Renal: ESRD Flashcards by Patryk Lasiuk

Most common treatment used for ESRD?

Hemodialysis

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Primary cause of ESRD?

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Overall mortality rate of dialysis?

13%, decreasing since 1988

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Dialysis life expectancy is…

20-25% of a healthy individual

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1 killer of patients on dialysis is…

ASCVD

infections 2nd most common cause

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When do you start dialysis?

planning once eGFR or ClCr <30ml/min

benefits and risks of actual start should be eval when eGFR or ClCr <15 ml/min (when to start within next short period of time)

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Criteria for starting dialysis

1 = pts clinical status (Persistent anorexia, N/V, weight-loss, fatigue, low serum albumin lvls, neurologic deficits or itching

concomitant diseases (uncontrolled HTN/CHF)
Adv/Disadvantages of HD and PD

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How often is and how long is each HD session

3/week for about 3-5hrs

larger pts will require long treatment time

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What is Dialysate solution?

Purified water and electrolytes

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What is important to add with HD?

Add heparin to prevent clotting of blood running through the lines

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Two options for access in Hemodialysis

Arterial venus fistula

Synthetic AV graft

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Arterial Venus Fistula

Take artery and connect with vein

takes like 6 months before you can use it

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Primary Artery used for AV fistula

usually radial or cephalic in forearm

start closer in wrist, if issue can move farther back up

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Central venous catheters

are temporary and have a high rate of infection

placed in femoral, subclavian or internal jugular vein

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Pro/Con of Native AV fistula

Pro:

longest access survival
lowest rate of complications
inc survival = decrease hospitalizations
most cost-effective

Con:

require 1-2 months to mature before use
difficult to rate in some pt…(elderly, PVD, anyone with Vascular disease)

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Pro/Con of Synthetic AV graft

Pro:
1. 2-3 wks to mature

Con:

shorter survival vs fistula
increased infections/thrombosis

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Pro/Con of Central Venous Catheter

Pro:

used immediately
pts like small kids, severe PVD, morbidly obese

Con:

short life span
most infections/thrombosis
mayn’t provide adequate blood flow for dialysis

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Diffusion

movement of substances along a conc gradient

Rate depends on conc difference between blood and dialystate, solute characteristics, dialyzer membrane comp and flow rates

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Ultrafiltration

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

primary means for removal of excess body water

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Convection

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

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HD membranes: conventional/standard

small pores

limit clearance to smaller molecules

HD membranes: High efficiency

large surface area

can remove water/urea/other small molecules

HD membranes: High Flux

Large pores

capable of removing high-molecular-weight substances

drugs like vancomycin

Shorter treatment times occur with which membranes?

High efficiency and High flux due to increased clearance

Flow rates required for High efficiency/flux membranes

>400 mL/min blood flow > 500 mL/min dialysate flow can increase risk of hypotension and muscle cramps

Pro/Con of HD

Pro: 1. higher solute clearance = intermittent sessions 2. Technique failure rate low 3. closer pt monitoring Con: 1. Multiple visits/wk to HD center 2. SE = Hypotension, muscle cramp, disequilibrium 3. Infections 4. Vascular thrombosis

Complications during HD

Hypotension | Muscle cramps

Point of Air detector in HD?

To prevent embolism if air is in the lines

can you still urinate on dialysis?

Yes they can you want to maintain any kidney functions they have as it can improve their outcomes

What causes Hypotension in HD

taking out too much fluid too fast more common in DM and elderly

What causes muscle cramps in HD

excessive ultrafiltration = decreased plasma volume and decrease muscle filtration pulls volume out of tissues into vasculature

Acute Hypotension during Dialysis treatment

1. Trendelenburg postion 2. decrease ultrafiltration rate 3. 100-200ml bolus normal saline 4. 10-20 ml hypertonic saline bolus

Prevention of Hypotension during Dialysis treatment

Midodrine = 1st choice | 2.5-10mg 30min prior to start

Acute Muscle Cramp during Dialysis treatment

1. 100-200ml normal saline bolus | 2. 10-20ml hypertonic saline bolus

Prevention of Muscle cramp during Dialysis treatment

1. Vit E 400IU daily = 1st choice (well tolerated, cheap, easy) 2. Quinine

What to do if thrombosis occurs during HD?

give alteplase/reteplase

How to treat infections from HD

1. remove catheter | 2. give ABX depending on infection based on what it is

Who gets Peritoneal Dialysis

1. Hemodynamically unstable 2. Sig residual kidney function 3. Pts who desire to maintain sig degree of self care as long as they can be trained

PD vs HD

1. PD is much less efficient 2. No easy method to regulate blood flow 3. No countercurrent of flow PD session will be much longer than HD session

Pros/Cons of Peritoneal Dialysis

Pro: 1. More hemodynamic stability vs HD 2. Better preservation of residual renal function 3. Can admin some drugs IP 4. Freedom from HD machine 5. Less blood loss/iron deficiency Con: 1. Peritonitis 2. Catheter malfunction 3. Infection 4. Inadequate dialysis and ultrafiltration 5. High rate of tech failure

How to treat PD Peritonitis

give ABX intraperitoneally

Prophylaxis of Peritonitis in PD pts

Test for Staph aureus in nose = increase risk Can give mupirocin intranasal BID/5 days/month Place daily on exit port

Continuous Renal Replacement Therapies

Used in acute renal failure by toxic substance

CVVH primary clearance is through...

convection

CVVHD primary clearance is through....

Diffusion

CVVHDF primary clearance is through....

Convection and diffusion

Pros/Cons of CRRT vs IHD

Pro: 1. Less BP issues 2. increase solute removal/day 3. improved survival 4. faster ARF resolution Cons: 1. increase thrombosis 2. Special equip 3. intensive RN care & $$$, pharmacy care 4. Little known about drug dosing in CRRTs 5. ?? nutrition requirement changes

Drug dosing in Dialysis

1. If drug dialyzable, schedule admin after dialysis to avoid supplemental dosing 2. if in doubt, drug drug levels. need pre/post dialysis levels

Efficiency of drug removal determined by....

1. Membrane characteristics 2. Dialysis characteristics (Blood flow, duration of dialysis, Dialysate flow rate & composition) 3. Drug characteristics (MW, water solubility, protein binding = most important, Volume of Distribution = the higher it is, the lower removed by dialysis)

Small MW of drug influenced by....

Diffusion

Large MW of drug influenced by....

Convection

Volume of Distribution effect on dialysis drug removal

The higher the volume of distribution = the less is removed by dialysis