Renal Replacement Therapy - Dialysis

Question 1

What is ESRD?

Answer 1

End stage renal disease = irreversible damage to a persons kidney’s so severe that to maintain life they must have either dialysis or a transplant

Question 2

What stage will CKD patient start showing symptoms?

Answer 2

Until stage 4 or 5 patient may be asymptomatic

Question 3

What is the syndrome of advanced CKD called?

Answer 3

Uraemia

Question 4

What are uraemic symptoms?

Answer 4

Symptoms can involve almost any organ system

Earliest cardinal symptoms are malaise and fatigue

Question 5

When is renal replacement therapy indicated?

Answer 5

When eGFR reaches <10 ml/min

Question 6

What is eGFR?

Answer 6

Estimated GFR based on serum creatinine, age, sex and race.

Question 7

Types of renal replacement therapy?

Answer 7

Transplants
Haemodialysis
Peritoneal dialysis
Conservative kidney management

Question 8

What is dialysis?

Answer 8

a process where the solute composition of a solution, A, is altered by exposing solution A to a second solution, B, through a semipermeable membrane

Question 9

Pre-requisites for dialysis?

Answer 9

A semi-permeable membrane
Adequate blood exposure to the membrane
Dialysis access
Anticoaglation

Question 10

What is the semi-permeable membrane used in dialysis?

Answer 10

Artificial kidney in haemo

Peritoneal membrane in PD

Question 11

Where is the blood needed for adequate blood exposure to the membrane taken from?

Answer 11

Haemo - extra-corporeal blood

PD - Mesenteric circulation

Question 12

Where is dialysis access taken from?

Answer 12

Haemo - vascular

PD - peritoneum

Question 13

When is anti-coagulation used?

Answer 13

haemodialysis only

Question 14

Describe the types of vascular access taken in haemodialysis.

Answer 14

Permanent - Arteriovenous fistula or a AV prosthetic graft

Temporary - Tunnel venous catheter or a temporary venous catheter

Question 15

What 2 things should you restrict from dialysis patients?

Answer 15

Fluids and diet

Question 16

How is fluid restriction dictated?

Answer 16

By residual urine output and interdialytic weight gain

Question 17

what is restricted in the diet of a dialysis patient?

Answer 17

Potassium
Sodium
Phosphate

Question 18

Why is a patient on haemodialysis given heparin?

Answer 18

To prevent coagulation

Question 19

Give a brief explanation of how PD works?

Answer 19

Dialysis solution is inserted into peritoneal cavity and uses the peritoneal mesothelium as a dialysis membrane

Question 20

Types of PD?

Answer 20

CAPD - continuous ambulatory peritoneal dialysis

APD - Automated PD

Hybrid of both

Question 21

When is a CAPD or APD done usually?

Answer 21

CAPD - day

APD - night

Question 22

PD complications?

Answer 22

Exit site infection
PD peritonitis
Ultra-filtration failure
Encapsulating peritoneal sclerosis

Question 23

If PD peritonitis is caused by a skin containment then what type of bacteria causes it?

Answer 23

Gram pos

Question 24

If PD peritonitis is caused by bacteria of bowel origin then what type of bacteria causes it?

Answer 24

Gram neg

Question 25

If there is a mix of gram pos and neg then what would be the cause of PD peritonitis?

Answer 25

A suspected complicated peritonitis - example perforation

Question 26

What are the indications for dialysis in ESRD?

Answer 26

Advanced uraemia - GFR 5-10 ml/min Severe acidosis - bicarb at <10 mmol/l Treatment resistant hyperkalaemia - >6.5 mmol/l Treatment resistant fluid overload

Question 27

REVISION - what is the mnemonic used for remembering indications for dialysis in AKI?

Answer 27

AEIOU ``` A - acidosis E - electrolyte balance (K) I - intoxication O - overload U - uraemia ```

Question 28

What is fluid overload? How is it treated?

Answer 28

Hypervolemia - treated via diuretics

Question 29

Explain fluid balance in a haemodialysis patient.

Answer 29

restricted to 500-800 ml/ day The intake allowed is calculated by - urine output+ insensible loss

Question 30

What is fluid balance like in a PD patient?

Answer 30

Usually more liberal as continuous ultra-filtration is often achieved using this method

Question 31

What is used to treat dialysis related anaemia?

Answer 31

Erythropoitein injections | IV iron supplements

Question 32

What is used to treat dialysis related/renal bone disease?

Answer 32

Activated vitamin D - Calcitriol | Phosphate binders with meals

Question 33

Complications of haemoD?

Answer 33

CV issues - intra-dialytic hypotension. cramps, arrythmia's Coagulation - clotting of vascular access, heparin issues Allergic reactions to fialysis Dialysis accidents = death (rare)

Question 34

How is a dialysis modality chosen?

Answer 34

Patient choice via education and shared decision making Perceptions of effectiveness Cost

Question 35

Limitations of dialysis?

Answer 35

Not the best substitute for a kidney BUT Only one available to keep ESRD patients alive

Question 36

What is conservative kidney management?

Answer 36

Supportive care focusing on symptomatic management and anticipatory care planning Involves a multi-professional approach