Sumathi Chinnadurai29 May 2014

DEFINITION EPIDEMIOLOGY TYPES OF DIALYSIS INDICATIONS OF DIALYSIS COMPLICATIONS OF DIALYSIS

• DIALYSIS is a form of renal replacement therapy in patients with end stage renal disease.

- To remove nitrogenous end products

- Correct salts, water and acid-base imbalance.

- It does not correct the endocrine dysfunction of the diseased kidney

There are currently 20,766 people in Australia who are on renal replacement therapy.1

Currently, the three most common causes of kidney disease requiring kidney replacement therapy in Australia are diabetes, glomerulonephritis and hypertension.1

Dialysis treatment was the number one reason for hospitalisation in 2009-10, making up over 1.1 million hospitalisations, or 13% of the total hospitalisations for this period.2

1. State of the nation, CKD in Australia, May 20142. AIHW - Dialysis and kidney transplantation in Australia: 1991-2010

HEMODIALYSIS•Intermittent Renal Replacement Therapy(Intermittent Hemodialysis)•Sustained Low efficiency Dialysis•Continous Renal Replacement Therapy( CVVHD, CVVHF, CVVHDF, SCUF)PERITONEAL DIALYSISCAPD, CCPD, NIDF

Acidemia Fluid overload with anuria or oliguria Electrolyte disturbance Urea> 35 mmol/l Creatinine>400micromol/l Toxins

• Empirically when GFR< 10ml/min/1.73m2 or GFR< 15ml/min/1.73 m2 in diabetics.

• IDEAL STUDY - Early vs Late initiation of Dialysis

• Often when symptomatic(uraemic) - Nausea, vomiting, Anorexia, fatigability, confusion

Urgently when signs of uremia•Pericarditis•Refractory Pulmonary edema•Refractory hyperkalemia•Metabolic acidosis•Asterexis•Peripheral neuropathy/foot drop/wrist drop

• Hypotension: occurs in 25-50% due to

Excessive ultrafiltration- cardiac arrhythmias, IHD, air embolus, pericardial tamponade;

- Haemorrhage – Gastric ulcer, Intracranial bleed, retroperitoneal bleed

Sepsis Anaphylaxis.

Muscle cramps: 15-20%

Nausea and Vomiting: 5-15% - prolonged treatment times and /or ultrafiltration with excess solute removal.

Disequilibrium Syndrome: occurs in first few dialysis sessions in elderly frail pts. Cerebral oedema due to excessive urea removal from bld than CSF resulting in osmotic gradient fluid shift

Heamolysis Bleeding – excessive heparin. Fever –Bacteremia, overheated dialysate. Seizure – Excessive Urea clearance, failure of

dialysis conc delivery system. Air Embolism Amyloidosis – Inadequate clearance of B2-

microglobulins using low permeability cellulose dialysis membrane.

• Access problems

• AV Fistula – Thrombosis, Infection, Finger ischaemia.

• Hickman line, Vascular catheters – Thrombosis, bleeding, Infection.

• Bladder perforation on insertion of PD catheter

• Peritonitis especially in CAPD >100cells/microl

• Tunnel abscess & Pericatheter infections – also a common source of peritonitis

• Umbilical hernia

Sclerosing encapsulated peritonitis / Encapsulating peritoneal sclerosis

Inflammatory stage – Fever, ^CRP, mild ileus,Incrsing ascites. Rx with Methylpred

Encapsulating stage- If early stage not relieved or reccurs <1mnth. Rx with TPN and decrease steroid

Ileus stage – If Ileus symptoms persist despite absence of inflammatory signs & ascites. Rx with laporotomy and enterolysis

Prompt recognition of diagnosis is essential.

Hypotension is most common presentation.

There is an overlap of symptoms/signs in various complications.