Renal Disease and Renal Disease and DialysisDialysis 101 101

Shalini BumbAugust 2013

ObjectivesObjectivesCKDDialysisAccessEckel pearlsScenarios

Chronic Kidney DiseaseChronic Kidney Disease

Types of dialysisTypes of dialysis

1. Hemodialysis (HD)2. Ultrafiltration (UF)3. Continuous Veno-Venous

hemofiltration (CVVH)4. Peritoneal Dialysis

HemodialysisHemodialysisSemipermeable membraneSolute removal via passive

diffusion◦Inversely proportional to the size (ie

effective removal of K, urea, C; not of PO4)

UltrafiltrationUltrafiltrationuse of hydrostatic pressure

gradient to induce convection (filtration of water)

solvent drag (pulls dissolved solutes) across

removal of excess fluid

CVVHCVVHhighly permeable membranefluid and solute removal via

ultrafiltrationfiltrate is discardedreplacement fluid is infused similar

to plasma (but no K, urea, Cr, PO4)used in ICU, runs 12-24h, through

double lumen catheterless drastic fluid shifts

Peritoneal DialysisPeritoneal Dialysisperitoneal

membrane = partially permeable membrane

dextrose dialysate

diffusion and osmosis until equilibrium

3-10 dwells per night with 2-2.5 L per dwell

Indications for DialysisIndications for DialysisAcidosisElectrolytesIngestionsOverloadUremia

AccessAccessArteriovenous fistula (AVF)Graft Tunneled catheter

Arteriovenous FistulaArteriovenous Fistula

◦Highest patency◦Lowest risk of

infection◦Low risk of thrombus

◦Maturation time (3-4mo)

◦Steal syndrome (poor blood supply to the rest of the limb)

◦Aneurysm formation

Arteriovenous GraftArteriovenous GraftEasier to createMaturation time 3-6

weeks

Poor patency (often requires thrombectomy or angioplasty)

InfectionAneurysmsSteal syndrome

Tunneled CatheterTunneled CatheterImmediate useBridge to AVF/AVG

Poor flow (decreased HD efficiency)

High infection riskVenous stenosisThrombosis

Dialysis Rx:Dialysis Rx:Time: 2-5 hoursBathBlood flow rate: 400-450cc/minDialysate flow rate: 500-800cc/minAnticoagulantAdditives:

◦Anemia (EPO, blood)◦Bone metabolism (vit D, calcitriol, etc)◦Meds (antibiotics)

Dialysate BathDialysate Bath

Common Admissions on Common Admissions on EckelEckelComplications of missed HD

◦SOB from fluid overload◦HTN crisis◦Hyperkalemia

Line infectionsAccess issuesAnd everything else…

Eckel Pearls: presentationEckel Pearls: presentation

75 yo AAM with ESRD 2/2 DM (HD MWF via RUE AVF, at CDC East, nephrologist Dr. Wish, dry weight 82kg, oligouric)

Eckel Pearls: historyEckel Pearls: historyhow did the last HD session go?complications since being started

on HD?◦infections?◦multiple access points?

medically compliant?get run sheets from dialysis

center

Eckel Pearls: physical Eckel Pearls: physical examexamVitals: no BP in the arm of the

accessVolume statusAccess:

◦Infection?◦Aneurysms◦Bruits/thrills

Page 1Page 1RN LK50: OMG’s K is 3.1. Can

we replete?

•Had dialysis 3rd shift. Finished 2hrs ago

Labs in ESRDLabs in ESRDGet labs before or 4h after HDOnly the H/H is accurateFloor RNs can’t use HD linesCan ask to have cultures drawn

at HD from the line

Page 2Page 2RN LK20: New admit AMS on floor.

Hard to arouse. Please eval

ED presentation with abd painWorkup initiated since there are no

beds…Pain meds: morphine 1mg, then

1mg, then 2 mg, then 3mg IVPSent to the floor

Medications in ESRDMedications in ESRDAntibiotics

◦Renally dose◦Loading dose, then maintenance dose

No lovenox dvt ppx, use heparinNo morphine

◦Hepatic metabolism – but active metabolites◦Limit the other opioids

Dilaudid: hepatic metabolism – but metabolites can cause neuroexcitiation

constipation/GERD : avoid magnesium/phosphate containing agents

Page 3Page 3RN: new admit OK. Called wound care

for leg.

After lunch you walk on over to the patient room. ESRD admitted for access.

OK is doing ok. Vitals stable. Comfortable.

CalciphylaxisCalciphylaxis

Calcinosis cutis

Page 4Page 4RN LK20: Code white, WAA is hypoxic,

83% on RA. Now 92% on VM.

Acutely SOB. Looks uncomfortable.Your co-NF points that one leg is bigger

than the other.You ask, “have you had a blood clot

before?”WAA nods yes.Hmmm….amongst other things, CTPE?

Imaging in CKDImaging in CKDAvoid contrast in CKD patientsIf you have to, prep

◦volume expansion: isotonic IVFs 3 cc/kg x 1h before 1cc/kg x 6h after

◦? alkalinization: sodium bicarbonate◦? acetylcysteine ◦radiology can give you the protocol

(treat empirically)

Imaging in ESRDImaging in ESRDCT with contrast is okMRI with gadolinium is NOT:

◦Nephrogenic Systemic Fibrosis (NSF)◦IF you must: HD x 3 over 3

consecutive days, with the first right after

Page 5Page 5RN LK20: Lost access on GRR.

Can you order a PICC?

Finally, an easy question. CKD. Sure, why not?

Access in CKDAccess in CKDAvoid PICC/midlines in CKD stage

4-5Try to preserve accessTry for the feet/EJBut if you need to, order a midline

PCP should refer CKD stage IV to nephrologists in anticipation of HD

Don’t treat them lightlyDon’t treat them lightly

The end.The end.

ResourcesResources UpToDate Lavinia Negrea. “Dialysis Access.” Microsoft Powerpoint. August 2013. Claire Sullivan. “Intern Boot Camp: Renal Disease and Dialysis (ie surviving Eckel).”

Date last modified 2012. Microsoft Powerpoint. August 2013. Van Stone, JC. Hemodialysis: Hemodialysis apparatus. In: Handbook of Dialysis

Daugirdas, JT, Ing, TS (Eds), Little, Brown, Boston, 1994. p53. Yassine Mrabetis. “Hemodialysis Diagram." Online image. Dialysis Definition.

Creative Commons Attribution-Share Alike 3.0, Wikepedia. August 2013. “Peritoneal Dialysis Diagram.” Online Image. Alniche: Types of Dialysis. Alniche Life

Sciences Pvt. Ltd. August 2013. Po Ming Teng. “Aneurysm.” Online Image. Chronic renal failure and dialysis.

Surgical-tutor.org.uk. August 2013. “Calciphylaxis.” Online Image. The UK Calciphylaxis Study. The Renal Association.

August 2013. Jonathan Z. Li and William Huen. “Calciphylaxis with Arterial Calcification.” Online

Image. 2007. N Engl J Med. August 2013. Shaofeng Yan. “Calciphylaxis Histology.” Online Image. 2006. Mihm’s

Dermatopathology: Calciphylaxis.  Martin C. Mihm, Jr. August 2013. “Nephrogenic Systemic Fibrosis.” Online Image. Skin & Allergy News: Nephrogenic

Fibrosis Is Tied to Contrast Agents : Moderate- to end-stage renal disease patients are most susceptible to the scleroderma-like syndrome. International Medical News Group, LLC. August 2013.

Michael Shaw. “They’re willing to throw in their kidneys.” Online image. 2008. New Yorker Cartoon. August 2013.

Cartoons from www.lightersideofdialysis.com. August 2013.