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Renal Replacement Therapy Flashcards

1
Q

When do we start planning for dialysis?

A

Stage 4 CKD

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2
Q

What is the primary concern for dialysis initiation?

A

Clinical status

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3
Q

What are the criteria for initiation of dialysis?

A

One or more of the following:
Sx or signs attributable to kidney failure (serositis, acid base or electrolyte abnormalities, pruritus)
Inability to control volume status or BP
A progressive deterioration in nutritional status refractory to dietary intervention
Cognitive impairment

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4
Q

What factors should be considered when initiating dialysis?

A 
Dialysis accessibility
Transplantation option
Vascular access
Age
Declining health
Compliance with diet and medications
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5
Q

What are the types of dialysis?

A

HD
PD
Continuous renal replacement
Hybrid

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6
Q

Which types of dialysis are for chronic use?

A

HD

PD

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7
Q

Which types of dialysis are for acute use?

A

Continuous renal replacement

Hybrid

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8
Q

What are the advantages of HD?

A

Higher solute clearance -> intermittent use
Low technique failure rate
Closer patient monitoring

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9
Q

What are the disadvantages of HD?

A

Requires multiple weekly visits to dialysis center
Disequilibrium, hypotension, muscle cramps are common
Vascular access complications (infections and thrombosis)

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10
Q

What are the advantages of PD?

A

More hemodynamic stability
Suitable for pt that cannot tolerate HD
Sense of independence

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11
Q

What are the disadvantages of PD?

A 
Protein and aa loss and decreased appetite -> malnutrition
Catheter malfunction and/or infection
Patient burnout (decreased compliance)
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12
Q

What type of membrane is in HD?

A

Semipermeable that separates blood and dialysate

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13
Q

What type of current is used in HD?

A

Countercurrent

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14
Q

What is another name for convection?

A

Ultrafiltration

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15
Q

What are the two ways HD is performed?

A

Convection and diffusion

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16
Q

What does diffusion rate in HD depend on?

A

Concentration gradient, solute characteristics, dialyzer composition, and flow rates (blood and dialysate)

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17
Q

What does convection rate in HD depend on?

A

Hydrostatic pressure gradient across the membrane and dialyzer composition

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18
Q

What are the types of vascular access?

A

AV fistula
AV graft
Cuffed or tunneled venous catheters

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19
Q

What is the preferred type of vascular access?

A

AV fistula

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20
Q

How long does it take for an AV fistula to “mature”?

A

2 months

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21
Q

Which type of vascular access has the lowest rate of complications?

A

AV fistula

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22
Q

What is the 2nd line option for vascular access?

A

AV graft

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23
Q

How long does it take before an AV graft can be used?

A

2-3 weeks to endothelialize

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24
Q

Where is a cuffed or tunneled venous catheter placed?

A

Subclavian or internal jugular vein

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25
Which vascular access has the most complications?
Cuffed or tunneled venous catheters
26
What are the characteristics of the dialysate in HD?
Purified water and electrolytes | Heated to body temperature
27
What is the most conventional type of dialysis membrane in HD?
Low-flux
28
How is an anticoagulant administered in HD?
Bolus 3-5 minutes before HD, d/c 1 hour before HD ends
29
Why are anticoagulants administered in HD?
To prevent blood from clotting to tubing
30
What type of anticoagulant is typically used in HD?
IV heparin
31
What is a common HD regimen?
3-4 hours 3 times a week
32
What are the goals for HD?
Achieve dry weight | Adequate removal of endogenous waste products
33
What are complications of HD?
``` Hypotension Muscle cramps Thrombosis Infection Dialyzer reactions ```
34
What is the most common complication of HD?
Hypotension
35
What are predisposing factors for hypotension?
Excessive ultra-filtration Target dry weight is too low Take anti-hypertensive medications or eating food before HD Diastolic dysfunction
36
What is the acute treatment of hypotension in HD?
Trendelenburg position Decreates ultra-filtrate rate Give IV fluids
37
What are the IV fluid options for patients with hypotension in HD?
100-200 mL Bolus of 0.9% NaCl 10-20 mL hypertonic (23.4%) solution over 3-5 minutes 12.5 g mannitol
38
What is the most common IV fluid option for patients with hypotension in HD?
100-200 mL bolus of 0.9% NaCl
39
What are non-pharmacologic preventions for hypotension in HD?
Adjust dry weight Use bicarbonate buffer solutions Avoid food before HD pulls blood flow to the gut
40
What are pharmacologic preventions for hypotension in HD?
Midodrine 2.5 - 10 mg PO 30 minutes prior to HD | Less studied: caffeine, levocetirizine, fludricortisone
41
What is the cause of muscle cramps in HD?
May be related to plasma volume contraction and decreased muscle perfusion
42
What are the acute treatments for muscle cramps in HD?
IV fluids: 100 - 200 mL bolus 0.9% NaCl 10 - 20 mL hypertonic (23.4%) solution over 3-5 minutes 50 mL D50 - non-diabetic patients
43
What are the non-pharmacologic prevention strategies for muscle cramps in HD?
Adjust dry weight | Stretching exercises
44
What are the pharmacologic prevention strategies for muscle cramps in HD?
Vitamin E 400 IU QHS | Less studied: oxazepam, prazosin, hydroquinine
45
What is the most problematic type of thrombosis?
Catheter thrombosis
46
What are the non-pharmacologic treatment for thrombosis in HD?
Forced saline flush Surgical thrombectomy Exchange of catheter over guidewire
47
What are the pharmacologic treatments for thrombosis in HD?
Alteplase | Reteplase
48
What is the order of prevelance of infection in vascular access in HD?
Venous catheters > AV grafts > AV fistulas
49
What do we do if patient experiences fever during HD?
Culture blood immediately | If temporary catheter -> remove tip and send for culture
50
What are the medications for empiric coverage of gram positive abx in HD?
Vanc | Cefazolin
51
What are the medications for empiric coverage of gram-negative abx in HD?
Gent | 3rd generation cephalosporin
52
What is the predominant cause of infections in HD?
S. aureus
53
What is the treatment for tunneled catheter infections that are localized to the catheter exit site with no drainage?
Topical abx
54
What is the treatment for tunneled catheter infections that are localized to catheter exit site with drainage?
Systemic gram positive coverage
55
What is the treatment for tunneled catheter infections that has bacteremia w/ or w/o systemic sx?
Gram positive coverage
56
What is the treatment for tunneled catheter infections that has bacteremia w/sx in 36 hours?
Remove catheter
57
What is the treatment for tunneled catheter infections that has bacteremia and is stable w/no sx?
Change catheter and give culture-specific abx for a minimum of 3 weeks
58
What is the treatment for AV graft infections that are local?
Empiric abx | Narrow once cultures return and treat for 2-4 weeks
59
What is the treatment for AV graft infections that are extensive?
Empiric abx Narrow once cultures return and treat for 2-4 weeks Total resection of graft
60
What is the treatment for AV fistula infections?
Empiric abx x 6 weeks
61
What are the types of dialyzer reactions?
Anaphylactic (Type A) | Nonspecific (Type B)
62
What are type A dialyzer reactions?
Hypersensitivity to sterilizing agent Usually on initial exposure Usually bioincompatibile membranes or certain high-flux membranes with ACEi use
63
What are type B dialyzer reactions?
Chest pain Back pain Compliment activation
64
What type of membrane is used in PD?
The peritoneal membrane acts as the semipermeable membrane
65
What are the differences in PD from HD?
No intimate contact between dialysate and blood -Waste products have to travel through bleed vessels to get to peritoneal membrane No countercurrent flow No way to control blood flow rates Slower process -Must be virtually continuous to achieve acceptable waste removal
66
How is PD installed?
Permanent indwelling catheter Tunneled inside abdominal cavity Most of the peritoneal catheter is on the outside of the body with Luer-lock at the end
67
What are the characteristics of the dialysate in PD?
Electrolytes Osmotic gradients -Dextrose in hyperosmolar concentrations (monitor in pts with DM) -Icodextrin (alternative to dextrose)
68
What are the types of PD?
Continuous ambulatory peritoneal dialysis (CAPD) | Automated peritoneal dialysis (APD)
69
What is the procedure for CAPD?
1-3 L of dialysate flows into peritoneal cavity under gravity over 15 minutes Dwells in peritoneal cavity 4-6 hours -> drain -> replace with fresh dialysate Repeated 3-4 times a day
70
What are the types of APD?
Nocturnal intermittent peritoneal dialysis (NIPD) Continuous cycling peritoneal dialysis (CCPD) Nocturnal tidal peritoneal dialysis (NTPD)
71
With whom are APDs used?
When patients unable or unwilling to perform aseptic technique manipulations to catheter
72
When are APDs used?
Device set up in the evening -> catheter attached at bedtime
73
What are the goals of PD?
Achieve dry weight | Adequate removal of endogenous waste products
74
What is the CrCl goal in PD?
> 60
75
What does Kt/Vd explain?
Quantitates fraction of total body water cleared of urea during dialysis
76
What is the goal Kt/Vd in PD?
> 2
77
What are the types of complications in PD?
Mechanical Exacerbation of DM Peritonitis Catheter site infections
78
What are the types of mechanical PD complications?
Kinking of catheter | Catheter obstruction
79
What is the cause of exacerbations of DM as PD complications?
Glucose load from the dialysate | ~60% of glucose absorbed by patient during each exchange
80
What are the sx of peritonitis?
Abdominal pain/tenderness Cloudly effluent Fever and chills N/V
81
What are the signs of peritonitis?
Cloudy effluent | Dialysate: WBC > 100 with at least 50% neutrophil
82
What is the most common bacteria in peritonitis?
S epidermis
83
What is the route of administration for abx in peritonitis?
Intraperitoneal
84
What type of abx are used for gram positive coverage for peritonitis?
First generation cephalosporin or vancomycin
85
What type of abx are used for gram negative coverage for peritonitis?
Third generation cephalosporin or AG
86
What is the treatment duration of peritonitis?
14 - 21 days
87
Do you treat patients with catheter site infections with systemic or local abx?
Systemic
88
What type of abx are used for gram positive coverage in catheter site infections?
Penicillinase-resistant penicillin or first generation ceph
89
What type of abx are used for gram negative coverage in catheter site infections?
FQs
90
What is the treatment duration for catheter site infections?
At least 14 days
91
What is the exit site care for the prevention of peritonitis and catheter site infections?
Topical abx Intranasal abx Both

Renal (8 decks)

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