Dialysis

Question 1

Most common cause of ESRF needing Hdx

Answer 1

Diabetes GN HTN PCKD Reflux nephropathy

Question 2

Indications of Hdx - Chronic (and planning)

Answer 2

Plan when eGFR <20 Usually start is symptomatic - LOA, itchy, metallic taste in mouth, LOW, difficulty concentrating Start around eGFR 7-8 (if eGFR <5, start even if asymptomatic as will develop complications)

Question 3

Indications of Hdx - Acute

Answer 3

Below, not responding to usual therapy Acidosis HyperK Fluid overload/APO Oliguria/anuria Symptoms of uraemia -n/v/lethargy -LOA/LOW -cog impairment -loss of appetite for meat -declining nutritional state

Question 4

HDX Types

Answer 4

Haemodialysis - uses dialysate to precipitate diffusion across dialyser membrane Haemofiltration - uses additional replacement fluid, added into blood circuit to create hydrostatic pressure and push water and solutes across membrane Haemodiafiltration - a bit of both

Question 5

HDX Modes

Answer 5

HF HD SLED - 12 hours/overnight, good for hyperK CVVHDF - 24 hours, very slow, expensive, not good for hyperK

Question 6

PD Types

Answer 6

• Automated peritoneal dialysis (APD) - overnight, connected to a machine • Continuous ambulatory peritoneal dialysis (CAPD) -intermittent, manual

Question 7

HDX Access Types Complications

Answer 7

Permanent 1. AV Fistula - best method, needs 6-8 weeks to mature 2. Loop graft 3. Tunnelled catheter (SVC) Cx - infections, malfunction Steel syndrome Temporary 1. Vascath 2. Permacath

Question 8

Hdx Cx

Answer 8

1. Dialysis- disequilibrium syndrome - Uric acid being removed too quickly - Sx - high ICP sx, confusion -Start Hdx slow 2. Hypotension 3. Cramps 4. Dialysis related amyloidosis -due to accumulation of B2 microglobulin -not often seen now

Question 9

Cx of PD

Answer 9

1. PD peritonitis 2. Pleuroperitoneal leak 3. Encapsulating peritoneal sclerosis -progressive inflammatory process -can encase small bowel–>obstruction –>high mortality 3. DM 4. PD membrane failure (will happen eventually, can test with PET - Peritoneal equilibrium test)

Question 10

Contraindications to PD

Answer 10

Absolute -non compliance -psych -environmental issues at home Relative -abdo surgery -high BMI -abdo hernia

Question 11

Steal Syndrome

Answer 11

Clinical manifestations - Sx of upper limb ischaemia - hand pain, coldness, reduces sensation, pallor, cyanosis, absent pulses -sx often worse during dialysis - Classified based on chronicity and severity Management - surgical

Question 12

Dialysis Assessment

Answer 12

-Kt/V - urea clearance rate (doesnt account for fluid and other molecules) -URR (Urea Reduction Ratio)- urea pre and post dialysis ratio -PET - gives Cr clearance and an idea of Kt/V -symptom improvement, fluid balance

Question 13

Cause of death

Answer 13

CVD (50%) Infections Withdrawal from Hdx

Question 14

Marker of mortality

Answer 14

Serum Albumin (<40) -single laboratory finding most closely associated with an increased probability of death, and the increase in the risk is dose-dependent.

Question 15

PD Peritonitis -Common causes -Common pathogens -CF -Mx

Answer 15

Caused - most commonly due to poor technique Common pathogens - cog neg staph, staph aureus, Enterobacter, Strep, Enterococcus CF - cloudy PD fluid, abdo pain, systemic features Mx (Empirical) IP Gent + Cefazolin If diverticular disease or intestinal per is suspected - add metro (PO preferably, or IV) Total duration of therapy - 14-21 days Remove catheter if not improving after 5 days Polymicrobial growth on culture –> surgical exploration