Hemodialysis

Question 1

most appropriate referral to nephrology

Answer 1

stage 3b or 4

Question 2

rule of 6 in AVF

Answer 2

at least 6 mm in diameter
at least 6 cm of overall needle accessible length
no more than 6 cm below the surface

Question 3

higher arterial steal phenomenon

Answer 3

side to side anastomososis

Question 4

advantage of end ro side appeoach

Answer 4

avoidance of venous htn

Question 5

ideal hd access

Answer 5

high prrimary patency rate 
instant usability 
long survival
low thrombosis rate 
low infection rate 
high blood flow rate 
patient comfort 
bathing/hygiene 
minimize needles
minimal cosmetic effect

Question 6

duration of lack of change on physical examination prognostic of nonmaturation

Answer 6

4 to 6 weeks

Question 7

most impt monitoring technique

Answer 7

good pe of av shunt

Question 8

avf has bounding pupsation, inc aneurysm size, does not flatten when arm raised above the head

Answer 8

venous outflow or central venous stenosis

Question 9

acess placement

Answer 9

gfr < 20

Question 10

factors influencing effective clearance: small molecules

Answer 10

Small FATmembrane 
flow (blood/dialysate) 
area (membrane surface) 
Time (treatment time) 
membrane permeability

Question 11

most impt intrinsic physical feature governing removal

Answer 11

size of molecule

Question 12

guards against excessive suction on the vascular access

Answer 12

arterial pressure

normal: -20 to 80

Question 13

gauges resistance to blood return

Answer 13

venous pressure

+ 50 to + 200

Question 14

affect solute clearance of a hemodialyzer

Answer 14

Increase clearance
- porosity, surface area, hydrophilicity, blood/dialysate flow

decrease clearance
- thickness, molecular weight/size, lipid solubility, protein binding, unstirred layer

varies
-membrane charge

Question 15

degree to which membrane activates blood components

Answer 15

biocompatibility

Question 16

min accetable internal fiber diameter

Answer 16

180 mcm

Question 17

target aluminum level in water

Answer 17

< 10 mg/L

osteomalaciac microcytic anemia, encephalopatjy

Question 18

direct exposure to this causes hemolysis and methemoglobinemua

Answer 18

chloramine

Question 19

cardiac arrhythmia and acute death

Answer 19

Fluoride

Question 20

Hard water syndrome - nausea vomiting weakness flushing labile bp

Answer 20

Excess ca and Mg

Question 21

target temp of water

Answer 21

77F-100F

Question 22

quality of dialysis water

Answer 22

lower maximal level of 100 cfu/ml bacteria and a max concn of less than 0.25 eu/ml for endotoxin

Question 23

action levels

Answer 23

25 cfu

0.125 eu/ml

Question 24

ultra pure dialysate

Answer 24

bacterial count of less than 0.1 cfu/ml

endotoxin less than 0.03 eu/ml

Question 25

monitoring of water quality

Answer 25

monthly

Question 26

post bun sampling

Answer 26

slowing the blood pump to 100 ml/min for 15s, stopping the dialysate flow for 3 mins, drawing sample from dialysate inflow port

Question 27

clinical conditions with no anticoagulation or reginal anticoagulation

Answer 27

``` actively bleeding significant risk for bleeding major thrombi static defect major sx within 7 fays intracranial sx 14 days biopsy of visceral organs with 72h pericarditis ```

Question 28

Low dose heparin clinical conditions

Answer 28

Major sx beyond 7 days biopsy if visceral organs beyond 72h minor sx 8h prior minor sx within 72h

Question 29

either low dose or no anticoagulation

Answer 29

major sx 8h prior

Question 30

to prevent clotting

Answer 30

rinse circuit with heparinized saline less thrombogenic dialyzer flush the circuit with 100 to 200 ml 0.9% Nacl every 30 mins avoid blood or platelet transfusion through circuit high blood flow rate limit uf

Question 31

Mg for persistent intradialytic hypotension

Answer 31

Higher dialysate Mg

Question 32

Adynamic bone disease

Answer 32

lower dialysate Mg

Question 33

major complication of bicarbonate dialysate

Answer 33

bacterial contamination and precipitation of Ca and Mg salts

Question 34

surrogate marker for cardiovascular disease in hd

Answer 34

carotid intimal thickness

Question 35

reduce plasma isoprostanes and isofurans, markers of oxidative stress and endothelia function

Answer 35

coenzyme q10

Question 36

surrogates of overall bp status

Answer 36

prehd and post hd bp

Question 37

htn meds removed poorly with hd

Answer 37

losartan, fosinopril, ramipril, carvedilol, bisoprolol, propranolol

Question 38

when can false positive hbsag occur

Answer 38

3 weeks

Question 39

decrease in sbp 20 mmhg or more or a decrease in map of 10 mmhg with clinical events

Answer 39

hypotension

Question 40

interventions to consider in recurrent intradialytic hypotension

Answer 40

``` reassess dry wt reduce id Na gain assess id hypoca, hypoK, hypoNg avoid food intake during hd adjust antihtn assess cardiac function cool dialysate extend dialysis time or add sessions sequential Uf or uf remodeling midodrine ```

Question 41

measures in dds

Answer 41

1. shorter tx times of 1-2h 2. lowering blood flow rates to 200-250 ml/min 3. Reducing dialysate flow rate, concurrent flow 4. dialyzer with small surface area 5. Mannitol

Question 42

pericaridits that occurs within 8 weeks of initiation of hd

Answer 42

uremic pericarditis

Question 43

dialyzer reaction that occur within 5 to 20 mins and present with pruritus, urticaria, bronchospasm or anaphylactic shock

Answer 43

type A reactions

Question 44

cause of first use syndrome

Answer 44

IgE antibodies to membrane material or ethylene oxide

Question 45

Complement mediated, occur later, chest and back discomfort

Answer 45

Type B

Question 46

chest tightness, back pain, shortness of breath with acute pigmentation of the skin and port wine appearance of the blood in venous line

Answer 46

acute hemolysis discontinue without blood return check K, peripheral smear, hgb screen dialysate and blood tubing for contaminants

Question 47

foam in venous line

Answer 47

air embolism

Question 48

tx of air embolism

Answer 48

``` Stop blood pump clamp venous dialysis line to prevent further air entry administer O2 volume resuscitation keep patient supine ```