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Haemdialysis / Peritoneal Dialysis Flashcards

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1
Q

What does haemodialysis involve

A

Diffusion
Ultrafiltration
Through counter current system

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2
Q

What does haemodialysis require

A

Semipermeable membrane (dialyser)
Dialysate pumped counter current to blood (contained electrolyte)
Artificial kidney
Adequate blood exposure
Anti-coagulation
Dialysis access - high flow created from fistula

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3
Q

When do you not use haemodialysis

A

If haemdynamic instability

Use if kidney is the only issue

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4
Q

When do you use haemofiltration

A

ITU if harm-dynamic instability

Continuous but may delay mobilisation

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5
Q

What can be used for access

A

Central line in emergency
AV fistula - 6-8 weeks
- To check its working listen for murmur / thrill
AV prosthetic graft

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6
Q

What can you use whilst waiting for fistula / graft

A

Tunneled venous catheter (Permcath) - essentially a PICC line that is tunnelled to reduce infection
Temporary non-tunnelled venous catheter

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7
Q

What does a Permcath do

A 
Tunneled catheter
Goes underneath skin
Runs into vein
Reduce infection
Lasts months - 1 year
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8
Q

What does a non-tunnelled do

A

Direct into vein if fistula not ready

Lasts 2 weeks

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9
Q

What are the risks of lines

A

Infection
Thrombosis
Pneumothorax
Central venous stenosis

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10
Q

What veins are used for catheter

A

R+L jugular or subclavian

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11
Q

What veins / artery are used for fistula

A 
Snuff box - younger as may need to use more 
Brachiocephalic - most common
Radiocephalic
Brachiobasilic
of non-dominant hand
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12
Q

What do you need for fistula

A

Adequate artery
Adequate vein to connect to artery to drain fistula
Allows blood to flow from high pressure artery to vein and bypass capillary system

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13
Q

What do you do before fistula

A

Examination

Duplex USS

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14
Q

What are indications for graft / tunnelled catheter over fistula

A

Vein not suitable - congenital or been used
Frailty
Heart issues
Fistula failure

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15
Q

What causes fistula failure

A 
Thrombosis
Stenosis 
Aneuyrsm 
Infection
High output heart failure causing hypotension  
Trauma
Steal syndrome
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16
Q

What is steal syndrome

A 
Too much blood goes through fistula leading to ischaemia of the hand distal to the fistula 
Cold
Pain
Cramps 
Paresthesia
Gangrene
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17
Q

What are signs of thrombosis

A

Absence of thrill or bruit

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18
Q

What are signs of stenosis

A

High pitched bruit

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19
Q

How do you manage failure

A 
Address hypotension
Urgent thrombectomy if thrombosis 
Heparin infusion 
Fistuloplasty if stenosis
Temporary line
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20
Q

How do you monitor renal function on dialysis

A

URR (urea reduction ratio) - urea before and after dialysis

KTV = more accurate

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21
Q

Why can’t you use creatinine or eGFR

A

Fluctuates when on and off dialysis

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22
Q

What do you worry about

A

K levels

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23
Q

How do you work out how much to lose each dialysis

A

Patients have target weight which is considered euvolemic

Reduce target weight if overload

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24
Q

How does diet change when start dialysis

A 
Fluid restriction 
Salt, K and phosphate restriction 
Protein and calories restriction 
Phosphate binder
Vitamin supplements as lose water soluble 
Iron as lose when on dialysis
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25
Why might you not need BP meds
Dialysis deals with salt and fluid retention if this is the cause of high BP
26
What fluid restriction
600ml if anuric 1l HD 1.5l PD
27
What are complications of haemodialysis
``` IHD - high risk Intra-dialytic hypotension Fluid overload causing hypertension Electrolyte imbalance Arrythmia Endocarditis Site infections Clotting / heparin issue Altered drug clearancee Altered nutrition Catastrophic dialysis ```
28
What causes hypotension
Become too dry | Feel crampy
29
What is catastrophic dialysis
``` Massive haemorrhage due to anti-coagulant Air embolism Acute allergy Acute haemolytic reaction DIC Dialysis disequilibrium syndrome ```
30
What is dialysis disequilibrium syndrome
Between cerebral and blood solutes Leads to cerebral oedema Start dialysis gradually
31
How can PD be carried out
Continuous ambulatory PD 4x daily | Automated PD overnight
32
How long can you do PD for
5 years | High complications
33
What does PD require
``` Semipermeable dialyser membrane = peritoneal membrane Mesenteric blood supply Access Fill bag Drain bag ```
34
What access for PD
Tunnelled venous catheter in abdomen which is permanent
35
How does PD work
Dialysis solution (high dextrose) into peritoneal cavity Blood filters across dialysis peritoneal membrane into dialysis solution Drains out waste Fresh dialysate instilled
36
What does dialyse contain
Balance of electrolyte | Glucose most common
37
What are complications of PD
``` Exit site infection Catheter tunnel infection or blockage PD peritonitis as high glucose = very high mortality Peritoneal sclerosis Tube malfunction Abdominal wall hernia Ultrafiltration failure as membrane destoryed Malnutrition Metabolic - hyperG Weight gain Fluid retention Constipation ```
38
What causes tube malfunction
Constipation
39
What metabolic issues
Obesity Hyperglycaemia Malnutrition Protein wasting
40
What are symptoms of PD peritonitis and most common organism
``` S.epidermis Cloudy fluid - WCC + neutrophils Abdo pain N+V Fever GI upset Systemic upset ```
41
What is the best way to treat ESRD and common reason
Kidney transplant into R iliac fossa - DM - HTN - GN - PCKD - Autoimmune lupus etc
42
When would you remove non-functioning kidney
PCKD Pyelonephritis Malignancy
43
When is a transplant CI
Cancer with mets Active infection Unstable CVD
44
What are types of donation
``` Donation after brain death Living related Living unrelated Altruistic Paired Must be tissue matched ```
45
What are complications of surgery
``` Bleeding Infection Electrolyte imbalance Thrombosis Ureteric leak Arrythmia ```
46
What do you put in for 6 months after surgery
Ureteric stent due to risk of obstruction
47
What medication should you put on post-transplant
Monoclonal Ab at time of transplant to reduce acute rejection 2x immunosuppression Steroid Prophylactic anti-viral
48
Other
Anti-prolifertive mTOR inhibitor Costimulatory signal blocker
49
What is 1st line immunosuppression
MMF Tacrolymus - calcineurin inhibitor + small dose steroid
50
MMF can cause
Colitis
51
Tacrolymus can cause
SOB
52
What do you monitor if on tacrolymus
CVS disease- hyper lipid, high BP, hyperglycaemia Renal failure - nephrotoxic Malignancy - reduce sun
53
What are other forms of immunosuppression
Azathioprine (anti-metabolite)
54
When is it used
Can't tolerate MMF
55
Complications of azathioprine
Liver and bone marrow suppression | Enzyme test to see if will tolerate - APMT
56
What are complications of transplant
``` ATN of graft kidney Vascular thrombosis Opportunistic infection - UTI / CMV. /PJP / BK / KC Wound infection Graft rejection Malignancy - NHL or SCC of skin CVS disease DM due to steroids VTE Bone marrow suppression Recurrence of original disease ```
57
What can CMV cause
Pneumonitis Hepatitis Gastroenteritis Nephritis
58
What are types of rejection
Cellular (T cell) = most common Humoral (Ab) Vascular
59
What increases risk of rejection
Transfusions
60
What malignancy
Post-transplant lymphoma | SCC / BCC - skin surveillance
61
How do you investigate rejection
Blood test for donor specific Ab | Renal USS + biopsy
62
How do you treat acute rejection
Increased steroid + immunosuppression 1st line in acute
63
If someone deteriorates on dialysis
U+E CXR - Lung fields for overload Cerebral oedema
64
How long till fistula ready
6-8 weeks
65
What are common organisms in PD infection
S epidermis | S aureus
66
What is hyper acute, acute and chronic
``` Hyper = minutes Acute = <6 months Chronic = >6 months ```
67
What causes hyper acute
HLA mismatch
68
What causes acute
HLA Cell mediated CMV
69
What causes chronic
Cell or Ab cause fibrosis | Recurrence
70
How does chronic present
Deteriorating function
71
How does acute present
Like infection
72
What is 1st line for RRT whilst waiting for transplant
PD | Have to do haemodialysis if PD not suitable i.e. Chron's
73
What are indications for acute dialysis
``` Acidosis - severe or not responding Electrolyte imbalance - severe or not responding Intoxicaiton Oedema - severe and unresponsive Uraemic symptoms ```
74
What are indications for long term
End stage renal failure | Any of above that continue long term
75
What are Sx that disease not controlled on RRT
CKD symptoms
76
Kidney vs spleen
Kidney - No notch - No movement respiration - Can ballot - Enlarge inferior - Can get above Spleen - Splenic notch - Move down on inspiration
77
What do you do if someone comes in after transplant
FBC important as decrease immune U+E BM and HbA1c as steroid Tacrolimus level

Renal / Urology (16 decks)

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