ESRD

Question 1

Dialysis planning should begin once eGFR or Clcr

Answer 1

30 mL/min

Question 2

Benefits and risks of actual start of dialysis should be evaluated when eGFR or Clcr is

Answer 2

15mL/min

Question 3

Primary criterion

Answer 3

Pts clinical status

Persistent anorexia, N/V, weight loss, fatigue, low serum albumin levels, neurological deficits or pruritus

Question 4

Hemodialysis duration

Answer 4

3x/wk for 3 to 5 hours per session

Larger patients require longer treatment times

Question 5

Primary cause for ESRD

Answer 5

DM

Question 6

HD system: external vascular circuit

Answer 6

Pt’s blood transferred in sterile polyethylene tubing to dialysis filter or membrane (dialyzer) via mechanical pump

Blood then passes through dialyzer on one side of semipermeable membrane and back to pt

Question 7

Dialysate solution: purified water and electrolytes

Answer 7

Pumped through dialyzer countercurrent to blood flow on other side of semipermeable membrane

Systemic anticoagulation (with heparin) used to prevent clotting of HD circuit

Question 8

Native Arterio-venous (AV) fistula

Answer 8

created by anastomosis of a vein and artery (ideally radial artery and cephalic vein in the forearm)

Question 9

Synthetic AV grafts:

Answer 9

usually made of polytetrafluoroethylene

Question 10

Central venous catheters

Answer 10

placed in femoral, subclavian, or internal jugular vein

Question 11

Advantages of Native AV fistula

Answer 11

Longest access survival
Lowest rate of complications
   --> infxn & thrombosis
Pts: increased survival & decreased hosp.
Most cost-effective

Question 12

Disadvantages Native AV fistula

Answer 12

Require ≥1 to 2 months to mature before routine use

May be difficult to create in some pts: Elderly, PVD, anyone with vascular disease ( + DM)

Question 13

Advantages of Synthetic AV graft

Answer 13

2-3 weeks to mature

Question 14

disadvantages of Synthetic AV graft

Answer 14

Shorter survival vs. fistula

increased infections and thrombosis

Question 15

Advantages of central venous catheter

Answer 15

Can be used immediately

Some pts: small kids, severe PVD, morbidly obese

Question 16

Disadvantages of central venous catheter

Answer 16

Short life span
Most infections and thrombosis
May not provide adequate blood flow for dialysis

Question 17

Diffusion

Answer 17

movement of substances along a concentration gradient

Question 18

ultrafiltration

Answer 18

movement of water across dialyzer membrane due to hydrostatic or osmotic pressure

Question 19

Convection

Answer 19

dissolved solutes “dragged” across membrane with fluid transport (during ultrafiltration)

Question 20

Conventional or standard HD membrane

Answer 20

small pores

limit clearance to smaller molecules

Question 21

High efficiency HD membrane

Answer 21

large surface area

^ ability to remove water, urea, and other small molecules

Question 22

High Flux HD membrane

Answer 22

large pores

capable of removing high-molecular weight substances

Question 23

High efficiency + high flux

Answer 23

shorter treatment time
increased blood flow
increased rate of hypotension and muscle cramps

Question 24

HD advantages

Answer 24

Higher solute clearance = intermittent sessions
Technique failure rate low
Closer pt monitoring
In HD center

Question 25

HD disadvantages

Answer 25

Multiple visits/wk to HD center SEs: Hypotension, muscle cramps, disequilibrium Infections Vascular thrombosis

Question 26

Complications during HD

Answer 26

Hypotension - taking out too much fluid too fast - more common in DM and elderly Muscle Cramps - excessive ultrafiltration - plasma volume contraction - muscle perfusion

Question 27

HD hypotension acute treatment

Answer 27

Trendelenburg position -feet above head, increases blood flow to the head Hypertonic saline Mannitol

Question 28

HD hypotension prevention

Answer 28

Midodrine

Question 29

HD Cramps

Answer 29

1st line saline, vitamin E 2nd line Quinine (no longer marketed)

Question 30

HD complications less common

Answer 30

Thrombosis and infection

Question 31

Peritoneal Dialysis candidates

Answer 31

``` Hemodynamically unstable (e.g., hypotension on HD) Significant residual kidney function Pts who desire to maintain a significant degree of self-care as long as they can be trained ```

Question 32

PD

Answer 32

Instillation of dialysate into peritoneal cavity via a permanent peritoneal catheter Peritoneal membrane acts as semipermeable membrane across which diffusion and ultrafiltration occur Substances removed from blood across peritoneum via diffusion and ultrafiltration Excess plasma water removed via ultrafiltration created by osmotic pressure generated by various dextrose or icodextrin concentrations

Question 33

Dialysate-filled compartment in PD

Answer 33

peritoneal cavity

Question 34

Peritoneal membrane

Answer 34

semipermeable membrane

Question 35

Blood compartment

Answer 35

vessels supplying and draining the abdominal viscera, musculature and mesentery

Question 36

Advantages of PD

Answer 36

More hemodynamic stability vs. HD Due to slower filtration rate Better for elderly? Better preservation of residual renal function Can administer some drugs IP Freedom from HD machine Less blood loss and iron deficiency vs. HD

Question 37

disadvantages of PD

Answer 37

``` Peritonitis Catheter malfunction Infection Inadequate dialysis and ultrafiltration Esp in large pts High rate of technique failure ```

Question 38

PD complications

Answer 38

Peritonitis: common increase risk of infection Prophylaxis: Mupirocin daily at exit site

Question 39

Continuous Renal Replacement Therapies (CRRT)

Answer 39

Solute removal slower vs. HD, but more can be removed over 24 hr period

Question 40

Advantages of CRRT

Answer 40

Hemodynamically unstable pts increased solute removal/day Improved survival Faster ARF resolution

Question 41

disadvantages of CRRT

Answer 41

``` increased thrombosis Special equipment Intensive RN care More $$$ increased pharmacy care Little known about drug dosing in CRRTs ? Nutrition requirement chgs? ```

Question 42

Dialysis membrane characteristics

Answer 42

Surface area of dialyzer membrane Membrane porosity

Question 43

Dialysis characteristics

Answer 43

Blood Flow Duration of dialysis Dialysis flow rate and composition

Question 44

Drug Characteristics

Answer 44

Molecular weight Water solubility protein binding (most important) Volume of distribution