When to start dialysis

Question 1

List the complications of kidney disease

Answer 1

1. Electrolyte misbalance
   - Hyperkalaemia,
   - hyponatraemia
2. Acidosis
3. Fluid retention
4. Retention of waste products
   - Small molecules, e.g., urea, creatinine, urate
   - Phosphate
   - Middle molecules, e.g., peptides, ß2-microglobulin
5. Secretory failure
   - Erythropoietin
   - 1.25 vitamin D

Question 2

Symptoms resulting from renal failure

Answer 2

Tiredness, lethargy
SoB, oedema
Pruritis, nocturia, feeling cold, twitching
Poor appetite, nausea, loss of/nasty taste, weight loss

Anaemia – exacerbates tiredness
Renal bone disease – aches & pains, pruritis

Question 3

What happens in renal failure if there is no renal replacement treatment

Answer 3

Hyperkalaemia – arrythmias, cardiac arrest
Pulmonary oedema
Nausea, vomiting
Malnutrition / cachexia
Fits
Increasing coma
DEATH

Question 4

What are the two types of renal replacement treatement

Answer 4

Dialysis and transplantation

Question 5

What are the two types of dialysis

Answer 5

Haemodialysis
-Predominantly hospital-based, but can be done at home

Peritoneal dialysis
-Home treatment

Question 6

What is the aim of renal replacement treatment

Answer 6

• Correct electrolyte imbalance and acid-base status
• Remove waste products
• Restore fluid balance
• Improve symptoms and maintain QoL for patient

Question 7

What is the timeline for RRT

Answer 7

When GFR <20ml/min, need to start talking about it

Establish access to chosen RRT

Start dialysis when:

1. eGFR<10ml/min and benefits outweigh risks
2. eGFR<6ml/min and no reversible features
3. Life threatening complications

Question 8

How is access established for haemodialysis and peritoneal dialysis

Answer 8

HD= fistula

PD=catheter

Question 9

Benefits of starting dialysis

Answer 9

Improve uraemic symptoms (turedness, nauesea pruritis)

Improve fluid balance (less SoB, oedema)

Avoid life threatening evens (acidosis, hyperkalaemia and pulmonary oedema resistant to diuretics)

Question 10

Risks of starting dialysis

Answer 10

Dialysis related complications:
Infection (HD and PD)
Hypotension, arrythmia (HD)
Access related (HD and PD)

Adverse effects on QoL:

• work
• family life
• travel

Question 11

What can dialysis not help with

Answer 11

1. Lack of erythropoietin
Anaemia 
2. Lack of 1.25 vitamin D
Hyperparathyroidism
Renal bone disease
3. Other diseases – comorbidities
SLE
Diabetes
Vascular disease

Question 12

Compare the frequency of HD and PD

Answer 12

HD: 3 times a week
4 hours only but time to recover plus transport

PD: Daily and continuous

Question 13

What is the benefit of PD compared to HD

Answer 13

PD causes less haemodynamic stress

Question 14

What kind of access is needed for each type of dialysis

Answer 14

For HD, catheter or A-V fistula

For PD, Limited by access to peritoneum and ability to do technique

Question 15

Compare QoL with HD and PD

Answer 15

HD: done for you so not invading home, limits travel and work but loss of independence

PD: maintains independence, easier to travel/work, avoids swings of HD, less dietary and fluid restructins

Question 16

Benefits of renal transplantations

Answer 16

Better renal replacement,

Improvement in metabolic disorders e.g. Anaemia
Renal bone disease

Costs less in long-term

Prolonged survival

Quality of life

• Avoids disadvantages of HD/PD
• Much easier to travel, work, maintain independence

Question 17

Risks of transplantations

Answer 17

• Older patients not eligible
• Often worse off if/when the transplant fails
• Immunosuppression can predispose to infection and malignancy
• Not a cure: surgical complications and hospital visits frequently at the start

Question 18

What is the top dialysis outcomes for patients vs medical professionals

Answer 18

Patients: ability to travel, dialysis adequacy, dialysis-free time, fatigue

Medics: Vascular access problems
Cardiovascular disease
Death/mortality