluent WBC count > 100/uL
Positive fluid culture
What is the preferred treatment for PD associated peritonitis?
Vancomycin + Cefepime
(Intraperitoneal unless septic)
What is the most likely pathogen causing PD associated peritonitis?
Coagulate negative staphylococcus (S. epidermidis)
How do you assess PD related peritonitis response to treatment?
Repeat effluent cell count or culture 3-5 days into treatment
How can you prevent PD related peritonitis?
Systemic antibiotics prior to catheter insertion
Daily topical antibiotics to exit site
Antibiotic prophylaxis prior to dental work, colonoscopy, invasive gynecological procedure
Antifungal prophylaxis for those on prolonged antibiotics
When should you remove the PD catheter for those with peritonitis?
Fungal or mycobacterium infection
Abscess
No clinical improvement after 5 days
Culture negative peritonitis with persistent effluent cell count and symptoms
What are the following definitions for PD associated peritonitis:
Recurrent?
Relapsing?
Repeat?
Refractory?
Recurrent = < 4 weeks of completing treatment but different bug
Relapsing = < 4 weeks of completing treatment but with same bug
Repeat = > 4 week of completing treatment but with same bug
Refractory = treatment failure at 5 days
What are the symptoms and treatment for encapsulating peritoneal sclerosis?
Symptoms = constipation + hemoperitoneum
Treatment = tamoxifen
Next steps for hydrothorax in patient on PD?
Stop PD
Surgical patch
Next steps for hemoperitoneum in patient on PD?
Heparin flushes to prevent catheter clotting
Next step for suspected tunneled PD catheter infection?
Ultrasound to rule out abscess
What do the variables mean in Kt/V?
K = dialyzer clearance
t = time
V = volume of distribution of urea
What does dialyzer efficiency refer to?
How well small molecules are cleared (KoA)
What does dialyzer flux refer to?
How well large molecules are cleared (KUF)
What are the sizes of small, middle, and large molecules as it relates to dialysis clearance?
Small < 500 Da
Middle 500-5000 Da
Large > 5000 Da
What is the mechanism of clearance for:
CVVHD?
CVVHF?
CVVHDF?
CVVHD = diffusion
CVVHF = convection
CVVHDF = diffusion + convection
Why is Kt/V superior to URR in determining dialysis adequacy?
Kt/V accounts for urea generated during HD and clearance of urea during ultrafiltration
What is the Kt/V goal for patients on HD?
1.2+
How to increase Kt/V for high transporter PD patient?
Increase number of exchanges
How to increase Kt/V for low transporter PD patient?
Decreased number of exchanges
Is CAPD or CCPD better for high and low transporters?
CCPD is better for high transporters
CAPD is better for low transporters
Compare high and low transporters with regards to solute clearance and ultrafiltration?
High transporter: good at clearance, poor at UF
Low transporter: poor at clearance, good at UF
What is the Kt/V goal for patient on home HD?
2.1+
True or False: Eosinophilic PD-associated peritonitis is benign?
True
How can you diagnose a PD associated hydrothorax?
Measure glucose concentration (or stain with iodine in event icodextrin was used)
How do you formally diagnose beta 2 microglobulin amyloidosis?
Synovial tissue biopsy
What is the formula for calculating ideal 3% NaCl infusion rate for treatment of hyponatremia?
Expected Na+ mEq change for every 1 liter of 3% NaCl = (512 - serum Na+) / (TBW + 1)
What is the formula for calculating ideal post-filter 3% NaCl infusion rate to maintain hypernatremia?
3% infusion rate = [(target Na+ - 140) / (513 - 140)] * replacement fluid rate
What is the formula for calculating ideal post-filter D5W infusion rate to prevent overcorrection of hyponatremia?
[(RFR * 140) / (RFR + X)] = goal serum Na+
Contrast what a carbon tank and RO/DI systems remove in a dialysis unit?
Carbon tank: Cl-, chloramine
RO/DI: Fl-
Surgical approach for steal syndrome?
DRIL
“Port wine” colored blood in dialysis circuit is concerning for what?
Hemolysis (chloramine, bleach exposure)
“Foam” in venous dialysis line is concerning for what?
Air embolism
What is the typical timing of presentation, pathophysiology, and treatment for Type A dialyzer reaction?
First 10 minutes, ethylene oxide exposure, stop HD without returning blood
What is the typical timing of presentation, pathophysiology, and treatment for Type B dialyzer reaction?
30-60 minutes, complement activation, no need to stop HD
What is the formula for calculating recirculation %?
(Plasma urea - Arterial urea) / (Plasma urea - Venous urea)
> 10-15% is significant
What is the treatment for severe ASA toxicity?
Hemodialysis
Diagnosis of elevated triglyceride level in peritoneal effluent?
Chyloperitoneum (from trauma)
What are the treatments for instillation pain and drain pain?
Instillation pain Tx = Neutral pH dialysate
Drain pain Tx = Tidal PD mode
How do you calculate daily residual renal Kt/V?
(UUN * UV) / (BUN * TBW)
How do you calculate daily peritoneal urea Kt/V?
(DU * EV) / (BUN * TBW)
Which component of a dialysis unit’s water treatment facility removes endotoxins?
RO
Which method to screen for latent TB is best in a ESKD patient?
IGRA
Right shoulder pain in a PD patient is concerning for what?
Intraabdominal air
Li2+ level and indication for hemodialysis?
4-5
Difficult cannulation can be seen with AVF __________ stenosis
Arterial
Increase CVVH venous line pressure can be seen during which 3 access issues?
Venous clot
Venous stenosis
Kinked tubing
What lab is used to evaluate for carnitine deficiency in dialysis patient?
Acylcarnitine:free carnitine > 0.4
What are the SSRIs of choice for ESRD patients?
Sertraline
Paroxetine
Fluoxetine
